1. Symonds, Anita MS, BSN, CEN, SANE-A, SANE-P
  2. Oldham, Jennifer BS, RN, CEN

Article Content

Sexual assault can play out many different ways; the nurse may have just medicated a patient with opioids for post-op pain. When the patient wakes up, a stranger is touching her breast. She screams and he disappears into his relative's room, two doors down. How would you handle this in your facility?

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A nurse may be visiting a patient in her home, when the patient confides in the caregiver that her husband forced her to have sex last night and she's still bleeding. Is your clinical nurse prepared to assist her?


Research studies have shown that sexual assault can happen anywhere. Police stations, day-care centers, group homes, churches, personal homes, hospitals, long-term-care facilities, and schools are just a few examples. According to the National Center for Injury Prevention and Control (CDC), nearly 1 in 5 women and 1 in 71 men reported experiencing rape at some time in their lives.1


Nurse managers need to be aware that sexual assault is a possibility within their institutions, and have the moral, legal, and ethical responsibility to protect their patients and staff members. The Joint Commission hospital accreditation standards state that patients have the right to be free from exploitation, neglect, and abuse, including verbal, mental, physical, and sexual abuse.2


Who's at greater risk?

Research has shown that sexual assault remains a risk throughout the lifespan. Unfortunately, individuals with cognitive and/or physical disabilities are at a higher risk for abuse, including sexual assault, when compared with nondisabled persons. Some studies have estimated as high as 80% of women with disabilities have been sexually assaulted. Also, women with disabilities are three times more likely to be sexually assaulted than women without disabilities.3


It's important for those who work in institutions to know approximately 3% of long-term-care facilities and 0.7% of institutional care facilities have identified at least one sex offender living within its institution.4 It's a general belief within the sexual assault service community that many sexual assaults go unreported. Reasons for a victim not to report sexual assault may include personal beliefs, fear, embarrassment, mistrust in the justice system, or inability to report due to a physical or cognitive disability. When a person depends on caregivers, his or her caregivers should be able to recognize and address the signs and symptoms found with victims of abuse, as well as sexual assault.


Nurses need to recognize there are certain circumstances that may increase a patient's risk of becoming a victim of sexual assault. Patients with temporary or permanent disabilities, as well as patients under the influence of sedating medications (that may lower a person's awareness), are at an increased risk of becoming a victim of sexual violence. One of the obstacles that sexual assault presents to clinical nurses is that nurses don't always recognize signs and symptoms of an assault.


Red flags for abuse include unexplained injuries or delays in seeking treatment for those injuries, as well as the history, provided by a caregiver, being inconsistent with the patient's injury. Specific indicators, which may allow one to consider sexual assault, include anal, genital, and oral injuries. Bruising involving inner thighs, genitalia, breasts, anus, "suck" or bite marks, and sexually transmitted infections (STIs) should also cause the healthcare professional to consider the possibility of a potential sexual assault. Fear of a specific caregiver, family member, or visitor should also be taken seriously. Changes in behavior, including fearfulness, depression, and loss of sleep, may also be signs of abuse.5


Healthcare providers often misinterpret or inadvertently overlook the physical signs of sexual assault on the older adult and/or disabled population due to complicated medical histories, dementia as a diagnosis, and prescribed medications. Also, healthcare professionals may not believe a patient's disclosure, due to the lack of awareness for sexual violence in the older adult population.6 It's important for clinical nurses not to ignore or disregard the victim's disclosure. Doing so, the healthcare provider has denied that person the basic right to have a complaint believed and investigated. More important, if the victim is ignored, the nurse has denied the patient proper medical treatment. Further, the healthcare provider has put his or her license on the line and possibly opened himself or herself up to a civil law suit by failing to protect the patient. This can be avoided by providing education to staff members on policies pertaining to abuse or neglect concerns within your institution.


Consider implementing a policy for institutional response to acute sexual assault. Nurse managers should provide specific education related to sexual assault, recognizing signs and symptoms, and identification of patients at an elevated risk of becoming a victim of sexual assault. This education should include recognizing potential offenders residing within institutions, as well as staff members who may display inappropriate behavior such as making sexual comments, providing special attention to specific patients, or wanting to be alone with a specific patient. Since sexual assault, abuse, and neglect are such serious offenses, the facility should provide a 24/7 resource person for staff member questions related to these offenses. (See Clinical nurse preparation.)


Physical and biological evidence

It's extremely important that the potential biological and physical evidence be collected and managed by a specially trained professional. DNA is found in almost every cell of the human body. Every person's DNA is individual to that person, with the exception of identical twins. This makes it very important to attempt to collect potential sources of DNA after a suspected assault. DNA can both identify and rule out a suspect. Sources of DNA include blood, hair, mucus, saliva, semen, skin cells, perspiration, tissue, and vaginal and rectal cells.7


Potential DNA evidence can be found on anything that came in contact with the victim and/or suspected offender, including clothing, sheets, condoms, cigarettes, furniture, and anything in the room, house, or crime scene with which the suspected offender or victim may have come into physical contact. It's important for nurse managers to consider hiring sexual assault nurse examiners (SANE), especially in the ED. A SANE is an RN who's specifically trained to provide all-inclusive care to a patient who's a victim of sexual assault. He or she provides victim-centered care while remaining objective during the exam. The SANE is also prepared to testify in court related to findings.8 A SANE may be an employee of a medical center, police department, or other victim advocacy program. He or she is also able to provide testimony in a court of law about the forensic exam and care rendered.8,9


Preserving the evidence

In sexual assault, the victim's body is considered part of the crime scene. This raises multiple challenges for evidence collection. Each and every victim of sexual assault has individual needs that must be considered during evidence collection. For that reason, a professional with specific sexual assault training should examine and collect evidence from the victim.


As soon as an assault, or potential assault, is discovered, immediate actions should be taken by a hospital or law enforcement agency to initiate safety, protect evidence, and have the victim examined by a SANE. A medical screening must take place to evaluate for serious and acute injuries, which needs to be addressed before evidence collection. This would include, but isn't limited to, victims with heavy bleeding, possible broken bones, decreased level of consciousness, and victims of strangulation. If serious injuries are noted, then 911 should be activated.


It isn't in the victim's best interest for a healthcare professional without specific sexual assault training to examine the victim and "decide" whether the victim needs evidence collection. For example, an OB/GYN shouldn't insert a speculum into someone who has presented with a complaint of sexual assault if the plan is to send the patient for evidence collection. By inserting and removing the speculum, the risk of losing potential evidence increases.


Evidence is time sensitive. Every hour a victim goes without proper evidence collection increases the chance of losing evidence. Because of the time sensitivity, most jurisdictions limit evidence collection based on time. The time limit on evidence collection was 72 hours; however, with advanced techniques some jurisdictions have increased collection times up to 7 days.9 Some circumstances would extend the time limits for evidence collection, for example, if a victim hasn't showered since the assault. However, it's still preferred to have evidence collected as soon as possible.


Evidence must be collected, preserved, labeled, and packaged as to the jurisdictional or institutional policy. Chain of custody must be maintained, including documentation of all handling, transfer, and storage of evidence.9 If policies aren't followed and chain of custody has been broken, the evidence is at very high risk for not being allowed into the courtroom. Nurse managers should ensure that victims are cared for as soon as possible by personnel specifically trained in treating sexual assault victims.


Avoiding revictimization

A forensic medical exam may be performed at a hospital or other healthcare facility, by a SANE, a sexual assault forensic examiner, or, if necessary, by another medical professional. This exam is complex and, on average, takes approximately 3 to 4 hours. Although this may seem lengthy, medical and forensic exams are comprehensive because the victim needs and deserves special attention to ensure that he or she is medically safe and protected. In addition, it's important to collect evidence so that if the victim chooses to report the crime to the police, he or she can access the stored evidence.1 With the exception of situations covered by mandatory reporting laws, victims, not healthcare workers, make the decision to report a sexual assault to law enforcement.9 Consenting to a SANE exam doesn't mean that the victim has to press charges.


This decision to involve law enforcement can be made at a later date, as long as the evidence is properly collected. It's also important to know that the victims aren't responsible for paying for evidence exams. Nonvictim billing procedures should be implemented and explained to victims by the facility providing sexual assault evidence services. Nurse managers should ensure that all policies are followed, which may include ruling in or ruling out mandatory reporting when a sexual assault has taken place.


The purpose of the exam is to first assess the patient, then document threat and force or recent sexual contact, identify a suspect, and corroborate the facts of the assault.9 It also includes preventing further injury by screening and treating for sexually transmitted infections, while attempting to maintain the victim's dignity and personal control over the exam process.


The SANE will inquire about the sexual assault to assess what type(s) of medical care the victim may need. For example, if the victim describes any kind of physical restraint to his or her wrists, the examiner will look for potential evidence that may be collected from the hands and arms. It would also trigger the healthcare provider to consider if X-rays or skin/wound care are needed. It's important for the trained examiner to obtain history from the victim, and/or any witness, if the victim is unable to communicate.


Evidence may be collected in many different forms during the SANE exam. A specifically designed sexual assault kit is used to collect evidence, which can be found in the victim's hair, skin, blood, fibers, and so on. Photographs may be taken, and blood may be drawn to check for any STIs. Clothing may also be collected because evidence may be in the shape of stains, debris, hair, and fibers. Hair combings and oral swabs may be helpful in evidence collection. Other areas of the body that may be swabbed are the fingernails, vagina, penis, anus, rectum, and any areas of skin-to-skin and/or mouth-to-skin contact. Maintaining the chain of evidence is essential, and includes documentation of all evidence and its handling, transfer, and storage.


The sexual assault exam

The exam begins with obtaining consent either from the victim, or his or her guardian, if the victim isn't competent to give consent themselves. A thorough medical history, including any allergies, preexisting diagnoses, recent procedures, and any medications that may influence the exam, is obtained. This medical history should also include last consensual sexual intercourse, if the victim is sexually active. Obtaining information regarding complaints of pain, tenderness, or bleeding since the assault also helps to guide the exam. The history should include the time of assault, details of the assault, and any activities that took place after the assault that could affect interpretation of findings and evidence collection. After the history, clothing is collected carefully as not to lose any potential trace evidence.


Next, a head to toe external exam is done, swabbing potential areas of evidence, as well as documenting and treating any minor injuries. Documentation usually includes written notes, as well as photographs. The external exam is followed by an internal exam, where swabs may be collected as evidence, and any internal injury documented. If drugs or alcohol were suspected or involved, the examiner needs to be informed and will take urine and/or blood samples for toxicology.


All victims of sexual assault should be offered prophylaxis for STIs. Pregnancy prophylaxis should also be offered when the victim is in child-bearing years. In 2010, the CDC published recommendations for the prevention of STIs and pregnancy following sexual assault.10


Crisis intervention should be offered during and after the exam. For victims with significant cognitive disabilities, such as dementia, standard counseling won't be effective. In these cases the presence of an advocate who continually reassures the victim may be helpful.11 An advocate can educate the caregivers and healthcare staff members on how assault and trauma can affect victims. For example, studies have shown that when an assault takes place at the victim's care facility, he or she may have feelings of being unsafe and may benefit from being moved to another facility.11


Discharge from the medical facility should include a safety plan, any medications given, and clearly indicate if follow-up treatment is needed for injury. The victim should have a physical follow-up to address any injuries and STIs. Psychological follow-up should be included, ensuring the best recovery possible. Older adult victims with dementia have shown the same postassault trauma behaviors as those without dementia.12 When the victim is a disabled person, caregivers need to learn how to assist with decreasing triggers and/or how to respond to trauma behaviors.


Organizational tips for prevention

A study of sexual violence in care facilities revealed that 43% of the offenders were employees responsible for older adults' care, and 41% were other residents. Assisted living facilities, psychiatric facilities, group homes, and long-term-care facilities were included in the study.13 Nurse managers must be prepared to face this unfortunate reality no matter where they work.


The following is a list of suggestions to help organizations properly prepare for the treatment of sexual assault victims:


1. Background checks, including mental health screenings, should be performed for all potential staff.14


2. Background checks, including mental health screenings, should be performed for all patients going into a long-term-care facility.14


3. A positive background or mental health screening for a history of violence and/or potential for violence should be noted in the patient's chart. This may indicate the need for increased observation and no unsupervised one-to-one visitation between other patients and staff members. For example, patients shouldn't be cohorted.14


4. Staff education on recognition, screening, and intervention of abuse and sexual assault should be performed.5


5. Staff education should include a clear definition of sexual assault that's communicated organization-wide. Education is imperative to reducing the risk of sexual attacks and abuse/neglect.14


6. Management needs to culture an environment with zero tolerance for abuse/neglect/violence (verbal or physical) involving staff members or patients. Cultivate an environment where staff members feel comfortable speaking up about odd, eccentric, or dangerous behaviors that their peers may exhibit.14


7. Panic alarms on walls or personal panic alarms for staff members should be provided or available.


8. Visitors must show identification at the entrance to the facility and be verified that they're allowed to visit the patient.


9. Review and consider revising any policy that allows visitors or staff to be alone with incapacitated patients.14


10. Video monitoring in all public areas of the facility should be instituted.


11. Protocols that address abuse should be in place.



Helping patients is mandatory

Although many states don't participate in mandatory reporting when the victim is a competent adult, this isn't true when medical personnel treat a child, older adult, or vulnerable adult who was the victim of a crime. (See .) Although states use different legal languages, nurses may be required to report abuse, neglect, and sexual assault to adult protective services and/or police. A healthcare professional who doesn't meet the mandatory reporting requirements can be exposing him or herself to fines, loss of license, and possible time in jail.


The nurse manager needs to assist and oversee the reporting of the sexual assault. (See .) Managers should verify that the institutional policies include a clear and accessible activation plan for the clinical nurse. Individual employer and institutional policies should include all mandatory reporting required by law and governing bodies. This may include Medicaid, Medicare, The Joint Commission, adult/elder protective services, public health departments, and local police departments, as well as institution-specific departments such as risk management.


Although nurse managers may not be at the bedside, they play an important role in helping to raise awareness of sexual assault. Managers must educate themselves and their clinical staff members about best practices in caring for and treating victims, as well as how to identify abuse.


Clinical nurse preparation


* Ensure safety for yourself and the victim. If you come upon an assault in progress, call for help. If it's something you can physically stop without endangering yourself, such as one patient assaulting another patient, stop the assault and remove the offender from the room. Have someone stay with the victim to assure them that they're now safe.6


* Notify your immediate supervisor and activate your protocols related to violent crimes on the premise or abuse protocols. Some facilities have protocols specific to sexual assault.


* To preserve evidence, ask the victim not to eat, smoke, drink, or use the bathroom, if possible. Don't wash or bathe the victim. Don't change clothing or incontinence pads, disposable underwear, or other clothing, and don't comb the victim's hair or brush their teeth. By performing any of the above, physical evidence may be lost or damaged. In most circumstances, physical evidence may be collected up to 72 to 120 hours, depending on the specific forensic program guidelines. Keep in mind that the longer it takes to collect the evidence, the chance of finding usable evidence decreases.12


* Don't clean up the crime scene-don't remove anything (such as the sheet from the bed if the assault occurred on the bed or bedding/belongings that were on the bed after the assault). Don't move anything the offender may have touched. After the victim has been removed, close the door and don't allow anyone in the room until the police say they've processed the room and it's okay to return to normal usage.12


* Initiate and prepare the victim for transfer to a facility that's equipped to provide sexual assault exams with evidence collection. To obtain the name of your local facility contact, call the National Sexual Assault Hotline (800-656-HOPE). This hotline will connect you with your local crisis center that's capable of answering questions. If the victim is a competent adult, they can talk to the crisis line to find out about local resources and options for reporting or not reporting, and some crisis centers provide an advocate to accompany the victim at the hospital. This is also a good resource for families and/or the caregiver of a victim.


* As the caregiver of the victim, it's very important to clearly communicate to the examiner or receiving hospital the victim's medical history, including medications and cognitive difficulties. The examiner will need to know about any consent issues, such as if the victim isn't competent and has a legal guardian. If this is the case and you notify the guardian of the situation, make sure he or she is available by phone or in person to consent for the evidence collection exam.6


* Document everything; if you were a witness, document what you saw. If the victim disclosed to you, document what was said using quotes as much as possible. Don't include your opinions; document only the facts.8


* If a victim is disclosing to you after the fact, listen, validate that you'll notify proper authorities capable of investigating, and get them the help to meet medical needs related to the assault.


* If the person who discloses is a competent adult and doesn't fall under any mandatory reporting laws, they may choose not to report to the police. Maintain confidentiality and allow them to make an informed decision as to having an evidence exam or not.6


* Believe and address all concerns that patients verbalize, and address patients that appear to be fearful of something or someone.


* Encourage all nurses at your facility or place of employment to recognize the signs and symptoms of abuse and sexual assault.5 Review your policies related to victims of crimes and know your mandatory reporting requirements.


* Encourage your facility to do background checks on all residents. Staff should be aware if a patient has a history of assaultive behavior, and safety measures should be employed with that patient. An example would be to have that patient in their own room, and not have them alone with any other patient.


* Prevention methods include a milieu culture in which staff members question anyone in the hallways of hospitals or healthcare facilities who doesn't look familiar, doesn't have identification displayed, or appears to be loitering about the unit. This culture should include a zero-tolerance rule for failing to notify management when concerning behavior is observed such as inappropriate conversations, touching, and staff members acting overly attentive toward specific patients.6


Mandatory reporting


* Know the mandatory reporting laws, educate staff members about the laws, and refer to the institutional policies and procedures.


* Support the clinical nurse when reporting assault to local law enforcement and when reporting to the institution in which the victim resides/is being treated.


* Be aware of all governing body requirements because the assault may also need to be reported to the risk management department, institution executive, or insurance company.


* Notify the victim's family, significant other, legal guardian, and/or power of attorney in a timely fashion.


An example of steps to take for reporting sexual assault

It's quarter after 11 in the evening, a clinical nurse runs into your office and tells you that she witnessed one of the care assistants sexually assaulting a patient. What do you do next?


* Notify police or security.


* Have more than one staff member respond immediately to the location of the assault.


* Attempt to stop the assault, only if it can be done safely.


* Assess the victim for life-threatening emergencies and, if present, dial 911.


* Have a staff member remain with the victim for safety and offer emotional support.


* Initiate your institutional policy on sexual assault:


- Protect the crime scene (don't allow other staff members into the crime scene except the staff member who's with patient).


- Protect the evidence (no food/drink, don't bathe or change clothing).


- Prepare for transport to a local facility that provides sexual assault services (if not performed at your institution).


- Notify appropriate parties (police, patient's family/next of kin, power of attorney, local rape crisis center, and so on).


* Notify human resources, risk management, and (possibly) the institutional insurance provider, as well as mandatory reporting.


* Acknowledge the potential for multiple victims due to employee access to patients.


* Prepare to screen your other patients for sexual assault victimization.


* For additional assistance related to sexual assault, call the National Sexual Assault Hotline at 800-656-HOPE.





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