Sexual assault nurse examiners (SANEs) are nurses who have undergone specialized training to provide trauma-informed forensic care for patients who have experienced a recent sexual assault.* SANEs undergo advanced training to assess and document wounds, collect forensic evidence, and provide these services in a manner that avoids retraumatization. With 5,273 emergency departments in the United States, but only 902 SANE programs nationwide, access to SANE care is not uniformly available (Emergency Medicine Network, 2015; International Association of Forensic Nurses, 2018). Patients in urban and more densely populated areas of the country may have access to hospitals associated with SANEs, but many rural and more isolated communities do not. In 2012, the Massachusetts Department of Public Health's SANE Program was awarded funding from the U.S. Department of Justice, Office for Victims of Crime, to pilot the use of telemedicine technology to respond to acute sexual assault in underserved areas. The grant established the National TeleNursing Center (NTC), an on-call service providing expert clinical guidance on trauma-informed examinations and evidence collection via videoconferencing technology, 24 hours a day, 7 days a week. The NTC virtually transports "teleSANEs" into the examination room to offer clinical guidance and support to emergency department clinicians and patients throughout the examination and evidence collection.
The NTC project is a pioneering effort to provide telenursing care to adult and adolescent sexual assault patients. There is little information regarding a foundation for the delivery of nursing practice through the use of telemedicine equipment, otherwise known as telenursing. A literature review conducted by Cross, Cross, and Walsh (2016) likewise shows that there are minimal data regarding training for use of a telemedicine platform. To ensure that the teleSANE response meets the same standard of care as on-site SANE services, the NTC determined that Duffy's (2009; 2018) Quality-Caring Model (QCM), recently adopted by the International Association of Forensic Nurses, is most closely aligned with the goals of this project. Thus, the QCM was adopted as a framework for the TeleSANE Professional Practice Model, which is composed of three phases: the Preencounter, Encounter, and Postencounter. In this article, we present a brief summary of the QCM and describe how the NTC used this model to create a foundation for the delivery of telenursing care for sexual assault patients.
Quality-Caring Model
The QCM is built on the premise that caring is the essence of nursing practice and that caring relationships lead to positive health outcomes for patients, providers, systems, and communities (Duffy, 2009, 2018). Nursing quality is fostered through four primary relationships: the patient and family, others, self, and the community. In addition, Duffy posits that there are eight caring behaviors: mutual problem solving, attentive reassurance, human respect, encouraging manner, appreciation of unique meaning, healing environment, basic human needs, and affiliation needs. When these behaviors are operationalized within the four primary relationships, it leads to a sense of "being cared for" and helps to engage patients in their healthcare (Duffy, 2009, 2018).
NTC: Caring Relationships in Action
Caring for Patients and Their Families
Patients presenting for care after a recent sexual assault have unique needs that require clinicians to provide: (a) emotional support and crisis intervention; (b) the assessment and treatment of injuries; (c) the administration of pregnancy, sexually transmitted infection, and HIV prophylaxis; and (d) the knowledge and experience to properly conduct a forensic examination and collect evidence. Because of their specialized training, SANEs provide such care through a trauma-informed lens, maximizing patient dignity, safety, and confidentiality. These skills promote positive patient outcomes and play an important role in a coordinated criminal justice response (Campbell, Patterson, & Lichty, 2005; Campbell et al., 2014; Fehler-Cabral, Campbell, & Patterson, 2011; Schmitt, Cross, & Alderden, 2017).
During an NTC encounter, the patient's on-site clinician, or "remote site clinician" (RSC), assumes all responsibility for patient care. The presence of a teleSANE provides an additional layer of expertise, mentoring, and quality assurance, enhancing the RSC's ability to deliver quality patient care. Bidirectional videoconferencing technology, consisting of a camera, a monitor, and speakers, allows the teleSANE to be transported into the patient's room (see Figure 1). The teleSANEs play an active role throughout the examination: They may participate by reviewing steps with the patient as anticipatory guidance, offering emotional support, or providing advice regarding resources. In addition, they utilize trauma-informed interviewing techniques to elicit information in a way that avoids retraumatization, and they interact with and evaluate the patient and family while the RSC is focusing on the collection and packaging of evidence. One teleSANE described the encounter as "being a part of the team" (Walsh & Cross, 2017, p. 23). By participating directly with the patient and enhancing the RSC's ability to complete the forensic examination and evidence collection process, the teleSANE is able to improve both the patient's experience and the quality of evidence collected.
Caring for the patient is further illustrated through the NTC's requirement that pilot sites engage with community-based sexual assault advocates. Involving advocates in the patient's acute teleSANE encounter can further extend emotional care and support. Advocates also connect patients to community resources that can meet their unique needs beyond acute post-sexual-assault care, such as trauma-informed counseling and legal advocacy. This may positively impact the sexual assault patient's long-term health and well-being.
Caring for the Healthcare Team
TeleSANEs play a critical role in providing support and guidance to the RSC, the on-site healthcare professional. The level of experience for RSCs varies with each pilot site, from certified sexual assault examiners to healthcare professionals with limited to no prior forensic evidence collection experience. The teleSANEs customize support to meet the clinician's individual needs. One RSC, a SANE-certified examiner, remarked, "I can't express how much it helps. It's like having two extra hands and an extra brain" (Walsh, Cross, & Cross, 2017, p. 30). Another RSC, without SANE certification, stated: "I am not feeling anxious anymore and am telling the other nurses to believe me that you will never need to feel afraid again of taking care of these patients" (M. A., RSC, personal communication, May 2016). Real-time advice and support allow the RSCs to feel confident that they are providing the highest level of care to the patients.
The NTC also provides both live, interactive education and training and recorded webinars. Topics span a wide range and include trauma-informed interviewing, wound assessment, documentation, forensic photography, and court testimony, among others. Educational initiatives support the RSC's personal practice and professional growth.
Studies have shown that vicarious trauma, the cumulative impact of working with victims of trauma, is higher among SANEs versus other women's health nurses (Raunick, Lindell, Morris, & Backman, 2015); this may contribute to high attrition rates in many sexual assault examiner programs. For this reason, the NTC has integrated the opportunity for the RSC to debrief with the teleSANE into every clinical encounter as well as the opportunity to engage in a formal consultation with a clinical expert in the area of vicarious trauma and self-care. Together, these interventions reduce isolation for the RSC and show a commitment to their care and well-being.
Caring for Self
Although the teleSANE is not physically present in the examination room, they are not immune to the emotional strain of bearing witness to both individual patients' experiences and the cumulative effects of exposure to trauma. The experience has been described as being "in the room" with the patient (Walsh et al., 2017, p. 6). The NTC hosts bimonthly staff meetings to discuss the emotional impact of cases and to provide an opportunity for teleSANEs to connect with each other, thereby developing a sense of community and decreasing feelings of isolation. Staff meetings and newsletters are also opportunities for the NTC staff to make and share suggestions for self-care practices. TeleSANEs are also encouraged to reach out to NTC leadership to discuss any issues that arise and may schedule a formal debriefing with a vicarious trauma expert, if needed.
Caring for Community
The NTC works to create a positive change not only in the patient's experience but also in the community, hoping to improve the response of hospitals, agencies, and communities in supporting and caring for sexual assault patients. Duffy (2018) describes participation in community groups as intrinsic to caring for the community. In addition to participating in team meetings with remote pilot sites, NTC staff support and mentor remote site liaisons in our more isolated tribal and rural hospitals to become leaders in their hospitals and their communities.
The NTC has strived to create a partnered response between the RSC and the rape crisis advocate by encouraging close engagement between the remote pilot site and their community advocacy agencies or rape crisis centers (RCCs). In some NTC remote sites, RCCs have been involved in training and meetings to help acclimate advocates to the role of teleSANEs and to improve RCC-site relationships. Anecdotally, we have witnessed increased utilization of RCC services in most remote site communities. Increased access to these important community resources further indicates a sense of caring for the community's well-being.
Engagement with local law enforcement agencies, as well as providing education about NTC services, is also an important part of creating a responsive and informed community. Studies have shown that, when SANEs have participated in a postassault response, not only are patients more likely to report the assault to law enforcement (Crandal & Helitzer, 2003), police collect more evidence and conduct more suspect interviews, and the case is more likely to progress through the criminal justice process (Campbell, Bybee, Kelley, Dworkin, & Patterson, 2012; Campbell et al., 2014; Campbell, Patterson, & Bybee, 2012). Given the correlation between a SANE examination and continued progression through the criminal justice system, it is important for SANEs to engage with their community's criminal justice partners. To this end, local law enforcement departments and local prosecutors were included when the NTC staff conducted remote site visits. The NTC has encouraged remote site clinical liaisons to participate in local multidisciplinary teams, such as sexual assault response teams. In some sites, law enforcement staff are invited to participate in NTC trainings with RSCs. Outreach to, and collaboration with, law enforcement builds a community of people focused on providing the best process for responding to sexual assault.
In its tribal site, the NTC engaged a tribal specialist from the National Indigenous Women's Resource Center to educate the teleSANEs about Hopi and Navajo culture, increase awareness of sexual assault in the tribal communities, and help to address cultural barriers that may prevent patients from coming forward for care. The extension of NTC teleSANE services into these communities conveys a message of caring-that sexual violence is unacceptable, that patients deserve clinical expertise and support, and that improving the quality of forensic evidence may enhance a prosecution, which could impact the public's safety and the community's sense of being cared for.
Applying QCM Behaviors to the NTC TeleSANE Professional Practice Model
The goal of the NTC teleSANE is to model a trauma-informed approach to patient care that incorporates the concepts of patient empowerment and choice. It is important that there is synergy and a sense of teamwork between the clinicians. When the patient feels that members of the team are working together for their well-being, they are most likely to feel cared for (Duffy, 2009). In addition to focusing on the four caring relationships, the NTC and teleSANEs implement the QCM by integrating the eight QCM caring behaviors into patient care. We show how teleSANEs use caring behaviors in the interaction between the teleSANE and the RSC (see Table 1) and between the clinician team and the patient (see Table 2) during the NTC's three-phase professional practice model.
The Preencounter
The Preencounter is a critical step to cultivate patient confidence in their care team. This takes place outside the patient's presence, once a patient has consented to a forensic examination and to the involvement of the NTC in his or her care. During this phase, the two clinicians discuss the RSC's experience with conducting forensic examinations, what concerns the RSC may have, if there is patient- or case-specific information that could provide a challenge, and what approaches might be helpful to mitigate negative outcomes (mutual problem solving). The Preencounter gives the teleSANE time to acknowledge and appreciate the RSC's prior experience (human respect), shows a supportive approach, and reassures the RSC that the teleSANE will be "by their side" throughout the entire patient encounter (encouraging manner). A critical component of the Preencounter is to establish a negotiated "gentle interruption," a key phrase or signal that either party can use if the RSC requires additional assistance (attentive reassurance; McAllister, Tower, & Walker, 2007; Simonelli, 2016). Negotiating the interruption before the patient interaction assures the RSC that the teleSANE is there to provide guidance and support and will not undermine the RSC's role in front of the patient (human respect). Developing trust and team building during the Preencounter helps to create a coordinated and supportive experience.
The Encounter
The Encounter begins when the videoconferencing equipment is activated and the teleSANE enters the patient examination room. The NTC has worked with each remote site to determine the best emergency department room for encounters to enhance the patient's sense of privacy and safety (healing environment). Upon entering, the teleSANE introduces herself** to the patient and team, explains her role, and verifies that the patient has consented to NTC participation (mutual problem solving). The teleSANE identifies the patient's chosen name and pronouns and uses them throughout the examination (human respect). The teleSANE adjusts the camera to establish good eye contact with the patient (human respect) and then pans the NTC consult room with the camera to show visual and auditory privacy and reiterates that nothing is video-recorded (basic human needs, healing environment). The teleSANE reminds the patient that they are in control of the examination process, discussing choices during the examination (mutual problem solving), and reviews that the teleSANE will check in with them several times during the examination to ensure that the patient is comfortable continuing with NTC participation (attentive reassurance). The teleSANE may reassure the patient while steps of the kit are completed (encouraging manner). The teleSANE's "bird's-eye view" of the room allows for assessment of verbal and nonverbal cues from the patient and other team members, providing input, encouragement, and feedback to both the RSC and the patient as needed (attentive reassurance).
The Postencounter
The Postencounter begins after the patient has been discharged and provides an opportunity for the teleSANE and RSC to review documentation, packaging of evidence, and chain of custody. The team may discuss what went well and what could be improved upon (mutual problem solving) and debrief about the emotional impact of the case. If needed, the teleSANE reviews vicarious trauma and self-care resources available through the NTC. It is also a time for the teleSANE to acknowledge the RSC's ability to provide excellent care during what may be a stressful experience (affiliation needs).
Implications for Clinical Forensic Nursing Practice
The introduction and application of telecommunication and information technology to healthcare and nursing is a rapidly growing area (American Hospital Association, 2019; Souza-Junior, Mendes, Mazzo, & Godoy, 2016), with many programs extending services to emergency departments in rural areas (Ward, Jaana, & Natafgi, 2015). However, there is little research or information available about how to best deliver nursing care as we embark on treating patients from a distance (Cross et al., 2016; Nagel & Penner, 2016). The NTC pilot project served six pilot sites, approximately 120 RSCs and 283 patients during the 50 months that clinical services were active under the Office for Victims of Crime grant. Forty-one teleSANEs were recruited and trained from the Massachusetts SANE program. The NTC developed a professional practice model for delivering teleSANE care, which integrates the QCM theoretical framework and its caring behaviors to provide a solid framework for the delivery of telenursing services, and the formal evaluation of the NTC project showed that this model successfully supported clinicians when conducting acute forensic examination for sexual assault patients (Walsh, Meunier-Sham, & Re, 2019). Although structured interviews with, and surveys of RSCs, revealed positive patient responses to the teleSANE intervention, additional research specific to this question should be considered (Walsh et al., 2017). In addition, because of the length of time from patient presentation to trial, the effect of the teleSANE on criminal justice proceedings has not yet been evaluated. At this time, no teleSANE has been subpoenaed for testimony. Given the promise of the program so far, the NTC has been continued as a pilot under the Massachusetts Department of Public Health SANE Program. The NTC's model shows that, even through technology, the work of SANEs can stay true to the underlying tenets of the forensic nursing profession by carefully considering components of practice and ensuring that they adhere to a framework that promotes compassionate care.
Acknowledgments
We would like to acknowledge and thank the following people for their support and critical review of this article: Dr. Joanne Duffy, Dr. Jessica Shaw, Dr. Sheridan Miyamoto, Dorma Sahneyah, and Erin Miller. We would also like to express gratitude to our teleSANE staff for their efforts in providing excellent care to patients through this innovative platform and for their feedback during the development of the NTC and its practice model and, most importantly, to the sexual assault patients who entrusted us with their care during this pioneering pilot project.
References