Sexual assault nurse examiner (SANE) practice is challenging and requires a wide array of skills and competencies. Although there are many options for obtaining training in this specialty area, most programs focus intensely on content required for certification and SANE practice basics. Many trainees have little exposure to content that may augment learning, and holistic approaches to learning in the transition to SANE practice are lacking. A holistic approach invokes a comprehensive model of care and emphasizes the nurse engaging with the patient as a whole-attending to their specific, individual needs and to the process of providing care (Zamanzadeh et al., 2015). This may be particularly important to patients seeking SANE care services, as most SANE clients are recently traumatized, under significant stress, and at risk for numerous poor health effects related to their experience of abuse or assault (Vrees, 2017). Holistic preparation for SANE practice supports both the nurse trainee and the patient population in maximizing potential for adaptive coping during and subsequent to the SANE examination.
Why the Holistic Approach?
SANE training involves acquainting trainees with the myriad of potential effects of violence and abuse relevant to the collection and preservation of forensic evidence; however, the psycho-neuro-emotional and cultural ramifications for both the patient and the SANE may be overlooked (Patterson et al., 2017). For the SANE, this can lead to increases in compassion fatigue, burnout, and secondary traumatic stress (Flarity et al., 2016). Where students in prelicensure and advanced practice education are often encouraged to consider how they interact with patients in an environment of care, SANE trainees may instead be encouraged to focus on the legal and criminal justice ramifications of their practice-programs with this focus are described as "high prosecution" (Patterson et al., 2017). As Campbell and colleagues note, the "[horizontal ellipsis]conceptualization of nursing practice as a caring profession rooted in a holistic understanding of patients' lives is theoretically antithetical to the adversarial culture of the legal system" (Campbell et al., 2011, p. 17). This is an important point of comparison because it reflects the ways in which SANE training may create a sense of separation from the broader nursing profession.
This disconnect may partially explain why there are fewer practicing SANEs than needed in the United States: In 2017, there were roughly 400,000 sexual assaults in the United States (Morgan & Oudekerk, 2019) yet only 2,600 SANEs in practice (Stern, 2017). The work done by SANEs is technically and psychologically demanding; many who complete training leave practice within 2 years (Iritani, 2016). One study of sexual assault care providers suggested that those who had more extensive experience with different types of patients and more awareness of what they were likely to see in practice had better odds of remaining in the specialty (Horvath et al., 2020). This suggests there may be ways of enhancing SANE training to improve overall retention in practice. Two possible avenues for improvement are incorporating attention to multidimensional perspectives on trauma and diversifying trainee experiences with special populations and situations.
Multidimensional Perspectives on Trauma
According to the Substance Abuse and Mental Health Services Administration (2014), trauma is any event or set of experiences or events that an individual perceives as physically or emotionally harmful and/or life-threatening and that has lasting adverse effects on functioning in mental, physical, social, emotional, and/or spiritual areas of well-being. This definition makes clear the impact of trauma is neither time limited nor restricted to only some parts of an individual's existence. Trauma influences multiple dimensions of health and accounted for in care planning. Given that generalist nursing education typically espouses providing care that addresses all aspects of an individual's health and functioning, it is interesting that scant attention is paid to the effects of trauma on health (Bruce et al., 2018; Burton et al., 2019; Williams et al., 2016). Nurses may therefore be unschooled in providing trauma-informed care and unaccustomed to managing trauma sequelae in patient care. The situation may be compounded in SANE training, where time-limited educational programs focus on evidence collection and other basics of practice (Patterson et al., 2017). As a result, SANEs may feel unequipped to engage in trauma-informed care when interacting with patients who likely have the greatest need.
Diversifying Trainee Experiences
Traumatic experiences, particularly violence and abuse, are not limited to a single population or group and may have amplified effects on those already rendered vulnerable by structural or personal characteristics (Burton et al., 2019). SANEs are likely to encounter patients from a range of backgrounds. Unfortunately, some patients may harbor discomfort with medical institutions, while simultaneously, SANEs report lacking expertise in providing appropriate culturally and socially contextualized care to many populations including trans* persons (Du Mont et al., 2019), older adults (Du Mont, Kosa, Yang, et al., 2017), Indigenous survivors (Du Mont, Kosa, Macdonald, et al., 2017), women of color (Gagnon et al., 2018), and male survivors (Matthews et al., 2018). Poor outcomes for both the SANE and the patient can occur when training does not adequately prepare SANEs to practice effectively with these and other groups. The patient may be further traumatized, particularly if the care received creates a sense of cultural distress: culturally based negative feelings in an environment where the individual is not in control of what is going on (DeWilde & Burton, 2017). Concurrently, the SANE may experience moral distress related to feeling unable to provide appropriate and holistic care (Wocial, 2020).
Holistic SANE Training
As a recipient of Health Resources and Services Administration (HRSA) Advanced Nursing Education Sexual Assault Nurse Examiner grant, faculty and staff of the University of California Irvine (UCI) Sue & Bill Gross School of Nursing, engaged in the development of a training and preceptorship program for new SANEs. In addition to standard didactic training and clinical preceptorships, we incorporated training components to prepare trainees to engage appropriately with as many different types of patients as possible. The rationale, in part, was the affiliation of our training program with a School of Nursing, where a number of the trainees were newly licensed nurses with limited clinical practice experience. For other trainees, it was important to ensure they felt comfortable applying skills learned in SANE training across diverse groups. From a practical standpoint, because this was a new initiative in our region, we also wanted to provide as many in-house opportunities as possible for trainees, rather than having them seek out their own. We sought to offer a wide variety of options such that trainees could complete the requirements for International Association of Forensic Nurses (IAFN) Adult Sexual Assault Nurse Examiner (SANE-A) certification (40 hours of didactic instruction plus 300 practical hours) even if they were unable to take every available opportunity. This became critically important with the advent of the COVID-19 pandemic, as many trainees were only available sporadically. We initially planned for all trainees to complete requirements for certification within one calendar year of starting training, but expectations were adjusted as needed throughout the pandemic.
For the purposes of our program, we defined the holistic training approach as encouraging application of skills acquired via didactic SANE training in a wide variety of patient population contexts. A primary program goal was increasing trainee confidence with both physical examination skills and patient interactions as they prepared to begin preceptorship. Secondarily, we aimed to support trainees in completing the required training and practice hours to be eligible for SANE certification from the IAFN. Toward these ends, we assembled an array of options emphasizing both population-oriented and patient-centered approaches. The three main domains addressed by our framework are skills learning and training content, peer support, and community engagement (see Figure 1). The training is summarized and rationale is provided for topic inclusions below. Trainees were asked periodically to comment via anonymous surveys on which topics they appreciated and/or found most helpful, as well as to indicate which ones they found least useful or would like additional training on. We have included direct comments from the trainees where applicable, and Table 1 displays initial plans with adaptations necessitated by the COVID-19 pandemic. Notably, there were no comments indicating that any specific topics were not useful; however, there were requests for additional sessions on court testimony, secondary trauma, and review for the certification examination. The primary topics covered are described in the following sections.
Skills Learning and Training Content
Trainees completed either an in-person didactic training via the California Clinical Forensic Medical Training Center (CCFMTC) or the IAFN online training. The CCFMTC training included orientation to the Cal OES 2-923 Sexual Assault Forensic Medical Report Form, the form required in California, and its instructions that constitute the California Medical Protocol for Examination of Sexual Assault. Trainees also completed CCFMTC's Forensic Photography course, covering basic forensic photography skills needed for documenting bodily injuries from sexual assault, intimate partner violence (IPV), child physical and sexual abuse, and elder abuse. In-person training was initially preferred for hands-on skills acquisition; however, the COVID-19 pandemic forced us to shift entirely to virtual training (see Table 1). To ensure that trainees completing the IAFN training received similar instruction on the California forms and photography skills, the Project Coordinator-a certified SANE who had completed training-prepared virtual learning sessions for trainees (see Table 2). These and other training opportunities were typically offered in blocks of 1-2 hours to provide for maximum flexibility and participation among trainees. One notable exception was the daylong strangulation intensive course described below.
Clinical and Practice Based
Before beginning preceptorship, trainees were also offered opportunities to practice speculum and anoscope examinations with standardized patients facilitated by the Project Director, Preceptor Site Director, nurse practitioner faculty from the Sue & Bill Gross School of Nursing, and physicians from the UCI Health Department of Obstetrics-Gynecology. Content included brief instruction on basic techniques for these examinations followed by four speculum examinations and one anoscope examination under supervision. These sessions allowed trainees to practice the examinations with experienced clinicians and standardized patients accustomed to the examination process, so trainees could establish some level of comfort with the procedures before conducting an examination on a real patient. This helped reduce trainees' apprehension about causing harm or further trauma to patients during their preceptorship.
Additional clinically oriented training included basic and advanced training on strangulation injury, provided by the Training Institute on Strangulation Prevention, and training on the dynamics of IPV by a local advocacy agency. These were crucial, as this content is not always covered in-depth in basic SANE didactic instruction yet nonfatal strangulation is common in both IPV and sexual assault incidents (McQuown et al., 2016; Murphy et al., 2011). One trainee noted that these sessions were especially helpful because "strangulation and trauma of the brain were the most applicable to my practice. I didn't realize that a huge percentage of strangulations don't show physical evidence[horizontal ellipsis]. I am thankful that I learned this in my first month of training because I ended up being able to apply it to a case early on." In the advanced strangulation training, trainees joined multidisciplinary colleagues from law enforcement and the judicial system to explore the roles of each profession in investigating forensic strangulation cases. During the IPV training, trainees heard from advocates and survivors about the experiences and concerns of those affected as well as the long-term emotional and physiological effects of trauma. This training was especially well received by the trainees because there was no other IPV or in-depth trauma-informed care-related content in any of the didactic training. As one of the trainees commented, "I think trauma, no matter the event or circumstances from which it was caused, results in a certain degree of vulnerability. I feel I have gained a new awareness and therefore a heightened perception of patients in these vulnerable moments and how to comfort them while maintaining professional and skilled nursing interventions."
Our final skills training focused on court testimony beyond content covered in foundational SANE training-a significant concern raised by trainees unfamiliar with testifying or working with legal teams. Initially, we aimed to collaborate with our regional IAFN chapter to provide a comprehensive training with a nationally recognized expert, but pandemic conditions forced a shift to IAFN's existing virtual training and worked with the director of our preceptorship site to develop protocols for identifying critical elements of testimony. The latter included understanding the full scope of practice for the forensic nurse, establishing credibility, employing research, and other evidence in court. As we are able, we also plan to engage with the UCI School of Law's Domestic Violence Law Clinic on mock trial exercises with emphasis on SANE and attorney collaborations.
Diversity
To address special populations SANEs might encounter, we sought expertise from across our campus and community. In partnership with the UCI LGBT Resource Center, we provided trainees with education on language, concepts, and terminology for working with the LGBTQ community. Content from these sessions included overviewing differences among sexual, gender, and romantic orientations; gender expression and appropriate use of pronouns; healthcare provider considerations; and the California Gender Recognition Act. Through the UCI Division of Gender Diversity, we provided instruction on practicing trans-affirming care; reviewing differences among gender identity, gender expression, physical/emotional attraction, and sexual orientation; addressing trauma-informed trans-affirming care, including gender-affirming physical examinations; and special considerations for transmasculine and transfeminine patients. The latter included how to appropriately establish pronouns, communication, and terminology for anatomical references. To our knowledge, this content is almost completely omitted from much of U.S.-based SANE training, although colleagues in other countries have piloted curricula and interventions (Du Mont et al., 2019, 2020). One notable exception is the training developed by fellow Health Resources and Services Administration grantees at the University of California San Francisco, which is a comprehensive SANE didactic course and does include considerations in providing SANE care to nonbinary and transgender individuals (Nathan & Ferrara, 2020).
Other training topics identified in the areas of diversity and inclusion in practice were assessment of injuries on different skin tones, implicit bias, cultural safety, and care of patients with disabilities. Scheduling many of these sessions was affected by the COVID-19 pandemic, and several were either postponed or pending as of this writing.
Peer Support
In addition to providing numerous opportunities to acquire needed skills and knowledge, we sought to establish avenues of peer support among trainees. We believed this would support retention of program participants throughout training and in practice; however, the COVID-19 pandemic rendered opportunities to connect as a group even more crucial for trainee development. Given the impact of COVID-19 on nurses across the country and the world (Pappa et al., 2020), we were acutely aware that our trainees were juggling multiple stress and trauma triggers across their personal and professional lives. We therefore moved rapidly to further infuse trauma-informed approaches into training, with a focus on providing trainees themselves with trauma-informed learning environments as well as helping them learn to provide such environments for patients. As per the Substance Abuse and Mental Health Services Administration (2014) framework, critical principles of trauma-informed approaches include peer support; collaboration and mutuality; and empowerment, voice, and choice. To enact these for our trainees, we established regular virtual peer engagement sessions with program staff and trainees at all levels, providing a venue for trainees to share experiences of preceptorship, certification preparation, and interesting or difficult cases. The Project Coordinator created activities to accompany these sessions, including a game-show-style SANE certification review, case reviews, mindfulness self-care practices, group discussion of a movie depicting the experiences of a sexual assault survivor, stalking, photography, and other relevant topics (see Table 2). These activities enhanced trainees' engagement with the program while facilitating important interactions. One trainee remarked, "I like the zoom reviews for cert and Jeopardy as it was preparing me to take the exam," whereas another added, "Each of the meetings informed my SANE practice especially those that provided step-by-step details."
Addressing Secondary Trauma
A particular focus at the height of the COVID-19 pandemic was assisting trainees in coping with secondary trauma in both their regular practice and the SANE training context. Secondary trauma is distress resulting from constant contact and empathic engagement with traumatized individuals, particularly when negativity bias goes unchecked because of persistent circumstances such as a critical pandemic (Ludick & Figley, 2017). Secondary trauma has long been acknowledged as an issue among nurses, particularly SANEs, and likely to be exponentiated under pandemic circumstances. To address this, we invited one of the senior trainees who was also a UCI Health Emergency Department Mental Health Advocate to develop a presentation for the other trainees. By utilizing within-group knowledge, we were enhancing opportunities for trainees to identify sources of peer support, while also encouraging collaborative and mutual interactions. Having a fellow trainee address the issues facing the whole group, while specifically applying her own practical knowledge, facilitated trainee confidence in the applicability of material and identified a reference point for future contacts. This also encouraged trainees, through example, to begin identifying ways to integrate existing nursing expertise with newly acquired SANE practice skills. The session was well received; one trainee commented, "[This session] was very helpful as a new nurse to prevent burnout as early on as possible."
Community Engagement
The last element of our holistic training was preparation for community education and outreach. The term "community" was conceptualized broadly, encompassing everything from a unit nursing staff to local and statewide regions. We initially planned for trainees to provide interactive education to regional at-risk and underserved communities on SANE practice and access to services, as well as to seek input from these communities on the needs specific to their stakeholders in regard to sexual assault services, but were again stymied by the rapid spread of COVID-19. Instead, we worked with trainees to determine meaningful and achievable ways to apply their learning to educational initiatives. Some chose to provide information to their regular practice units, whereas others prepared presentations for virtual poster sessions or conferences. Applying the tenets of engaged learning practice, we encouraged collaborations and self-directed efforts-these have been shown to increase self-efficacy and improve problem-solving capacity for learners (Zhang & Cui, 2018). Within our holistic training approach, this engagement facilitated trainees' transition from learner to educator, an important step in developing expertise in practice (McBride, 2011).
Discussion
The work of SANEs is complex and challenging. It is critical that clinicians pursuing this specialty have sufficient skill, confidence, and support to develop as practitioners. Implementation of a comprehensive, holistic approach to SANE training can help ensure new SANEs are well equipped for their entry to practice. Although many skills in evidence collection and documentation can be easily practiced, it is less feasible for a SANE trainee to prepare for different patient interactions and their responses thereto. For example, a study comparing the incidence and severity of vicarious (secondary) trauma between SANEs and other women's health nurses found that the former scored higher on the Trauma and Attachment Belief Scale than other groups (Raunick et al., 2015). Although secondary or vicarious trauma may seem like an obvious and even expected exposure risk for SANEs, how the SANE reacts to, engages with, and processes the experience of that trauma are crucial to professional development and retention in practice.
Interactions with diverse patient populations can be stressful for new SANEs, particularly those whose clinical experiences are limited to a single area or those who are new to the nursing profession generally. This is congruent with a qualitative study of campus-based survivors, healthcare providers, and advocates that reported on the need for inclusive and nonjudgmental approaches to service access and provision (Munro-Kramer et al., 2017). The holistic training approach can contribute to decreasing novice SANE stress: first, by allowing SANE trainees to confront and interrogate their own potential biases or misinterpretations about specific populations and, second, by increasing self-efficacy in interacting with different types of patients before entering practice (Strunk, 2017). Particularly when caring for sexual assault survivor populations with significant fears about others' perceptions or confidentiality violations-such as male survivors, undocumented persons, and/or military personnel-the SANE's facility with these interactions can bring relief and encourage further help-seeking (Payne, 2018; Porta et al., 2018).
In addition to individual confidence and competence in clinical practice, the holistic approach to SANE training assists trainees to develop important peer support relationships. Such relationships have been shown to help prelicensure nursing students navigate unfamiliar situations and achieve personal goals (Andersen & Watkins, 2018). Although SANE trainees are necessarily already licensed, the entry into specialty practice may seem nearly as fraught as early career practice because of the added pressures of the need to support criminal prosecution and preventing patient retraumatization (Cole, 2018; Patterson et al., 2017). For SANE trainees, peer support provides opportunities to review aspects of practice, process secondary or vicarious traumas, and engage in mutual collaboration and learning. Having such relationships can create a sense of safety and self-efficacy for trainees, insofar as there is always a resource-even if just as a sounding board for reflection-among the group (Lombardo et al., 2017).
One final but critical consideration for the implementation of holistic training is the time commitment necessary. Many trainees have difficulty securing time away from their regular practices to attend even short-term didactic or skills training, and the process of completing a holistic training can take significantly longer. Incorporating activities that can be counted toward the practice requirements for certification such as peer case review and peer-to-peer teaching alleviates some of the time demand for those seeking certification.
Finally, as there are yet few documented SANE training programs employing the holistic type of training model, research into the effects of such approaches is lacking. Future efforts in this area could assess how participants in holistically designed training feel in terms of their own competency and efficacy in entry to SANE practice, as well as the long-term impact on compassion fatigue, burnout, and secondary traumatic stress among SANEs. Although some programs may provide ongoing training that eventually covers the same content as holistically designed training, there may be differences in self-efficacy and sense of competence related to how early the content is incorporated into individual practice. For smaller programs lacking the resources to provide such training, the initial didactic training may also be the main or even the only opportunity to receive such content. These and other considerations suggest important directions for future scholarship.
Implications for Clinical Forensic Nursing Practice
The typically high rates of turnover and difficulties retaining qualified practitioners associated with SANE practice in the United States reflect the challenges of this practice area. Training costs for new SANEs can be quite high, especially when factoring in didactic training and preceptorship; it is in the interest of the profession to ensure trainees are well prepared for entry into practice. Unfortunately, demand for trained SANEs means that many didactic programs are brief in duration and focus solely on the logistical and clinical functions of practice. A holistic approach to SANE training encourages trainees to address concerns and identify personal needs for improved skill or facility in certain areas before engaging in patient care and evidence collection. This may help reduce turnover long-term and improve patient satisfaction with SANE care overall. Especially for SANEs practicing in locales with large populations of vulnerable individuals, having a strong sense of self-efficacy in the SANE practice with diverse patient populations and effective self-care may reduce overall stress and alleviate moral distress. Programs providing training to prospective SANEs should consider a holistic approach to enhance the trainee experience and reduce high turnover costs.
Conclusion
SANE practice could be characterized as having extraordinarily opposed poles: Although it can be challenging and emotionally taxing, this specialty area of nursing practice can also be extremely satisfying and empowering for both the nurse and the patient. Moving from strict clinical and evidentiary practice training to a more holistic training approach can increase the chances for the latter over the former. Furthermore, holistic approaches to training can facilitate more effective and productive entry into practice for those with limited clinical experience. In fact, such an approach may facilitate early entry into SANE practice among newly licensed nurses, thereby increasing availability of SANE services and potential for growth of the practice.
References