Creating Programs in Unique Community Settings

All communities face challenges when trying to develop a SANE program. The next section looks at specific types of communities and explores strategies for providing care.

Tribal Communities

There are presently 567 federally recognized American Indian and Alaska Native (AI/AN) groups representing an estimated 1.5 to 2 million individuals living in the United States. Historically, violence within native communities was rare because it was believed to be unnatural and a threat to harmony (NSVRC 2000⁵⁵). Women were revered as sacred life-bearers who should be respected and honored; however, the systematic oppression of native peoples, beginning with colonization, led to a legacy of historical trauma that included genocide, marginalization, sexual violence, and devaluation of women. 

Individuals within AI/AN communities experience sexual assault and violent victimization at a higher rate than most populations. More than 1 in 3 AI/AN women, and nearly 1 in 5 AI/AN men, will be sexually assaulted in their lifetimes. This is more than 2.5 times higher than for the general United States population.⁵⁶ In some communities, the rate is up to 20 times the national average (Amnesty International 2006).⁵⁷  The rate of unreported sexual assaults, as well as polyvictimization, is also predicted to be higher in AI/AN communities. 

These alarming statistics clearly demonstrate the need for comprehensive and culturally sensitive medical and forensic services within AI/AN communities. Despite this fact, less than one-third of tribal land is within a 60-minute drive of a facility offering sexual assault services.⁵⁸ 

Challenges to Program Development

1. Health care facilities in tribal communities are often required to provide for all health care needs of the population. Hospital administration may be hesitant to budget time and resources toward creating a program for a small number of patients that a program might serve.
2. There is often a high vacancy rate of health care workers at tribal facilities as well as a high level of staff turnover. 
3. There may be a lack of community resources, such as advocacy programs and shelters, which would provide additional services for victims.
4. When community resources are available, jurisdiction can be confusing as there are often multiple jurisdictions that must be considered (e.g., multiple tribal jurisdictions, state, federal).

Challenges To Providing SANE Care

1. Within tribal communities, there is often a lack of trust in the health care system, as well as other entities such as law enforcement, due to a history of oppression and exploitation. 
2. Similar to rural communities, confidentiality is an issue because quite often everyone knows everyone else. Victims may be reluctant to report a sexual assault or seek care. They may be concerned about social stigma and that they will be blamed for the assault. They may also be concerned about the impact that reporting may have on their families and on the community. 
3. Achieving and maintaining clinical competency is difficult for nurses who may perform only one or two examinations a year. Due to the high turnover of nurses, recruitment of new SANEs will likely be a consistent concern.

Creating Solutions to the Challenges 

1. Tribal communities are eligible for funding to provide sexual assault services from many federal sources, including the Indian Health Service Domestic Violence Prevention Initiative, the Office on Violence Against Women, and the Office for Victims of Crime, including victim assistance formula funding directed to the states.
2. Advocate for dedicated time and resources toward SANE program development. A program will not be sustainable if dependent solely on volunteered time. Provide information to hospital administration regarding the health care costs of sexual violence. Provide assurance that, once a program is established and community awareness is increased, the number of patients seen will also increase.
3. Health care facilities should work in collaboration with community resources with the goal of forming a Sexual Assault Response Team (SART).
4. Health care facilities and the community response should incorporate traditional values to emphasize the strengths of native cultures.
5. Community education is essential to increasing awareness of available resources as well as increasing the trust of the health care system. The health care system must possess cultural awareness and offer services such as medical interpreters and traditional healing options.
6. To address confidentiality concerns, a health care facility should consider strategies that allow a patient to bypass the emergency department waiting area when arriving for a medical forensic exam. 
7. It is imperative to develop a comprehensive training plan and thorough competency assessment for SANEs. Nurses should attend a SANE course that includes a clinical component. 
8. Tribal SANE programs with a low annual volume should partner with higher volume SANE programs that can provide precepting and mentoring experiences for nurses.
9. Scheduled mock examinations and skills sessions can be used for practicing skills and maintaining competency. Nurses may also be able to assist in a women’s health clinic to maintain competency with speculum examinations.

Rural Communities

According to the U.S. Department of Agriculture in 2014, 46.2 million people, nearly 15 percent of U.S. residents, lived in nonmetropolitan communities. The U.S. rural population occupies 72 percent of the country's land mass.⁵⁹ Rural communities experience many challenges when it comes to providing any type of health care services. The challenges faced by rural communities include geographic isolation, lower percentages of health care providers compared to urban communities, and populations that have higher rates of poverty and lower rates of having health insurance.⁶⁰ According to the Bureau of Justice Statistics, from 2005–2010, the rate of sexual violence for females in rural areas (3.0 per 1,000) was higher than the rate of sexual violence for females in urban (2.2 per 1,000) and suburban (1.8 per 1,000) areas.⁶¹ 

Challenges to Program Development

1. Similar to tribal health care facilities, rural hospitals are required to provide for all of the health care needs of a community. In an urban setting, those may be shared by several hospitals and other types of health care facilities. It may be difficult to justify the costs involved in creating a program for the small number of patients the program might serve. 
2. Rural communities may have limited resources for funding a SANE program. 

Challenges To Providing SANE Care

1. Confidentiality is an issue in small, rural communities where everyone knows everyone else. Victims may be reluctant to report a sexual assault or seek care. 
2. Initial training and maintaining clinical competency is difficult for nurses who may perform only one or two examinations a year.
3. Seeking care in a rural community does not eliminate the need for programs to be prepared to deal with problems more common in an urban environment. For example, while HIV prevalence may be extremely low in many rural communities, patient may be sexually assaulted in a higher prevalence urban area, but then return home to seek care. 

Creating Solutions to the Challenges 

1. When considering the cost to start a SANE program, rural communities need to look at the economic impact of sexual violence on the community, and the substantial burden of direct medical, mental health, lost productivity,⁶² disruption to families, and decreased safety in the community. 
2. Rural communities are eligible for funding from the Office on Violence Against Women (OVW) to provide sexual assault services. In addition to the formula grants available to all communities, rural communities can also apply for a rural discretionary grant from OVW. The Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program enhances the safety of rural victims of sexual assault, domestic violence, dating violence, and stalking, and supports projects uniquely designed to address and prevent these crimes in rural areas. Eligible applicants are states, territories, Indian tribes, local governments, and nonprofit entities, including tribal nonprofit organizations.
3. OVC’s annual crime victim assistance grants to states under the Victims of Crime Act (VOCA) may allow the funds to be used for forensic interviews for children and individuals with disabilities, to support forensic medical examinations for victims of sexual assault, and to pay a portion of the salaries for protective service workers who provide direct services to child victims and for SANEs who provide direct services to victims. As with all VOCA funds, eligibility requirements are determined by the state.
4. Consider the ways a hospital can improve the options for confidential care of patients. This might mean bypassing the emergency department waiting room when a patient comes to the hospital for a medical forensic exam. 
5. Make sure nurses attend a SANE class with a clinical component. 
6. Create a collaborative examination model where the ED physician works with the nurse to provide care to the patient. 
7. Have mock examinations to practice and maintain skills. Some communities use model patients, similar to practicing mock codes, to maintain skills. 
8. You may need to work collaboratively with a SANE program in an urban community for peer review and mentoring staff and leadership.
9. Consider other possible community resources to use, such as the public health department for HIV prophylaxis and Planned Parenthood for clinical training and skills maintenance.

Military/Deployed Settings

The U.S. Department of Defense (DoD) recognized the need to provide services to all military sexual assault victims and has been actively seeking to do so since the Task Force Report for Care of Victims of Sexual Assault was convened in 2004. In response to the Task Force’s recommendations and a National Defense Authorization Act for Fiscal Year 2005 directive, DoD developed an overarching sexual assault prevention and response policy and a permanent Sexual Assault Prevention and Response Office (SAPRO) in 2005. SAPRO serves as DoD's single point of authority for sexual assault policy and provides oversight to ensure that each of the Services' programs comply with DoD’s Sexual Assault Prevention and Response Program Procedures (DoD Instruction 6495.02). Under this program, every sexual assault victim will have access to a military victim advocate, legal support, medical and mental health services, and a sexual assault forensic examination (SAFE). 

Challenges to Program Development 

In civilian communities, staff turnover often makes it difficult to maintain a core of trained SANEs. In the military setting, this is an even more critical issue with the constant relocation of personnel to a new installation. This regular turnover in personnel also makes it more difficult to establish a working collaborative SART, which is important to coordinated patient care. On many stateside military installations, this was initially resolved by developing Memorandums of Understanding (MOU) with community facilities for advocacy and medical care. The more recent move, however, is to ensure trained Sexual Assault Medical Forensic Examiners (SAMFE) are available at military treatment facilities. If a military treatment facility does not have the capability to offer the SAFE onsite, the military continues to use partnerships through established MOUs in the community to provide the SAFE, while ensuring that patients receive the appropriate case management for any follow-on medical and behavioral health treatment. For additional information about the Sexual Assault Prevention and Response Program Procedures, visit the SAPRO website for details.

While military commanders initially insisted they be notified automatically when a member assigned to their command is sexually assaulted, since March 2005, the military has provided the option for members to make a Restricted report, where commanders and law enforcement are not notified of the identity of the victim. The only official notification, for documentation and data collection purposes, is that within 24 hours of a report of sexual assault, the sexual assault response coordinator must notify the senior commander of the assault without providing the person’s name or personally identifiable information. When a member of the military selects the restricted reporting option, they can choose to have a forensic medical exam, talk with the military victim advocate or a civilian victim advocate if available in their area, but not have the assault reported to the military police. Much like in the civilian community, they can change their mind and go Unrestricted at a later time, involving military police at that point. For additional information, visit the visit the SAPRO website for details.

Challenges To Providing SANE Care 

1. Frequent reassignment of medical personnel.
2. Inability to maintain competency once trained because of small caseload in remote locations.
3. Providing for patient confidentiality and followup care in remote settings.

Creating Solutions to Challenges

Per Directive-type Memorandum 14-003, DoD, working with the military services, established the Special Victim Capability Prosecution and Legal Support Program, a legal support function for victims of sexual assault, that provides legal advice and guidance and maintains a victim's confidentiality. A victim can access this support whether they file a Restricted or Unrestricted report.

Under this program, the Army, Air Force, National Guard, and Coast Guard refer to these professionals as Special Victims' Counsel (SVC), while the Navy and Marine Corps refer to them as Victims' Legal Counsel (VLC). SVC/VLCs receive specialized training to address the legal concerns of sexual assault victims. They understand the legal process and are able to advise victims of their rights and address other legal issues that arise, as not all cases result in a trial. For additional information about the SVC and VLC programs, visit the SAPRO website for details.

To address the challenge of maintaining competency, the Services developed a tri-service program for training SAMFEs. This training includes all of the requirements mandated by Congress, is mapped accordingly to the Department of Justice National Protocol for Sexual Assault Medical Forensic Examinations 2nd Ed, and provides a period of time for the individual SAMFE to develop competency in performing the SAFE, taking into consideration locations that are remote, low volume, or in a deployed position. 

In addition, the United States Department of the Navy engaged in a partnership with the National Sexual Assault TeleNursing Center (NTC), which provides the opportunity to enhance the quality of care delivered to victims of sexual assault in remote military locations. The NTC was developed by the Massachusetts Department of Public Health SANE Program, through a cooperative grant from OVC and the National Institute of Justice (NIJ), to provide a community of support for sexual assault clinicians to increase their confidence, competence, and retention, and to develop quality care for sexual assault patients. 

This partnership with the NTC affords the Navy the opportunity to enhance the quality of care delivered to victims of sexual assault in remote military locations. Naval Hospital Twentynine Palms (NHTP) became the first remote site to receive 24/7 real-time support and guidance from the NTC on November 1, 2014. As pioneers of this project, the NHTP SAMFE team and the NTC have developed protocols and best practice guidelines to deliver quality forensic examinations. This innovative application of telemedicine involves more than turning on a camera and consulting with an expert. The integration of technology during forensic evidence collection is thoughtful, with consideration of each patient’s unique needs, privacy, and security. The successful partnership with NHTP led to the addition of a second naval hospital. On February 1, 2016, Naval Hospital Camp Pendleton became the second naval hospital, and the third hospital in the Nation, to receive 24/7 support from the NTC. The University of Illinois at Urbana-Champaign is conducting a process evaluation to document and assess the NTC’s activities. For additional information on the NTC project, please visit the National TeleNursing Center.

Telemedicine Programs

Telemedicine is the practice of using technology to provide care or consultation to a remote site. Health care providers use telemedicine to provide health care to communities with limited access to resources or without access to specialty services available in larger medical facilities. Telemedicine can be used either for providing direct care or for providing expert consultation to local health care providers. Telemedicine is used most often for radiology, cardiac monitoring, neurology, dermatology, psychiatry and, for the past several years, to provide expert evaluation of child abuse findings.⁶³ Telemedicine can also include case review, photo review, and testimony preparations.

Telemedicine has been proposed for multiple types of SANE settings. Isolated rural and tribal communities may benefit from the ability to access expertise from SANEs who, by virtue of dealing with a higher volume of patients, can maintain and share their clinical expertise. Military installations and deployed personnel may be able to use telemedicine to provide or enhance care. For patients who are incarcerated, using telemedicine allows the patient to remain in their secure facility while receiving expert care. 

In 2012, OVC, in collaboration with NIJ and the Office on Violence Against Women (OVW), provided a grant to the Massachusetts Department of Public Health SANE Program to create the National TeleNursing Center. This Center, located at Newton Wellesley Hospital in Newton, Massachusetts, is just beginning to deliver care to several pilot sites throughout the United States. More information can be found here. 

Challenges to Program Development 

1. Isolated communities may not have sufficient infrastructure to provide digital access 24/7. 
2. In addition to the privacy concerns faced with traditional SANE exams, factors related to the security of transmission of video streaming during exams, consultations, and electronic data sharing needs to be addressed collaboratively by the telemedicine hub and remote sites. 
3. Equipment used for telemedicine needs to be incorporated into the exam to be as nondisruptive to the exam and the patient experience as possible. 
4. All costs for care need to be considered, including equipment and software, expert consultation and travel, and other expenses if consultants are subpoenaed for testimony. 

Challenges To Providing SANE Care 

1. Nurses must be licensed in the state where the telemedicine hub is located and the state(s) where they are providing consultation. Nurses providing telemedicine consultation may also be required to provide additional documentation or credentialing information at each hospital where services are provided.
2. Nurses need to be familiar with the operation of the telemedicine equipment used in their facility. (Staff turnover could be a challenge or a benefit to the use of telemedicine technology for sexual assault patients. This use of technology may help providers in settings with high turnover maintain a state of readiness.)
3. Some patients may not find telemedicine equipment acceptable. 
4. Nurses must be available at both locations when care is provided.
5. Formal agreements may be required between client organizations. 
6. Since the use of technology for real time adult medical forensic examinations is relatively new, there may be issues raised about the role of the nurse in providing testimony. Until cases are completed and charges filed, these issues may not be completely resolved.

Creating Solutions to the Challenges 

1. SANEs can start by using existing telemedicine resources to enhance their programs. For example, many community education institutions have remote video access that allows SANE programs to receive education at a distance.
2. Hospital SANE programs must work closely with HIPAA compliance/privacy officers to ensure any transfer of information is secure. 
3. There are varied levels of complexity in available telemedicine equipment, considerations need to be made to purchase equipment that is user friendly and does not require a high level of technical expertise. Nurses participating in these efforts should be involved in helping to select appropriate equipment.
4. As is the case with all patients, informed consent should be obtained prior to the use of telemedicine, and patients must get the opportunity to decline its use.
5. SANE programs should work closely with local prosecutors to determine if telemedicine consultants need to provide direct testimony in trials and hearings. 
6. SANE programs should routinely collaborate with a rape crisis counselor who can provide the victim additional support, information, and case management.