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Building a Theoretical Framework for SANE Practice

For a SANE program to survive and be sustainable, it must begin with a strong foundation. When starting this process, many groups begin with a business plan or budget. This section proposes that programs start the SANE development process with acknowledgment of the importance of incorporating a theory of nursing practice into every aspect of the program. Providing care as a SANE is one of the most challenging areas of nursing practice. It requires a nurse to be an expert in psychosocial skills, physical assessment, critical thinking, collaboration, and coordination. The Quality-Caring Model© developed by Joanne Duffy34  provides a nursing theoretical framework that supports all aspects of the SANE role. This nursing theory recognizes what research about SANE practice already finds, that having a caring relationship with the sexual assault patient achieves the best outcomes for both the patient and the community.35  In her Quality-Caring Model, Duffy describes four caring relationships and eight factors of caring.36  The four caring relationships are (1) caring for the patient and family; (2) caring for self; (3) caring for others, which views collaboration as a form of caring; and (4) caring for the community. Examples of the four caring relationships within a SANE program are given below. The eight factors of caring provide specific categories of caring behaviors. Table B provides examples of what that caring looks like when provided by a SANE.

Four Caring Relationships:

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Table A. Four Caring Relationships

Caring for Patient and Family

One survivor described the importance of the care given by the SANE, “It just seemed like their arms were open, were wide open, and if you needed a hug, they’d give you a hug. If you needed somebody to hold your hand, they’d hold your hand. If you had any questions, they’d answer your questions, and they would be honest and try not to hide behind euphemisms or just patronize you or pat you on the back and say, ‘You’re fine now. Go away.’”37

– Giannina Fehler-Cabral

Caring for Self

“Compassion fatigue has been described among cancer care providers, emergency room personnel, chaplains, and first responders, among others. This fatigue may impact nurses in any specialty when, in the process of providing empathic support, they personally experience the pain of their patients and families.

It is important for nurses to become knowledgeable about compassion fatigue symptoms and intervention strategies and to develop a personal plan of care so as to achieve a healthy work-life balance.”38

– Compassion Fatigue: A Nurse’s Primer

Caring for Others (including collaboration as caring)

“The best approach to sexual assault investigation, prosecution, and recovery of the victim is the collaboration within multidisciplinary teams. This really addresses the victim throughout the whole process.”39

– Police Officer

Caring for Community

“[If we want a world without violence,] we must tip the balance in communities and replace current norms with norms that promote respect, safety, equality, and healthy relationships and sexuality. This beckons for a primary prevention approach and a community-wide solution.”40

– Spectrum of Prevention

Table B. Eight Factors of Caring41

Concepts Examples in SANE Practice
Mutual problem solving describes nursing behaviors that help patients and caregivers understand how to confront, learn, and think about their health and illness. This gives patients the information they need in order to be better partners in decisionmaking regarding their care and treatment.
  1. Providing options about evidence collection. 
  2. Discussing how to inform family and friends about the assault. 
  3. Performing a dangerousness assessment as part of safety and discharge planning. 
  4. Counseling about options for emergency contraception.
Attentive reassurance refers to availability and a hopeful outlook. Patients learn that they can rely on the nurse, and they feel a sense of security. This requires a conscious effort on the part of the nurse to concentrate fully on the patient at that moment.
  1. A nurse stopping the exam after realizing that the patient cannot stop shaking.
  2. Ensuring limited interruptions during the exam so the patient understands that they are the priority.
Human respect refers to honoring the worth of humans through unconditional acceptance, kind and careful handling of the human body, and recognition of rights and responsibilities.
  1. Providing the same respectful care and response to the homeless teenager, the commercial sex worker, and the undocumented immigrant.
  2. Asking a patient’s permission before examining any part of the body or collecting any forensic samples. Note: Some Native American patients may indicate that a nurse is not allowed to collect any forensic samples from them. This results from the tribe’s cultural practices.
Encouraging manner refers to displaying caring through the demeanor or attitude of the nurse. Messages of support, positive thoughts and feelings, and openness to the feelings of others are what make patients feel cared for with regard to this factor.
  1. Supporting patients appropriately when they self-blame after an assault.
  2. Reassuring patients about the extent and implications of their injuries.
  3. Providing comforting measures throughout the exam process.
Appreciation of unique meanings refers to knowing what is important to patients, including distinctive sociocultural connections associated with their experiences. Nurses use those features that are important to them in the provision of care.
  1. Having an examination room blessed by a native healer.
  2. Approaching tribal elders before starting a SANE program in a tribal community.
  3. Providing more than male/female options for gender identity.
  4. Allowing adolescents to text on their cell phone during an examination.
Healing environment refers to the setting where care is taking place. This environment is focused on holistic care and strives to maintain patient privacy, safety, and control.
  1. Providing care in a room that has door and walls instead of a curtained cubicle.
  2. Creating a point of entry for care that avoids having patients wait in a public waiting room.
  3. Allowing the patient to have a support person with them at all times.
Basic human needs refer to those needs identified by Abraham Maslow: physical needs, safety and security, social and relational needs, self-esteem, and self-actualization.
  1. Getting an oral swab first so a patient can eat or drink before starting an examination.
  2. Ensuring the sexual violence victim that his or her children are safe before focusing on the examination.
Affiliation needs refer to the need for belonging and membership in families or other social contexts. This factor focuses on the importance of families and other caregivers with regard to the health and well-being of patients in the hospital.
  1. Providing education to family members, friends, accompanying clergy, healers, and others about the normal response to sexual assault and trauma, and ways to be supportive.
  2. Allowing family members to be present during an examination if requested by the patient.

In addition to Duffy’s eight factors of caring, this Guide covers five key principles of SANE care that should be emphasized as a program is developed. The key principles are patient-centered care, trauma-informed care, evidence-based practice, recognition of community uniqueness, and a multidisciplinary approach. Without recognition and application of these key principles, it is impossible to provide comprehensive care to the sexual assault patient. In Table C, the Guide defines the principles and gives examples to help the SANE incorporate the principles into practice.

Table C. Five Key Principles of SANE Care

Key Principles Examples

Patient-Centered Care

The Institute of Medicine defines patient-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”42 

Respecting patient preferences regardless of outcomes is described as the right thing to do.43 This requires more than providing the sexual assault patient with information and options about what will happen during the examination; it requires taking a step back before starting the exam and finding out what the patient needs to have happen first. 

  1. Helping the patient arrange for someone to pick up their child from school before starting the examination. 
  2. Finding a place where the patient can smoke a cigarette before starting the examination. 
  3. Allowing the teen to use their cell phone during the exam.
  4. Allowing a urine pregnancy test to a patient who declines a blood draw.
  5. Conducting a smudging ceremony prior to an exam.

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Trauma-Informed Care

Trauma-informed care is defined as care that "involves seeking to understand the connection between presenting symptoms and behaviors and the individual’s past trauma history. As a practice and set of interventions, trauma-informed care involves the professional relationships and interventions that take into account the individual’s trauma history as part of efforts to promote healing and growth.”   
–  Gordon Hodas, M.D.44 

It is important for the nurse to understand that trauma history can include the present traumatic event, previous traumatic experiences, and, for some populations, it will also include historical trauma.

  1. Recognizing while taking a history of the assault that the patient may have disassociated during the traumatic event. Discussing with the patient strategies to prevent disassociation during the examination and reassuring them that the exam will stop if that happens. 
  2. Understanding that some individuals distrust the health care system and health care providers as a result of previous trauma or even historical trauma.

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Evidence-Based Practice 

The Agency for Healthcare Research and Quality defines Evidence-Based Practice as "applying the best available research results (evidence) when making decisions about health care. Health care professionals who perform evidence-based practice use research evidence along with clinical expertise and patient preferences." 45 
–  AHRQ, 2015

  1. Understanding and being able to explain why genital injury can be present or absent after sexual assault.
  2. Understanding that while valuable evidence may be lost if anal swabs are not collected, the patient has the right to not have it collected.

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Recognition of Community Uniqueness

When creating a SANE program it is important to recognize that communities have unique assets and problems that impact program development. The first SANE programs in the United States evolved in mostly urban hospital settings. One of the early frustrations for SANE program development was recognizing that the original models of care did not work well in rural or tribal communities. Since the first guide was published, nurses and other professionals have come to recognize that there is no "one size fits all" SANE program model. By incorporating various options and models of SANE care, each community should be able to develop a program that meets the needs of the people they serve. 

  1. Adapting existing program models to meet the needs of a community. 
  2. Allowing SANE programs to determine when a nurse is competent to provide an examination independently instead of having a required number of preceptored examinations.
  3. Recognizing that some communities cannot provide 24/7 SANE coverage and creating protocols that provide the best access to care. 
  4. Recognizing that some communities may need to use community health workers to perform evidence collection immediately after the assault. 

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Multidisciplinary Approach

Getting the best results for both the patient and the community requires a team approach. Every team member has an important role to play and a contribution to make. The multidisciplinary team approach is essential if sexual assault survivors are going to experience healing and perpetrators of violence are going to be held accountable. Because the SANE's primary duty is to provide health care to the patient, SANEs must be willing to work closely and collaboratively with advocates, law enforcement, prosecutors, forensic scientists, and other professionals in the community. Other professionals may include child and adult protective services, school counselors, and mental health care providers. 

  1. Creating protocols for team member response when one agency receives a report of a sexual assault.
  2. Valuing the contributions of each team member improves the care and outcomes of the patient by providing all team members with an opportunity to introduce themselves to the patient and offer services if the patient consents.

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The Impact of Trauma on Health - The ACE Study

In the 1990s, Dr. Vincent Felitti supervised a weight loss program for Kaiser Permanente in San Diego, California. He realized that many women who were able to lose a substantial amount of weight often regained the weight after a short period of time. After interviewing the women, he identified that they had a common history of childhood sexual abuse. With this information, Dr. Felitti and Dr. Robert Anda developed the Adverse Childhood Experiences (ACE) Study.46  The study examined the impact of childhood trauma on health behaviors and on long-term chronic illness. The study looked at more than 17,000 patients and found that exposure to childhood trauma was linked to an increased risk of unhealthy behaviors, such as smoking and substance abuse, which resulted in higher rates of chronic diseases, such as heart disease, depression, and chronic obstructive pulmonary disease. Since initial publication of the ACE study, many researchers have looked at the impact of trauma on various aspects of physical and mental health.

SANEs need to recognize that many of their patients will have a history of previous trauma. The ACE study helps explain why many patients with a history of trauma demonstrate unhealthy behaviors that place them at risk for sexual assault, such as excessive alcohol use and substance abuse. The risk of being sexually assaulted as an adult is 2.5 times greater for women who have a history of childhood sexual abuse.47 It is important to see these behaviors as symptoms of a problem that may not be solved until the underlying trauma is acknowledged. As Dr. Felitti states, “We need to change the question from what is wrong with you? to What has happened to you?” Being familiar with the ACE study and other research about the short- and long-term health impacts of trauma is an important first step. 

ACE Resources:
Adverse Childhood Experiences: Informing Best Practices
ACEs Too High News 


As you start the process of creating or enhancing a SANE program, it is important to understand the evolution of this essential nursing role, but it is most important to recognize that the success of SANE programs comes from having a strong nursing practice foundation. This is not a job for nurses who are tired of being a nurse and want something different; the work of a SANE requires the nurse to use all of his or her nursing skills to provide compassionate and evidence-based care to this extremely vulnerable population of patients.