Does My Program Need a Program Manager, Clinical Manager, and a Medical Director?
If you are starting a small program, it is possible for one person to fulfill the functions of both the program manager and clinical manager. This role would need to be held by a nurse because someone who is not a nurse cannot supervise nursing practice. If the nurse is licensed as a nurse practitioner or nurse-midwife, and has the legal ability to prescribe, the nurse may also fulfill the role of the medical director. If a program does not have a medical director, the legal responsibility of providing STD and pregnancy prophylaxis will need to be delegated to the medical providers of the emergency department where the SANEs are providing care. There will also need to be clear guidelines on when ED staff will become involved in patient care.
As stated in the SANE Sustainability Project, "Leadership is different than management… Leadership in nursing is about people—engaging with, inspiring, and building confidence in the team." As a SANE program is developed, acknowledging the importance of leadership, and providing opportunities and resources for developing leadership skills, will increase the success and sustainability of the program. As critical as leadership is, no program can function without effective management, and the people filling these roles need to work together to develop a cohesive team with a clear mission and vision for the future. Appropriate staffing for the critical management and leadership positions listed will give a new SANE program the best chance for success.
The SANE program manager/coordinator is not required to be a practicing SANE, or even a nurse, but if the program manager/coordinator is not a SANE, their role is limited to program administration. Program administration activities include budget development and implementation, scheduling of staff, and program logistics, which include patient populations served, hours in-house, or call time distribution. All of these functions need the input of the clinical nurses who provide the SANE care. Many SANE programs choose to combine the roles of program manager and clinical manager to address their needs.
When the program manager/coordinator is a nurse, compliance with nursing practice and supervision under the Nurse Practice Act can be handled by the role. When the program manager/coordinator is not a nurse, there must be allowances for supervision of the nursing staff in order to comply with the state Nurse Practice Act, so it is critical that systems are put in place for a nurse to evaluate and supervise staff competency.
The SANE program clinical manager/coordinator should be a practicing SANE, as this role is responsible for supervising both SANE policy and the practice of individual SANEs. This position usually reports to a program manager who may be an administrator of other areas in the institution, and who relies on the clinical manager's knowledge and expertise to ensure clinical competency within the program.
Because the licensure and scope of practice of physicians and nurses differ significantly, and because SANE programs are housed in a variety of settings, from hospitals to nonmedical facilities, the requirements for the medical director can vary dramatically. The role of the medical director, whether a licensed advanced practice nurse (APRN) or a physician, is to provide direction, feedback, and consultation to the SANE program. Regardless of licensure or structure, having an active and engaged medical director is a key component of SANE program success.
Choosing a Medical Director or Consultant
The medical director or consultant (this may also be an APRN with prescriptive authority) should be chosen by the program director and be someone who has a complementary vision and passion for the job. When selecting a medical director, it is important to choose someone whose work is familiar and who has a common vision/mission, shared values, and mutual respect. It is crucial to find a medical director who can act as a champion for the program. Hospital policy may dictate what specialty the medical director should come from, but there is no steadfast rule. In general, emergency physicians, pediatricians, public health officers, family medicine physicians, women’s health practitioners, and medical examiners are logical choices. A nurse practitioner with prescriptive authority can also serve as a medical director or consultant. The medical director should be a respected member of the medical community who has a good working relationship with nurses. There should be mutual respect among the members of the medical director's team and other medical staff.
Once there is agreement on a common vision for the medical director, other important issues to discuss include: controversies about SANE/forensic nursing practice, practice strengths and limitations, anticipated time commitments for the SANE coordinator and medical director, salary structure (if any), and medical director liability. There should be a job description for the medical director that outlines the requirements and expectations for the role. Open and frequent communication between the SANE program coordinator and the medical director is crucial to a positive working relationship and healthy conflict resolution interactions.
Role of the Medical Director
Depending on the program, some of the identified tasks may also be the responsibility of other key personnel.
Orders for diagnostic testing
HIV nPEP protocols
Participate in clinical issues working to assure that appropriate consultative services are available for SANE patients by collaborating with other physician specialties
Participate in quality assurance/quality improvement processes
Assist with clinical education
Participate in some administrative aspects of the program
Participate in strategic planning and benchmarking process
Available to staff when issues arise real time
Assist with clinical expansion and new program implementation
Oversee research protocols and adherence to state and federal regulations
Medical Director Role
Being a champion for the SANE program means supporting the role the SANE plays in provision of comprehensive care to sexual assault survivors of all ages. To that end, the medical director plays an important role clinically, administratively, educationally, fiscally, and strategically. Probably one of the most important aspects of the role is participation in the quality review/assurance process related to direct patient care. All team members need to be vigilant about not calling on the medical director to serve as a referee for team issues.
Many SANE programs begin and run successfully as a result of a “champion,” someone who is committed to making these services available for victims. This situation is ideal, until the champion steps down or other staff changes leave the program in jeopardy. For these reasons, succession planning within a SANE program can be critical to a program's sustainability. Succession planning should occur at two levels. First, there should be an emergency plan in place in the event key program members become unable to perform their jobs. Training staff to serve as backup for critical positions, including scheduling, payroll, and ordering supplies, will allow a program to continue functioning until the person can return to work or be replaced. Second, there should be succession planning for a change in program leadership. These plans should be discussed with staff and, when appropriate, members of the multidisciplinary team.
Staff do not stay with any organization indefinitely, and developing a succession plan that addresses what will happen when staff changes do occur can aid in that transition. Typically, this type of planning occurs for personnel who are crucial for operations or who, based on knowledge, skills, and expertise, will be difficult to replace. Program managers should consider whether internal staff could advance based on their qualities that prove successful in the current organizational structure.
Succession planning can also provide a great opportunity to allow nurses within the team to develop leadership skills. For example, one nurse can be in charge of peer review and continuing education while another nurse can be responsible for preparing nurses who are scheduled to testify in court. This kind of cross training supports individual professional development and team success.
Promoting Culturally Diverse Leadership, Staff, and Management
In order for programs to be welcoming to diverse populations, it is important to try to recruit staff and promote management that reflect the diversity of the community. This can be a challenge, but it is part of implementing the care concept of appreciation of unique meanings within the care experience of the patient.