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Sexual Assault Nurse Examiners

Finding, training, and retaining the nurses who will provide patient care to survivors of sexual assault is a critical component of SANE program development. Because the role of the SANE in many communities is a secondary nursing position, and due to the nature of working with trauma victims, SANE recruitment and retention tend to be ongoing issues within programs.

a. Hiring Nurses for a SANE Program

Since the SANE must be able to function both within the health care system and the criminal justice system, criteria for selection may be more rigorous than for other nursing positions. As a SANE, a substance abuse history might be used to challenge a nurse's integrity when it comes time for him or her to testify in a sexual assault trial. The SANE program staff should have a clear idea of the role and function of the SANE before starting the hiring process. It is important to consider several issues that may impact who should be hired as a SANE. (See Text Box E)

b. SANE Compensation

How SANEs are paid for both their on-call time and their time spent seeing patients will depend on the type of setting and the budget of the organization. Types of compensation may include:

  1. On-call pay plus case pay – Nurses receive an hourly wage (typically in line with other on-call staff at the facility) for hours of call they are available to respond when there is a patient. If called in to see a patient, they may receive time and a half for providing patient care. 
  2. Case pay – Nurses receive a flat rate for completing an examination.
  3. Shift pay – Nurses receive an hourly wage, with shift and/or weekend differential, like other departments.
  4. Court pay – Nurses receive an hourly wage from their employer for court preparation time and testimony time. 

In addition to paying nurses for their time, some programs provide compensation for—

  1. Cell phones
  2. Certification examination costs 
  3. Continuing education
  4. Health benefits
  5. Contribution to retirement plans, etc.
  6. Mileage

Compensation may be dependent on the status of the program. For instance, some programs have in-house examiners whose only responsibility is providing forensic evaluations and care. They work regularly scheduled shifts instead of on-call and are paid as part- and full-time employees. 

Some facilities avoid paying call time by circumventing a set call schedule and providing ED staff with a list of SANEs to call who come in only if they are available. The downside of this is there may be inconsistent coverage, which reflects poorly on the SANE program and the community partners. Other programs may have a system where they call in a backup nurse when a sexual assault patient comes to the emergency department if the SANE is working a regularly scheduled shift. If a hospital uses this system, it must ensure that the SANE is not placed in the position of trying to give care to emergency department patients and the sexual assault patient at the same time. 

If facilities choose not to utilize a SANE call schedule, there must be a plan in place for other available staff to address the needs of the sexual assault patient quickly and competently. It would be inappropriate for ED staff to keep a patient waiting for hours or send them away without proper care because the hospital could not reach a SANE. 

c. SANE Education

Functioning in the role of a SANE means functioning in a recognized nursing specialty, much like being an ICU, ED, or neonatal intensive care nurse. As such, it requires additional education to meet the minimum required expectations for practice. This minimal level of knowledge is outlined in the IAFN SANE Education Guidelines. The guidelines highlight both the required didactic as well as clinical expectations. SANE programs need to ensure that the nurses they hire meet these guidelines in order to practice in the role. Many programs hire trained SANEs to fill their staffing needs. In this instance, management must confirm the SANE training meets the expected standard. Programs may also choose to hire nurses who are not yet trained as SANEs. In this case, supporting the potential SANEs while they attend and fulfill the requirements of a course that meets the guidelines is equally important.

Many nurses will have attended the didactic portion of SANE training, but will require additional training as it relates to meeting the clinical requirements. Because most SANEs are registered nurses versus advanced practice nurses, one of the first clinical training expectations will be achieving competency in conducting speculum or pelvic exams. It is important for the manager to understand that competency is achieved at the local level. Even hiring a veteran SANE with 15 years of clinical experience requires the program to evaluate/validate that clinician’s skills in order to confirm that their education is up to date and they may function independently in the role. Managers should be familiar with the specific components of the Education Guidelines.

In addition to the base education required to become a SANE, nurses and programs should be prepared to address the ongoing continuing education needs of the SANE as it relates to sexual assault care. Remaining current in the science behind the practice is an essential aspect of ongoing competency.

d. Preparing the SANE for Clinical Practice

  1. Licensure: The SANE program, whether community- or hospital-based, should have a method in place to verify that newly hired staff, and those who work in the program, have unrestricted licensure to practice as a registered nurse (or the other provider levels such as P.A., M.D., or APRN). This should be completed on the date of the initial hire and be monitored annually as a component of the SANE performance appraisal process.
  2. Preceptorship: The preceptorship afforded the newly trained or newly hired experienced SANE is a critical aspect of assessing the competency of the practitioner. Because SANE programs vary dramatically from one area to another, this can be achieved in a variety of ways. Some programs utilize clinical simulation laboratories to teach and allow SANEs to practice or demonstrate specific skills as they relate to speculum exams, history-taking, genital exams, and other methods of assessment if used in the program, such as urinary catheter insertion for hymen visualization, use of colposcopes for magnification, photography techniques, and evidence collection. Others require a precise number of precepted sexual assault exams prior to independent practice. The key to success is outlining an orientation and preceptorship program that will work in your program while allowing for individualized competency to be determined by someone experienced in the activity being evaluated.
  3. Privileging: This is the process used by hospitals to make sure health care providers meet acceptable standards for licensure, education, and clinical competency. If a nurse is employed by a hospital, this process is included as part of the typical employment process. If the SANE program is independent of the hospital, but provides SANE services to the hospital, the SANE may be required to go through typical employment processes, or the SANE program may contract with the hospital to make sure all employment requirements are met. The SANE program becomes responsible for making sure each nurse is licensed, carries malpractice insurance, has required immunizations, complies with HIPAA, has the proper level of education, and maintains their clinical competency. If an APRN, physician’s assistant, or physician is part of the independent team that will provide patient care at the hospital, they must go through the medical staff credentialing process. When a SANE team contracts to provide care for a hospital, they usually have the hospital agree to waive any fees related to the medical staff application.
  4. Medical Malpractice Insurance: Every nurse should be covered under a malpractice policy when providing care as a SANE. Nurses can be covered under the following types of policies:
    1. Personal policy – This is a policy that is purchased by the nurse to cover any liability that occurs as a result of nursing practice. This policy covers the nurse no matter when or where he or she is practicing. 
    2. Group policy – Some SANE programs purchase a group policy that is prorated based on how many nurses are on the team and how many take calls at the same time. This policy only covers the nurse while working for the SANE program. 
    3. Hospital policy – Most hospitals either carry or provide malpractice insurance for their nurses. They typically cover the nurses who work for the hospital, and they may extend coverage if a nurse is doing community service work without pay.
    It is important to realize that a nurse must always have insurance that covers the highest level of their licensure. For example, if a SANE program hires a nurse practitioner who is performing the same job as a registered nurse, the nurse practitioner must have insurance covering his or her licensure as an APRN. Unfortunately, this might make it cost prohibitive to provide insurance for nurses who have the highest rates of malpractice insurance, such as certified nurse midwives, unless the nurses provide their own policies.

State SANE Certification

There are presently eight states that require SANEs to meet a state standard of certification in order to practice in this capacity. These states are: 

  1. SANE Certification: There are three types of certifications that are available to SANEs. They are— 
    1. Board certification through IAFN as a SANE-A®
    2. Board certification through IAFN as a SANE-P®
    3. State-specific certifications or credentialing
    IAFN SANE-A® certification is focused on the adolescent and adult population of sexual assault patients, and SANE-P® is focused on the pediatric and adolescent populations. The Forensic Nursing Certification Commission outlines the eligibility requirements needed to sit for the exam. These requirements are reflective of other national nursing certifications in their rigor and expectations of a specialty practice. No state currently requires IAFN certification in order to practice as a SANE. The certification examinations were designed to be taken and passed by experienced SANE nurses. They are not designed to be a test of entry-level knowledge, but instead as a professional recognition of nurses who have achieved high levels of specialized knowledge in the area of sexual assault care. While many programs encourage their nurses to become certified, it is important to understand that certification is not necessary for a nurse to give competent care or to be able to provide expert testimony in a sexual assault case.
  2. Performance Appraisal/Individual Staff Evaluation: It is very important to have an organized and ongoing evaluation process in order to have an efficient and successful program. “Performance appraisal is a process and a means of setting goals, measuring and enhancing individual and organizational performance. It also fosters professional and career development on behalf of ordinary staff members.”67

    The evaluation process should have clearly defined expectations of performance as well as timelines. The goals of the evaluation process are to provide a culture of continued development and professionalism, and should coincide with your program's goals. Each goal should meet the following criteria: S-specific, M-measurable, A-attainable, R-realistic, and T-time bound (think SMART). 

e. The approach of the program coordinator needs to be positive and constructive. 

  1. Performance appraisal should address professional expectations, including dress, attendance, punctuality, dependability, interpersonal relationships, and the practice appraisal. Examples of performance measures include determining if protocols were followed and amended to meet a specific patient’s needs, and if evidence collection was appropriate for the history obtained. Depending on the number of cases your program has, each nurse should have a minimum number of exams per year to maintain their skills. If there are few cases, simulated skills testing should be available. Set a timeline for meeting any certification requirements.
  2. Practice appraisal should include a well-defined position description, including performance expectations and standards. When developing a practice appraisal form, take the following into consideration: psychomotor skills, interpersonal skills needed to interact with the victims, law enforcement, families, and other medical providers; and critical thinking skills needed to provide forensically sound and safe care. The coordinator/manager should meet with each nurse regularly to discuss performance and the goals of the practice appraisal. Increase the frequency if issues arise throughout the year. Update goals if needed. There should be no unexpected conversations during the annual appraisal. If you need to remove a nurse from the program, the nurse should not be surprised.
  3. Peer Review: SANE peer review is a process by which the chart/report, including photos, is evaluated by a group of other nurses with experience in the SANE field. Every SANE chart should go through some type of Quality Assurance/Quality Improvement /peer review process that results in feedback to the examiner. In the beginning, the medical director or the coordinator may need to provide the peer review; however, every SANE nurse in the program should participate in the peer review process. This will increase competency, knowledge, continuity in care, and improve collaboration among team members.
  4. Maintaining a Healthy Nursing Staff: As stated in the introduction in Chapter 1, one of the important components of Duffy's The Quality Care Model© is the recognition of the importance of self-care for nurses. When creating or enhancing a SANE program, it is important to ensure there are resources available to the nurses who are dealing with the trauma of their patients. There are several strategies to ensure that the nurse's emotional health is maintained while working as a SANE.

    Some recommendations for addressing these issues in programs include:
    1. Provide formalized debriefing after difficult cases. 
    2. Partner with employee assistance programs (EAP) to provide support during staff meetings or to provide formalized EAP counseling for staff. 
    3. Partner with a community therapist to provide counseling to nurses.