24/7: The SANE Approach to Treating Rape Survivors
By Shari Mycek
Surviving rape takes more than good medical care. It takes the coordinated work and compassion of a circle of professionals. Although the SANE (Sexual Assault Nurse Examiners) program has its roots in hospital care, it depends on the cooperation of local police, district attorneys, rape-crisis counselors and courts of law to provide comprehensive care to rape victims and collect the forensic evidence necessary to convict the perpetrators. A decade after Trustee published an article about the SANE program at Hillcrest Medical Center in Tulsa, Okla., the innovative program is still going strong.
“With SANE, not only rape but now domestic violence survivors are evaluated in a much more comfortable and appropriate environment,” says Fred Garfinkel, M.D., chair of Hillcrest’s advisory board, which is responsible for approving and monitoring the hospital’s community benefit efforts. “Traditionally, these patients would require evaluation in a busy emergency room—that’s not the best environment and generates unnecessary ER time and cost. SANE patients are evaluated by people who are committed to the program and thus are treated with the dignity and respect they need and deserve.”
When Hillcrest first implemented SANE in the early 1990s, only seven such programs existed in the nation. By 2004, the International Association of Forensic Nurses counted 276 programs, 75 percent of which were hospital-based. Nearly all serve adolescents and adults, and approximately half serve pediatric patients as well.
Another early adopter of SANE was St. Vincent Hospital in Green Bay, Wis.
“Never underestimate the potential of a research paper,” advises Paula Hafeman, R.N., M.S.N., chief nursing officer at St. Vincent’s. Hafeman was the director of St. Vincent’s emergency department in 1992 when one of her nurses shared a research project she had done for her school on SANE. Her findings were compelling.
“At the time, rape survivors were essentially being re-assaulted when they came to the hospital for care,” says Hafeman. Seen as secondary to the “real” trauma cases, rape survivors were typically made to wait long hours in busy hospital emergency rooms, told not to eat or use the bathroom for fear of destroying evidence, and asked to give their “account” of the incident repeatedly—first to police, then to examining health professionals. According to Hafeman, physicians, especially, tried to stave off treating rape survivors because they eventually might have had to testify in court. And the nurses and caregivers who finally did attend to them were often not trained in forensics and evidence collection.
“While we [staff in the emergency department at St. Vincent’s] weren’t as bad here as other places, we were far from perfect,” Hafeman says. With the research paper as ammunition, she presented its findings to the hospital’s CEO Joe Neidenbach and the board of trustees and requested that the hospital adopt the SANE program.
“It wasn’t a hard sell,” Hafeman says. “Our physicians supported the idea to the point [where] they offered to donate their own money to launch the program. The district attorney actually did write a personal check for $1,000. There was such a need in the community; no one second-guessed it.”
“We were taking care of anyone who showed up in the ER, which included victims of sexual assault. Our mission was—and still is—to take care of the most sick and complicated cases. Well, rape is complicated,” Neidenbach says. “At that time, we had police trying to gather data; nurses and physicians trying to conduct medical exams.
“By bringing the medical and legal together, we could ultimately provide more compassionate care. We were seeing these patients anyway, but SANE enabled us to do so in a more coordinated way. The program wasn’t far-out. It wasn’t extreme. It was totally in line with our core mission.”
St. Vincent’s SANE program started with two nurses specially trained in forensics, an exact science of evidence collection that is used in courts of law. While Hafeman admits the program was a huge undertaking, it went a long way toward improving rape survivors’ care and collecting evidence to prosecute perpetrators.
Physical evidence is key in sexual assault cases—as is its timely collection, according to Mike Nick, a lieutenant with the Green Bay Police Department and one of the original officers who helped train St. Vincent’s SANE nurses. He stresses that exams should be conducted as soon as possible—and no later than 72 hours—following the assault.
A special suite, away from the busy emergency room, was set aside for physical exams. Since the program’s beginnings, high-tech equipment, such as a colposcope—a high-powered instrument that can magnify external and internal genital tissue up to 15 times, revealing microscopic cuts and abrasions—and an omnilight—a type of “black light” that makes secretions more visible and enables professionals to see bruises under the skin before they develop—have been added.
Two other Green Bay hospitals—Bellin Hospital and St. Mary’s, St. Vincent’s sister hospital—now support the program with $25,000 yearly donations. St. Vincent’s makes up the rest, which covers nurse training and pay (on-call and on-duty), and salary for its full-time coordinator, Sue Robertson. Robertson started two years ago, handling all the program’s details, from overseeing schedules to managing her nurses’ emotional health.
Keeping Nurses SANE
“SANE has been here since 1992, but in 2004 we stepped up the effort in terms of staffing,” Robertson explains. “We recognized that we needed more nurses. If a rape survivor came in and one of our two nurses wasn’t on duty—or was with a car accident or heart attack patient—there was a gap.”
Today, the St. Vincent’s SANE program employs 18 nurses (most are from the hospital), all of whom serve 40 on-call hours per month. The program is completely coordinated throughout the city: If sexual assault victims present at another hospital or with local police, they are immediately brought to St. Vincent’s where they tell their story once (to police and medical professionals), are examined physically for evidence collection, educated on STDs and pregnancy prevention, and counseled by an on-call member of the Sexual Assault Center of Family Services. Follow-up care is coordinated. And convictions are happening.
“We’ve had a 99.9 percent conviction rate, which is absolutely phenomenal,” says Hafeman. “Physicians oversee the nurses but are never called in to testify; our nurses are superb with [evidence] collection and presenting testimony.”
But that’s not to say the program is problem-free. One of the greatest challenges, according to Hafeman, is nursing turnover.
“I lasted only one year as an on-call SANE nurse,” Hafeman admits. “It’s very, very hard to see the assault. You spend sometimes five hours with these patients, and despite all your professional training, you feel a connection. You try to do everything in your power to make these patients feel comfortable, feel safe. But sometimes the physical findings are just so difficult—especially when your patient is a 3-year-old. I was there at the beginning, I helped start this program, but I had no idea until I did it myself why we had such a huge turnover. It’s emotionally very hard.”
To compensate in some way, Hafeman says the hospital tries to provide support for its SANE nurses. “We hired Sue [Robertson] to oversee scheduling, provide ongoing education, and most importantly, ensure nurses are emotionally healthy and have peer support. Forensic nursing is a tough, tough job. These nurses are called sometimes in the middle of the night, sometimes after working a full day at the hospital, and what they see—the violence—it’s hard.”
SANE Is OK
Hard, but necessary, in ways Hillcrest Medical Center in Tulsa never imagined when launching its SANE program back in 1991. When Trustee first reported on Hillcrest’s SANE program, none of the area’s hospitals was addressing rape or purposefully caring for rape victims. All five of the city’s emergency departments—claiming physician shortage—had taken assistance for rape survivors off their list of services provided.
In her September 1996 Trustee article, “The SANE Solution—Easing the Trauma of Rape,” writer Mary Peterson Kauffold, R.N., noted that “finding a medical safe haven for sexual assault victims was at the top of then-mayor Rodger Randle’s agenda.” He began by calling the top executives from the five Tulsa hospitals together and remonstrating with them about the lack of services for these patients.
John Goldthorpe, president of Hillcrest Medical Center at the time, told Kauffold, “[Randle] gave us a bit of a tongue-lashing that I think we deserved. He said there was a cadre of nurses trained as sexual assault examiners, and all they needed was a place to practice. While he was still talking, I raised my hand and said, ‘If you’ve got the manpower, I can find the space.’” In that same article, Goldthorpe was quoted as saying that a conversation he’d had two weeks earlier with the father of a preteen rape victim had compelled him to step forward.
“I just happened to walk into the doctors’ lounge and overheard a doctor talking about how his 12-year-old daughter had been home alone when a man broke into the house and raped her. All of a sudden, rape was part of life in Tulsa. It wasn’t just something that happened on a TV show. It happened to one of our own doctors. So when I heard the mayor’s appeal, everything clicked, and I knew it was the right thing for Hillcrest to do. I also knew our board of trustees would back me up 100 percent,” he said.
Although Goldthorpe is long retired from Hillcrest, board members there still “wholeheartedly, 100 percent support the SANE program,” according to Hillcrest’s Garfinkel.
“From a hospital board viewpoint, SANE is a wonderful program—we see 400 SANE patients per year,” Garfinkel says. “SANE represents a community service that is needed [for a problem that is] usually under-recognized. The people working in the program feel they are contributing to the community. The people receiving the service, who traditionally might see the hospital as a frightening place, now know it is a place which is caring and protective.”
SANE’s Mission Expands
Although SANE originally served adult rape victims only, in 1997, six years after the program began, a pediatric component was added. In 2001, the program expanded again to include children whose parents were manufacturing drugs in their homes and who were at risk for sexual assault and addiction by constant exposure to drugs, or by taking drugs by accident. As noted above, the SANE program most recently expanded once more to serve victims of domestic violence.
In late 2005, Hillcrest received a Violence Against Women Act grant from the State District Attorney Council to develop a Domestic Violence Nurse Examiner Program modeled after SANE. Through the program, forensic-trained nurses are available 24 hours a day, seven days a week to respond to one of three exam sites: Hillcrest Medical Center, Tulsa Regional Medical Center and the Family Safety Center in Tulsa County.
Ultimately, the goal is to bring the service to more hospital EDs, and to build additional family safety centers—freestanding facilities bringing law enforcement, medical, social services, legal aid and advocacy together under one roof.
“SANE cases continue to be coordinated to only one site—Hillcrest Medical Center,” says Kathy Bell, R.N., forensic nursing administrator at Hillcrest. “Everyone from law enforcement to rape crisis counselors to area hospitals knows to coordinate and bring rape victims to Hillcrest. We draw from all over—one-third of SANE patients are not from Tulsa or Tulsa county; they come from up to 75 miles away.”
Bell explains, however, that, “Domestic violence operates differently. Numerous sites are needed; these individuals are not going to take as many steps as a victim of rape will to access care [for a wide range of complicated, psychological reasons]. Police don’t have the manpower to physically bring every domestic violence case to one centralized location.” According to the 2003 Uniform Crime Report in Oklahoma, the number of domestic violence reports rose by 31 percent from 1994 to 2003. Interestingly, in her position as Forensic Nursing Administrator, Bell is actually an employee of the Hillcrest Police Department and not the hospital.
“Using SANE as a model for domestic violence and other violence-related crimes is a natural evolution, I think,” Bell says. “We’re drawing from the same core group of nurses, just expanding the patients we serve.”
Unlike St. Vincent’s, funding for the Tulsa SANE program is almost equally distributed across the community. The program’s 14 forensic-trained nurses are paid by the Oklahoma Crime Victim’s Compensation Board. Nurses are paid only when called into the hospital on a SANE case. All are independent—working at city hospitals, doctors’ offices and the health department. And all have made a 100 percent commitment to the program, showing up when called. Evidence collection is funded by Tulsa-area police departments; and the cost of medical supplies and space by Hillcrest Medical Center.
As with St. Vincent’s, everyone involved in the Tulsa SANE program is encouraged by the program’s effectiveness and its being recognized as safe and effective by survivors. Since it began, the total number of adult SANE exams has risen from 126 in 1991 to 447 in 2005; child exams have increased from 48 in 1997 (the first year Hillcrest performed pediatric examinations) to 97 in 2005.
Convictions of perpetrators are harder to track, Bell says, because not all cases go to court. But at this issue’s publication deadline, a major case was breaking in Tulsa. An alleged perpetrator had been arrested for serial rape that began in 2001, police reported.
“The investigation picked up a few years ago and became very active,” Bell says. “The youngest victim was 2 years old; the oldest in her 20s. All were female. SANE was very instrumental in finding this man and collecting the [DNA] evidence on him that, hopefully, will lead to his conviction. Six of us [SANE nurses] were involved and it was satisfying to all of us that we were so consistent in our care of patients.”
Because the case was still pending, details could not be released. But Bell seemed confident that SANE’s efforts would help lead to a conviction. “He’s going to have a lot of explaining to do. Why his DNA is all over the place and why six different nurses—over a course of time and series of patients—collected exactly the same evidence.”
Shari Mycek is a writer based in Belle Mead, N.J.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
To respond to this article, please click here.
