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SANE nurse shortfall is a national issue
Not enough nurses puts victims and criminal cases at risk
Marcia Frellick
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In Wisconsin, the U.S. Department of Justice subsidizes the training so the cost is reduced to $100, according to Terri Slapak-Fugate, RN, director of emergency/urgent care and the SANE program manager at Southwest Health Hospital in Platteville, Wis. But for many nurses and hospitals, cost can be a barrier.

When training is completed, nurses move to the clinical practice portion in which they learn to conduct  genital exams and observe courtroom testimony by forensic nurses.

SANEs provide special care
National standards proposed
One only has to look at the statistics regarding sexual assault to see the victims are not few or far between or without need for special services. According to
, an American is sexually assaulted every 98 seconds.   
Marcia Frellick is a freelance writer.
For too long healthcare has thought this has not been a healthcare issue, but a criminal justice issue. It’s been proven over and over again that it really isn’t.” Kim Day, RN
Slapak-Fugate has worked in the sexual assault field for 21 years. When she started, she had no training in sexual assault other than being told to read the directions on the rape kit. “I was really nervous,” she said. Being SANE-trained makes a huge difference for the nurse and the patient, she said. One difference is in the time spent, she said. “A non-SANE trained nurse/physician team would spend about 10-20 minutes with the actual evidence collection, whereas a SANE will spend 1 to 4 hours,” she said. Slapak-Fugate has had as many as seven SANEs trained to work on her team, which serves three counties. But now she has four, with two working on 90% of cases, she said. She has witnessed programs in other parts of the country fail because hospitals think one to two nurses can handle the number of cases administrators see coming in. The problem is, when a SANE nurse moves or even goes on vacation, one person is left for all the cases and programs can fall apart, she said.
One out of every 6 American women has been the victim of an attempted or completed rape in her lifetime and about 3% of American men — or 1 in 33 — have experienced an attempted or completed rape in their lifetime. And from 2009-2013, Child Protective Services agencies substantiated, or found strong evidence to indicate that, 63,000 children a year were victims of sexual abuse.

A nationwide shortage of nurses specially trained to work with people who have been sexually assaulted means access to optimal care varies geographically. In Illinois, for instance, only 32 of the state’s 196,000 registered nurses have been certified as sexual assault nurse examiners, or SANEs, by the International Association of Forensic Nurses to work with adult victims of assault sexual assault,
according to the Chicago Tribune
. Only 12 of the nurses in the state are SANE-certified to treat children. Yet, nearly 4,500 patients came to emergency departments in the state for alleged, suspected or confirmed sexual abuse or rape in 2016, according to the newspaper, which cited data from the Illinois Department of Public Health. A
bill awaiting Illinois Gov. Bruce Rauner’s signature
, would require all hospitals in the state, by 2022, have a specially trained medical provider ready to treat people who have been sexually assaulted within 90 minutes of them entering the hospital.
“Illinois would become the first state to mandate this type of services for every sex assault patient [if the bill is signed],” said Jaclyn Rodriguez, BSN, RN, BS, SANE-A, who is SANE coordinator for the Office of the Illinois Attorney General.
She said hospitals would either have to contract with or employ SANEs to provide these services 24 hours a day, every day of the year. “Providing specialized medical care to survivors is known to help them heal, increase their willingness to pursue justice and increase the number of successful prosecutions against offenders,” Attorney General Lisa Madigan told the Chicago Tribune. “We must do better for the thousands of women, children and men in Illinois who are victims of sexual assault every year.”
Illinois is not alone in a shortage of SANEs, said Kim Day, RN, SANE-A, SANE-P, IAFN’s Forensic Nursing Director.

“There are no states where there aren’t limitations on access,” Day said. There are many reasons, including that some go through the coursework, but are not able to complete the clinical practice requirements, she said.

The IAFN is composed of more than 4,000 members who practice and support forensic nursing in 26 countries, according to its website. There is no national (U.S.) association with the same or a similar function, according to Day. No national standards exist for whether a hospital has to have any SANE nurse or a certain number, Day said. She added there is little accountability as to how many patients are turned away, how long patients wait for care or even how many SANE-trained nurses the hospital has. Day said after an assault, a person could face several scenarios. The best is that there is a trained examiner on staff who can see them right away. The worst is that they go to a hospital and are told “we don’t do that here” and are not given a referral. “Most of those give up because it takes a lot of courage for them to even come to the point where they go for help. They want to forget it’s ever happened,” Day said. Recent bipartisan legislation aims to change the options. U.S. Senators Patty Murray (D-Wash.) joined by Republican Sen. Lisa Murkowski, (R- Alaska) re-introduced the
Survivors’ Access to Supportive Care Act
in July. “It is absolutely unacceptable that someone would go to seek care — and justice — for sexual assault and be told ‘not here’ or ‘try next door,’” Sen. Murray said in a press release. “The Survivors’ Access to Supportive Care Act, will help us make sure that no longer happens to survivors across the country seeking help.”
Why numbers are so low
Getting certified is a two-step process. First, nurses must complete 40 hours of classroom or online training. That can cost about $450, Day said, and in some cases hospitals ask nurses not only to pay their own fees but take the training via 40 paid vacation hours or 40 hours of time off without pay, she said. Further certification — such as a pediatric certification — takes additional time.
“In what other profession would you be asked to pay for your own training and use your vacation time?” she said. In Illinois, training is free through the attorney general’s office, including advanced training.
However, nurses’ requests for access to clinical training often meets resistance, Day said. Hospital managers often don’t want to pull the nurse off regular duties to train or don’t think the specialized training is necessary. Healthcare systems nationally have not prioritized the specialty training for SANEs, Day said. “For too long healthcare has thought this has not been a healthcare issue, but a criminal justice issue,” she said. “It’s been proven over and over again that it really isn’t.” Even when nurses finish both parts of the training, the nature of the work may lead them to drop out for two big reasons, Day said. Sometimes the reason SANEs entered the field was because they or a loved one was sexually abused, and the work can cause them to relapse and jeopardize their own recovery, she said. Also, nurses may see that although SANE work is critical to prosecution, the work doesn’t deliver the crime-fighting satisfaction they had hoped it would. “You don’t go into this to get the bad guy,” Day said. “If you are going into this because you want to take care of patients who have experienced the trauma of sexual violence, then this is the work for you. This is the essence of nursing. It is really, really heart work.”
Shortage hampers efforts to stop human trafficking
Sexual assault nurse examiners have an important role to play in spotting and treating people trapped in human trafficking situations, said Pamela Glenn, CNM, APRN, a field education supervisor at Walden University School of Nursing in Minneapolis, Minnesota.
SANEs are trained to notice the signs a person is being controlled by another and they know what questions to ask and how to ask them, Glenn said. They also are
trained to spot the signs of trafficking
when patients being trafficked don’t perceive themselves as victims of a crime. “Human trafficking victims are more likely to talk to providers knowledgeable about trafficking and someone who is nonjudgmental and respectful, which is what the SANE nurses are all about,” Glenn said. SANE nurses also are often working in emergency departments, which is most likely than other departments to see trafficking victims. Because they are trained in both the medical and legal realms, they are in a pivotal role to help the patients. “Without nearly enough SANE nurses, we’re not going to pick up on the trafficking,” Glenn said. “It’s as simple as that.”
Jaclyn Rodriguez, RN
Kim Day, RN
Terri Slapak-Fugate, RN