Title: Sexual Assault Nurse Examiner (SANE) Series: Development & Operation Guide Author: Linda E. Ledray Published: Office for Victims of Crime, July 1999 Subject: Victims of crime, child sexual abuse, rape and sexual assault, victim services 220 pages 520,000 bytes ------------------------------- Figures, charts, forms, and tables are not included in this ASCII plain-text file. To view this document in its entirety, download the Adobe Acrobat graphic file available from this Web site. ------------------------------- U.S. Department of Justice Office of Justice Programs Office for Victims of Crime Sexual Assault Nurse Examiner Development & Operation Guide Sexual Assault Resource Service Minneapolis, Minnesota SANE NCJ 170609 This document was prepared by the Sexual Assault Resource Service, under grant number 96-VF-GX-K012, awarded by the Office for Victims of Crime, Office of Justice Programs, U. S. Department of Justice. The opinions, findings, and conclusion or recommendations expressed in this document are those of the authors and do not necessarily represent the official position or policies of the U. S. Department of Justice. U.S. Department of Justice Office of Justice Programs 810 Seventh Street NW. Washington, DC 20531 Janet Reno Attorney General Raymond C. Fisher Associate Attorney General Laurie Robinson Assistant Attorney General Noel Brennan Deputy Assistant Attorney General Kathryn M. Turman Acting Director, Office for Victims of Crime Office of Justice Programs World Wide Web Homepage http://www.ojp.usdoj.gov/ Office for Victims of Crime World Wide Web Homepage: http://www.ovc.gov For grant and funding information contact U.S. Department of Justice Response Center 1-800-421-6770 ------------------------------- The Office for Victims of Crime is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance, the Bureau of Justice Statistics, the National Institute of Justice, and the Office of Juvenile Justice and Delinquency Prevention. ------------------------------- U.S. Department of Justice Office of Justice Programs Office for Victims of Crime Sexual Assault Nurse Examiner Development & Operation Guide Linda E. Ledray, PhD, RN, FAAN Sexual Assault Resource Service Minneapolis, Minnesota SANE Development and Operation Guide CONTENTS Chapter 1: Introduction --Project Goals and Objectives --Scientific Basis of This Guide --Terminology o She or He o Rape, Sexual Assault, or Abuse? o Victim or Survivor? --SANE Guide Evaluation Chapter 2: History and Development of SANE Programs --Rape in the United States --Demonstrating the Need for SANE Programs --History of SANE Program Development Chapter 3: SANE Program Model --What Is a SANE? SANC? SAFE? FNE? --SANE Program Values, Mission, and Goals o Values Statement o Mission Statement o Program Goals --SANE Scope of Practice o Medical Care o Reporting and Victim Support --Education, Training, Research, and Program Evaluation --SANE Standards of Practice --How a Model SANE Program Operates o Hospital-Based SANE Programs o Community-Based SANE Programs o Community Response and Responsibilities o SANE Responsibilities --Community Impact and Benefit Chapter 4: SART: A Community Approach --Who Is on a SART? --The Sexual Assault RESPONSE Team Model o How a Sexual Assault RESPONSE Team Operates o Sexual Assault RESPONSE Team Model Limitations --The Sexual Assault RESOURCE Team Model --Summary Chapter 5: Assessing the Feasibility of a SANE Program --Needs Assessment o Identifying Allies o Determining the Extent of the Community Problem of Rape --Assessing Community Services and Developing Community Support o Law Enforcement o Rape Crisis Center o Medical Facility o Prosecuting Attorney o Other Agencies --Identifying and Overcoming Obstacles: o Concerns About Costs o Fear of Interference o Concern the SANE Will Not Do the Exam as well as the Physician o Concern the SANE Will Not Be a Credible Witness --Deciding to Proceed --Starting a Formal Task Force --Developing a SART Chapter 6: A Look at Funding --Program Development and Operation Costs o Needs Assessment o Facilities and Utilities o Supplies and Equipment o Staff Advertising and Selection o Staff Training o Program Media Promotion o Staff Salaries --Current SANE Program Funding --SANE Program Funding Options o Where to Look for SANE Program Funding o Fundraising Process --Looking to the Future as You Begin --Summary Chapter 7: Starting Your SANE Program --How Long Can It Really Take? --Hours of Operation --Population Served --Deciding on Program Location --One Location or Multiple Exam Sites o Advantages of a Single Exam Site o Disadvantages of a Single Exam Site o Adapting the SANE Program to Multiple Exam Sites o Disadvantages of Multiple Exam Sites --Regional SANE Programs --Community-Based Program Exam Sites --Hospital ED-Based Exam Sites o Advantages of the ED Exam Site o Overcoming Disadvantages of the ED Exam Site --Hospital Clinic-Based Exam Sites --Summary of SANE Location Trends Chapter 8: SANE Program Staff --SANE Program Directors o Reporting Structure o Job Duties o On Call --The Role of the Physician --Staff Selection --Staffing Patterns --Staff Meetings --SANE Salaries --SANE Staffing Recommendations o Program Director o Medical Director o SANE Staff --Summary Chapter 9: SANE Training --Certification o National Certification o State Level Certification o Local Certification --SANE Training Options --SANE Training Today --Utilizing an Existing Training Program --Importing a SANE Training Program --Organizing Local SANE Training o Identifying Local Experts o Selecting a SANE Trainer --SANE/SART Training Resources o Color Atlas o Evidentiary Exam Videotape --SANE Training Components o Programmatic o Medical o Legal o Forensic Practices and Procedures o Psychological --Continuing SANE Education --Future SANE Training Trends --Summary Chapter 10: Establishing and Maintaining Program Coverage --Using Staff Positions --Using On-Call Positions o Length of On-Call Shifts o Assigning Your On-Call Shifts o Changes in the On-Call Schedule o Paid and Unpaid On-Call Service --Response Time --When Should the SANE Be Paged and by Whom? --Delayed Response --Selecting a Paging System --On-Call Backup --Using an Answering Service --Summary Chapter 11: SANE Program Operation --Medical Evaluation and Care of Injuries --The SANE Evidentiary Exam o Forensic Evidence Collection o Followup Forensic Exams o Helpful Tips for Evidence Collection --Additional Components of the SANE Exam o STD Evaluation and Preventive Care o HIV o HIV Post-Exposure Prophylaxis o Pregnancy Risk Evaluation and Prevention o Crisis Intervention and Counseling --Maintaining Chain-of-Evidence --Maintaining Evidence Integrity --Documentation --After the Exam --Testifying in Court --Working with Special Populations o Male Victims o Same Gender Sexual Assault o Gay and Lesbian Victims o People with Developmental Disabilities o People with Physical Disabilities o The Elderly o Self-Injury Victims o Refugees and Immigrants o Working with Interpreters --Providing Culturally Congruent Care --Additional Program Components --Summary Chapter 12: Pediatric SANE Exam --Setting --Special Training --Sexual Assault Response/Resource Team (SART) --Interview o Who Conducts the Interview o Victim Interview o Caretaker Interview --Consent, Confidentiality, and Reporting: o Minor Consent o Confidentiality o Adolescents o Mandated Reporting --Collection of Physical Evidence o Goal o Components o When to Do an Evidentiary Exam o Preparing the Child for the Exam o Exam Positions o Recommended Equipment o Evidence Collection Sites o STD Testing o Hair Specimens --Interpretation of Findings o Class 1-Normal Appearing Genitalia o Class 2-Nonspecific Findings o Class 3-Specific Findings o Class 4-Definitive Findings --Antibiotics for Prevention and Treatment of STDs --Pregnancy Risk Evaluation and Treatment --Psychological Considerations --Discharge Planning o Child Protective Services o Medical Care o Other --Summary Chapter 13: Policies and Procedures --Consent --Court Testimony --Drug and Alcohol Screening --Evaluation of Nongenital Injuries (When to Refer to a Physician) --Evidentiary Exam Timing (Rape Kit Completion; STD Treatment; Pregnancy Prevention) --Examination Sites for Evidence Collection --HIV --Holiday and Weekend Work --Interpreters --Malpractice Insurance --Mandatory Institutional Inservices --Mandatory Reporting of Sexual Assaults of Vulnerable Adults and Minors --Medication Administration --Noncompliant Victims --Nonreporting Victims --On-Call Schedule (Primary) --On-Call Schedule (Backup) --Photographs --Pregnancy Risk Evaluation and Emergency Interception --Program Evaluation and Research --Psychiatric Inpatient/Extended Care Unit Sexual Assault Evaluation --Rape Drug Screening --Records --STD Evaluation and Prevention (Other than HIV) --Statutory Rape/Teen Consenting Sex --Suicide Potential Evaluation --Time Cards/Time Sheets --Unavailability/Vacation --Unconscious Victim Chapter 14: Maintaining a Healthy Ongoing Program --SANE Vicarious Traumatization and Burnout o Identifying Symptoms o Symptoms of Vicarious Traumatization or Burnout o Reducing Impact on Staff --Program Evaluation o Formal and Informal Evaluation Strategies o Process Evaluation o Output Evaluation o Outcome Evaluation o Data Collection and Analysis o Evaluation Utilization o Steps of Program Evaluation Planning o Evolution of SANE Program Evaluation --Maintaining a Healthy Ongoing Relationship with Other Agencies and Organizations --Summary Appendixes A: Project Staff and Advisory Committee B: Participating SANE Programs C: Rape Kit Supply Resources D: SANE Training Programs E: SANE Trainers F: Funding Resources (Please see PDF file) G: Startup Checklist (Please see PDF file) H: Clinical Skills Competency Checklist (Please see PDF file) I: SANE Protocols (Please see PDF file) J: SANE Forms (Please see PDF file) K: SANE Evaluation Tools (Please see PDF file) Glossary (Please see PDF File) Bibliography SANE Guide Evaluation (Please see PDF file) ------------------------------- SUGGESTIONS FOR USING THIS GUIDE A multidisciplinary response is needed to serve victims of sexual assault, and OVC anticipates that individuals from many disciplines, not just forensic nursing, will use this guide to aid their efforts in establishing and operating a SANE program. Indeed, the impetus driving the development of several SANE programs has come from law enforcement, sexual assault victim advocates, and others. Therefore, this guide was written from the perspective that not everyone who reads it will have a forensic nursing or even a clinical background. At the same time, there are a few clinical issues addressed in this guide that cannot adequately be addressed in "layman's terms." We hope that this guide strikes a reasoned balance. As the effort to develop a SANE program should be a multidisciplinary one, we suggest that nonclinicians refer to the nursing and medical members of the organizing team for clarification or further discussion of clinical topics. To aid the nonmedical reader, a glossary of acronyms used throughout the guide is located after the appendixes. An important issue is the rapid development of State policies and procedures governing the processes and protocols of SANE programs that occurred during the writing and review of this guide. Users of this guide should understand that State statutes and policies always take precedence over the recommendations described in this manual. This guide was designed to be read in its entirety, with each chapter building on information presented in the previous chapter. Treating each chapter independently would have required much duplication of basic information, greatly increasing the length of the guide. Constant duplication of the same information in each chapter would also be annoying and distracting to most readers. In a few instances, information is repeated for clarity and to preclude frequent referral back to previous chapters. Readers who are unable to read the manual in its entirety are advised that: --The use of female pronouns for victims was a deliberate choice and the rationale is explained in Chapter 1, page 2, in the section "Terminology." --Female pronouns were also used to refer to SANE practitioners, as the overwhelming majority of them are female. --Throughout the guide, references are made to "the survey." This refers to a survey conducted of existing SANE programs at the beginning of the project and is described in Chapter 1, page 2, in the section "Scientific Basis of This Guide." A MESSAGE FROM THE OVC ACTING DIRECTOR OVC believes that an informed, effective response to violence in America transcends the criminal justice system, and builds on many disciplines, including the health care sector. We know that victims of sexual assault suffer psychological trauma and, all too frequently, long-term health consequences as a result of their victimization. Therefore, providing sensitive health care to victims is critically important in the aftermath of a sexual assault. Unfortunately, the traditional model for sexual assault medical evidentiary exams frequently compounds the traumatization of victims. Medical personnel in the emergency room setting often regard the needs of most sexual assault victims as less urgent than other patients in the emergency room. As a result, rape victims may endure long hours of waiting in the public areas of busy emergency rooms. They are not allowed to eat, drink, or even urinate while they wait for a physician to conduct the medical evidentiary exam. Frequently, the physicians or nurses who perform the exams have not been trained in medical evidence collection procedures or do not perform these procedures frequently enough to maintain their proficiency. Some physicians are reluctant even to perform the medical evidentiary exam, knowing that they might be called away to spend a day or more in court testifying or that their qualifications to testify might be questioned due to their lack of training and experience. In response to these issues, the first Sexual Assault Nurse Examiner (SANE) program was developed in 1976, offering a multidisciplinary, victim-centered way of responding to sexual assault victims. There are now more than 100 SANE programs throughout the U.S., but these programs are not enough to serve the hundreds of thousands of children and adults who are victims of sexual assault every year. The services of trained, experienced SANE practitioners help to preserve the victim's dignity, enhance medical evidence collection for better prosecution, and promote community involvement and concern with crime victims and their families. OVC has a strong interest in promoting the replication of programs such as SANE. This SANE Development and Operation Guide is the result of that interest and we anticipate that it will serve as a blueprint for nurses and other community leaders who wish to establish a similar program in their own community. OVC commends Dr. Linda Ledray and her colleagues in forensic nursing across the nation for their strong, visible leadership in developing and supporting programs that help sexual assault victims take the first steps toward healing. Kathryn M. Turman Acting Director Office for Victims of Crime ACKNOWLEDGMENT When Dr. Linda Ledray started the Sexual Assault Resource Service (SARS) at Hennepin County Medical Center in Minneapolis in 1977, she did so with the intent of developing a nursing focused service delivery model that could one day be implemented in rural Minnesota. At that time, according to Dr. Ledray, she did not understand the impact that this model, now known as SANE, would have across the country, and that 20 years later it would be considered a "new," innovative treatment model for sexual assault victims. Dr. Ledray was excited to discover in the mid 1980's that nurses in Amarillo, Texas; Memphis, Tennessee; and Tampa, Florida were also focusing on responsive treatment for sexual assault victims. These nursing pioneers realized that by pooling their resources of creativity, energy, and enthusiasm, progress in developing a treatment model for this victim population would happen more quickly. With the publication of this SANE Guide, Dr. Ledray has now identified 116 functioning SANE programs, and her organization has contacted many more SANE programs nearing operation in behalf of rape victims. The magnitude of effort required to develop the SANE program cannot be accomplished in a vacuum. It takes the combined efforts of many individuals with vision, commitment, and tenacity. It takes the efforts of those who know what they want to do is right and who are persistent in overcoming the roadblocks that might prevent the implementation of this vision for their community. As Dr. Ledray helped others to initiate SANE programs in their communities over the past 20 years, she noticed the same struggles that she had initially encountered in Minneapolis were occurring in these communities. The need for a SANE Guide became apparent. The Office for Victims of Crime at the Department of Justice also recognized the need for this SANE Development and Operation Guide in order to provide others the ability to efficiently and knowledgeably start SANE programs using the wisdom of those who have been operating SANE programs. With this Guide, others can learn from the trials and errors of those who went before, and they can move ahead more rapidly to improve services for sexual assault victims in their communities. This Guide has taken the combined effort and expertise of many individuals. Kathy Simmelink, MA, RN and Maggie Dexheimer Pharris, MPH, MS, RN together wrote the chapter on the pediatric examination pulling together information provided by SANEs across the country with a significant contribution from Pat Speck, MSN, RN, CS, FNP and Colleen O'Brien, MS, RN, who are both advisory committee members of this project. Based on the sage advice of Judge Isobel Gomez, also an advisory committee member, Maggie Dexheimer Pharris, MPH, MS, RN, rewrote the section on special populations to better focus on meeting the unique needs of individuals rather than perpetuating stereotypes. Patricia Moen, JD; Thomas Kiresuk, Ph.D.; Lee Barry, JD; Carolyn Levitt, MD; and Kit Mauer, BSN, RN, also on the advisory committee, contributed by reviewing the manuscript and making suggestions for additions and revisions. Pat Speck and Colleen O'Brien were gracious enough to carefully reread the revised manuscript numerous times without complaint and edit extensively as they did so. Susan Valentine from SARS offered sound advice, careful manuscript reviews, and good judgment to keep the project on track. This project also benefited greatly from the contributions of Joye Whatley, the project monitor at OVC, Olga Trujillo, Legal Counsel, OVC; Timothy Johnson, Program Specialist, OVC; Kristen Gremmell, Program Manager, Violence Against Women Grants Office, U.S. Department of Justice; and Ronald C. Laney, Director, Missing Children's Program, Office of Juvenile Justice and Delinquency Prevention, U. S. Department of Justice. Thanks also goes to Grace Coleman, the OVC editor, who spent many hours ensuring that the final product was one of quality and Chris Naylor, the SARS secretary, as always, also pitched in and stayed late when necessary to ensure that the project was completed. This Guide is the result of the efforts of these individuals and the many SANEs across the country who shared their materials and experience with Dr. Ledray and SARS. OVC hopes that it will assist others in developing and operating a SANE program so that communities across the nation can better meet the needs of sexual assault victims. If we cannot stop rape, at least we can work together to reduce the suffering of its victims and improve the system that responds to it. SANE Development and Operation Guide CHAPTER 1 INTRODUCTION In 1991, when the Journal of Emergency Nursing published the first list of SANE programs, there were only 20 programs listed (ENA: 91). In a 1996 update, 86 SANE programs were identified (Ledray: 96a). This updated list was used as the basis of a survey of SANE programs conducted by the Sexual Assault Resource Service (SARS) at Hennepin County Medical Center in Minneapolis in order to obtain information about current SANE program structure and practice. Fifty-nine (68%) of the 86 programs surveyed responded. Of these 59 programs responding, 3 were established between 1976 and 1979; 10 between 1980 and 1989; and 46 between 1990 and 1996. Although the initial SANE development was slow with only three programs in existence at the end of the 1970's, program development today is progressing rapidly. During the progress of writing this manual, 117 SANE programs were identified and are listed in Appendix B. It is anticipated that their number has already changed significantly. This list of existing SANE programs will be updated on a SANE Web site that has been funded by the Office for Victims of Crime, Office of Justice Programs, Department of Justice, which began functioning in January 1999. This current flurry of interest in SANE is to a great extent a result of the media attention created by the 1994 recognition of the Tulsa SANE program when it received the Innovations in State and Local Government Award from the Ford Foundation and John F. Kennedy School of Government at Harvard University (Yorker: 96). While Tulsa was certainly not the first community to develop a SANE program, the Tulsa program has taken an active role in promoting the concept. As a result, individuals and private and public institutions across the country became aware of the potential benefits of the SANE model for their own community, and they became eager to explore the possibility of starting a SANE program in their area. As a result, existing SANE programs have been inundated with requests for information about the development and operation of the SANE model. While those experienced in this field have been willing to do whatever possible to assist individuals and groups in developing new programs, this help has primarily been verbal assistance in answering questions and offering advice to help individuals anticipate and overcome obstacles. With each phone call from a new area, the process was repeated once again. The caller, while highly motivated, was often unsure where to start or even what questions to ask. The advice given was typically based on personal experience in one program and did not necessarily meet the needs of other communities. Project Goals and Objectives The Office for Victims of Crime (OVC), Office of Justice Programs (OJP), U. S. Department of Justice (DOJ), recognized the need for additional information and technical assistance when they funded this project. OVC's goal, and the goal of this project, is to facilitate SANE program development by providing information about existing SANE program operation and development in a systematic and comprehensive format. This manual is intended for those who want to develop a SANE program and for those already operating a SANE program who want to ensure that they are utilizing the most current information and standards. The goal of this manual is to provide the necessary information to develop and operate a SANE program in an easily understood format. It includes references for or samples of many essential forms, policies, procedures, protocols, training options, and program evaluation tools. Standards of Practice are provided when there is a recognized standard. When program options are a choice, advantages and disadvantages for each option are discussed. The distinguished project staff and advisory committee working on this project recognize that different communities have different needs and resources. Whenever possible, these differences are addressed and options provided with rationale for inclusion and selection. Scientific Basis of This Guide Work on this guide includes a complete review of the SANE literature. The information available is included in this guide, with references, for your use. In addition, this guide is based on information from the 59 (68%) programs who responded to the survey of the 86 programs identified in the 1996 JEN survey (Ledray: 96b). Followup phone calls were made to several programs to obtain additional information for clarification. Since not every question was answered on every survey, the information and numbers included are based on the answered questions only and do not always add up to 59. Since national certification or standardization of SANE programs and training has not yet been implemented, this manual reflects the experience and judgment of the project staff, advisory committee, and the programs who responded to our request for information (See Appendix A: Project Staff and Advisory Committee; and Appendix B: List of Participating SANE Programs), as well as the current SANE literature. Terminology She or He? While SANE programs deal with both male and female sexual assault and abuse victims, for the most part female pronouns will be used in this guide to refer to the victim population. This decision reflects the fact that the majority of victims within this victim population are female. No intent was made to exclude application to male victims. When it is established that there are different needs based on the sex of the victim, these are distinguished. Rape, Sexual Assault, or Abuse? Since the legal definitions of rape, sexual assault, and abuse vary from State to State, in this guide the terms will be used interchangeably to refer to any unwanted contact of one person's sexual organs by another, regardless of sex, with or without penetration, and with or without resulting physical injury. Victim or Survivor? The decision was made to refer to the victim of rape in this guide rather than the survivor. This decision was made because of the request of many victims to recognize the fact that they were victimized, and in the emergency department (ED) they feel like a victim, not a survivor. In the ED or SANE clinic during the initial period of crisis, few victims have moved to survivor status. SANE Guide Evaluation A questionnaire is included at the back of this guide to assist in evaluating its completeness and utility. The questionnaire consists of two pages which are designed to be pulled from the manual, folded in half with the address visible, stapled, and mailed. Your comments and suggestions will help to update and improve this guide in the future so that it will be even more useful. We truly want and need your assistance. Please complete the evaluation questionnaire and return it once you have reviewed the information in this guide. CHAPTER 2 HISTORY AND DEVELOPMENT OF SANE PROGRAMS Even though rape has likely occurred for as long as humankind has existed (Brownmiller: 75), there only has been a concerted effort to better understand the issue and better meet the needs of survivors has developed only since the early 1970's. One of the first researchers to systematically study the impact on and needs of this population was Ann Burgess who holds both a nursing degree and an Ed.D. (Burgess & Holmstrom: 74a). Burgess identified a pattern of psychological response which she referred to as Rape Trauma Syndrome (Burgess & Holmstrom: 74b), and she continues to be actively involved in furthering the scientific understanding of rape. Rape in the United States The 1996 Uniform Crime Report indicates that 97,464 women were forcibly raped in the United States in 1995. This represents a 5-percent decrease in reported rapes from 1994, and a 9-percent decrease from 1991. Even though the numbers reported in the survey are declining, this figure still indicates that in 1995, 72 of every 100,000 women in the United States were the victims of a forcible rape and reported the crime to the police. More rapes occurred in large metropolitan areas, where the rate was 76 victims per 100,000 population, compared with 49 per 100,000 in rural communities (Uniform Crime Report: 96). Geographically, 39 percent of the 1995 forcible rapes occurred in the most heavily populated Southern States, 25 percent in the Midwestern States, 23 percent in the Western States, and 13 percent in the Northeastern States. The 2-year trend indicates there was a decline in all regions of the country, especially in large metropolitan areas. During the 10-year period that the rate of reported forcible rapes declined 10 percent in large metropolitan areas, the rate actually increased 70 percent in smaller suburban cities and 40 percent in rural areas. The Northeastern and Midwestern States experienced a 6-percent decline, the Southern States a 5-percent decline, and the Western States a 2-percent decline in reported forcible rapes. In 1995, the highest reporting rate occurred in August, and the lowest reported rate was in December (Uniform Crime Report: 96). Despite these reported statistics, the actual rate of rape remains unknown. We can only speculate that this increased reporting rate outside of metropolitan areas represents an actual increase in crime. An increase in reported rapes may also be the result of better community education, increased service availability, and improved reporting of crime. Estimates of the number of women who are actually raped range from an additional four to an additional nine victims for every one woman who reports. In one SANE program, while approximately 20 percent of victims are uncertain about reporting when they first came to the ED, working through their fears and concerns with a knowledgeable SANE has empowered 95 percent of these survivors to report (Ledray: 92a). As with all Crime Index offenses, reports of forcible rape are sometimes considered "unfounded" by law enforcement, and they are then excluded from the crime count. The rate of "unfounded" cases is notably higher for rape than for any other index crime. In 1995, 8 percent of forcible rapes were determined by law enforcement to be "unfounded," compared with 2 percent of all other index crimes (Uniform Crime Report: 96). Some individuals in the criminal justice system may assume that all "unfounded" cases are false reports, deceitfully reported and baseless. However, this is not necessarily the case. Reported rape cases are actually classified by police as "unfounded" for a variety of reasons. These reasons for classifying a rape case as "unfounded" vary greatly from one community to another, but the following are the most common reasons: --The police are unable to locate the victim. --The victim decides not to follow through with prosecution. --The victim repeatedly changes the account of the rape. --The victim recants. --No assailant can be identified. --The police believe no rape occurred. There are also a variety of other situations that impede or prevent completion of the investigation and in which the case may be classified as "unfounded" (Aiken: 93). Unfortunately, not everyone distinguishes between "changing the story" and recalling additional data, or telling different aspects of the same story, or distinguishing between an untrue allegation and a victim who is so fearful of the assailant that she recants her story out of fear for her life or the life of her family. The number one reason victims give for not wanting to report is fear of the assailant, whose parting words in 76 percent of the cases were, "If you tell anyone... (or report to the police), I'll come back and kill you...rape you again...rape your child" (Ledray: 96a). Unfortunately, only 4 percent of rapists go to jail either as the result of guilty pleas or guilty verdicts (Minneapolis Police Chief's Report: 89). This is true even though 51 percent of reported forcible rapes in metropolitan areas are cleared by arrest and 52 percent in rural and suburban areas. The arrest rate for forcible rapes declined in 1995 by 4 percent in metropolitan areas, 6 percent in suburban areas, and 14 percent in rural areas (Uniform Crime Report: 96). The results were slightly better in an earlier Detroit report which indicated out of 372 reported rapes, convictions resulted in 13 percent of these cases (Tintinalli & Hoelzer: 85). Violence has a significant impact on the physical and psychosocial health of millions of Americans every year. Since women are so often the victims of violence, it is essential that women who present to emergency departments for even minor trauma be thoroughly evaluated. ED staff must be aware of the types of injuries most likely resulting from violence, and the victim must be asked about the cause of the trauma to determine if it is the result of violence and further evaluation is required (Sheridan: 93). When violence such as rape is identified, trained staff need to be available to provide services. Only in 1992 did the guidelines of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) first require emergency and ambulatory care facilities to have protocols on rape, sexual molestation, and domestic abuse (Bobak: 92). Fortunately, women's groups have been working to provide services to victims of violence, such as rape and domestic abuse, before large sums of money were available to support these grassroots programs. Rape centers began to be established across the country in the early 1970's, primarily utilizing volunteer staff. While the sexual assault recovery movement and most rape centers continue to depend upon volunteer labor, more money is becoming available to pay staff. Goodyear (1989) suggests that staff must be paid for their work with rape victims. Women working as volunteer workers help perpetuate the tradition of women as unpaid caregivers and allows society to avoid responsibility. The landmark Violence Against Women Act (VAWA) of 1994 was introduced by Senator Biden and signed into law on September 13, 1994, as Title IV of the Violent Crime Control and Law Enforcement Act of 1994. In addition to doubling the Federal penalties for repeat offenders and requiring date rape to be treated the same as stranger rape, this Act made $800 million available for training and program development over a 6-year period. This was an important recognition of the need for specialized services for female crime victims of violent crime. Demonstrating the Need for SANE Programs The impetus to develop SANE programs began with nurses, other medical professionals, counselors, and advocates working with rape victims in hospitals, clinics, and other settings. These individuals recognized that services to sexual assault victims were inadequate and not at the same high standard of care as for other ED clients (Holloway & Swan: 93; O'Brien: 96). When rape victims came to the ED for care, they often had to wait as long as 4 to 12 hours in a busy, public area; their wounds were seen as less serious than the other trauma victims; and rape victims competed unsuccessfully for staff time alongside the critically ill (Holloway & Swan: 93; Sandrick: 96; Speck & Aiken: 95). They were often not allowed to eat, drink, or urinate while they waited, for fear of destroying evidence (Thomas & Zachritz: 93). Doctors and nurses were often not sufficiently trained to do medical-legal exams, and many were also lacking in their ability to provide expert witness testimony (Lynch: 93). Even when they had been trained, staff often did not complete a sufficient number of exams to maintain their level of proficiency (Lenehan: 91; Yorker; 96; Tobias: 90). Even when the victim's medical needs were met, their emotional needs all too often were overlooked (Speck & Aiken: 95), or even worse, the victim was blamed for the rape by the ED staff (Kiffe: 96). Typically, the rape victim faced a time-consuming, cumbersome succession of examiners for one exam, some with only a few hours of orientation and little experience. ED services were inconsistent and problematic. Often the only physician available to do the vaginal exam after the rape was male (Lenehan: 91). While approximately half of rape victims in one study were unconcerned with the gender of the examiner, for the other half this was extremely problematic. Even male victims often prefer to be examined by a woman, as they too are most often raped by a man and experience the same generalized fear and anger towards men that female victims experience (Ledray: 96a). There are also many anecdotal and published reports of physicians being reluctant to do the exam. This was due to many factors including their lack of experience and training in forensic evidence collection (Bell: 95; Lynch: 93; Speck & Aiken: 95), the time-consuming nature of the evidentiary exam in a busy ED with many other medically urgent patients (DiNitto et al.: 86; Frank: 96), and the potential that if they completed the exam they were then vulnerable to being subpoenaed and taken away from their work in the ED to testify in court and be questioned by a sometimes hostile defense attorney (Thomas & Zachritz: 93; DiNitto et al.: 86; Speck & Aiken: 95; Frank: 96). This often resulted in documentation of evidence that was rushed, inadequate, or incomplete (Frank: 96). Many physicians even refused to do the exam (DiNitto et al.: 86). In one case, it was reported that a rape victim was sent home from a hospital without having an evidentiary exam completed because no physician could be found to do the exam (Kettelson: 95). As research became more readily available on the complex needs and appropriate followup of rape victims, nurses and other professionals realized the importance of providing the best ED care possible (Lenehan: 91). For 75 percent of these victims the initial ED contact was the only known contact they had with medical or professional support staff (Ledray: 92a). Nurses also were very aware that while they were credited with only "assisting the physician with the exam," in reality they were already doing everything except the pelvic exam (DiNitto et al.: 86; Ledray: 92a). It was clear to these nurses that it was time to re-evaluate the system and consider a new approach that would better meet the needs of sexual assault victims. History of SANE Program Development To better meet the needs of this underserved population, the first SANE programs were established in Memphis, TN in 1976 (Speck & Aiken: 95); Minneapolis, MN in 1977 (Ledray & Chaignot: 80; Ledray: 93b); and Amarillo, TX in 1979 (Antognoli-Toland: 85). Unfortunately, these nurses worked in isolation until the late 1980's. In 1991, Gail Lenehan, editor of the Journal of Emergency Nursing (JEN), recognized the importance of this new role for nurses and published the first list of 20 SANE programs (ENA: 91). In 1992, 72 individuals from 31 programs across the United States and Canada came together at a meeting hosted by the Sexual Assault Resource Service and the University of Minnesota School of Nursing in Minneapolis. At that meeting, the International Association of Forensic Nurses (IAFN) was formed (Ledray & Simmelink: 97). The IAFN is an international professional organization of registered nurses formed to develop, promote, and disseminate information about the science of forensic nursing nationally and internationally. Membership in IAFN surpassed the 1,000 mark in 1996 and continues to grow (Lynch: 96). While the initial SANE development was slow, with only three programs operating by the end of the 1970's, development today is progressing much more rapidly. We are now aware of 10 new programs that were established between 1980 and 1989, and 73 additional SANE programs established between 1990 and 1996. Eighty-six SANE programs were identified and included in the October 1996, listing of SANE programs published in JEN (Ledray: 96b). This number is likely to grow much more rapidly in the years to come. After years of effort on the part of SANEs and other forensic nurses, the American Nurses Association (ANA) officially recognized Forensic Nursing as a new specialty of nursing in 1995 (Lynch: 96). SANE is the largest subspecialty of forensic nursing. At the 1996 IAFN meeting in Kansas City, Geri Marullo, Executive Director of ANA, predicted that within 10 years the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) would require every hospital to have a forensic nurse available (Marullo: 96). Statewide networks of SANE programs have recognized the need to develop State policies, procedures, and guidelines to direct SANE program operations in their area. State guidelines and procedures always take precedence over the recommendations in this guide. CHAPTER 3 SANE PROGRAM MODEL Before deciding to start a SANE program, it is important to understand what a SANE program does and does not do, the scope of nursing practice, and how a typical SANE program operates. This chapter defines the terms typically used in relation to SANE programs. An example of SANE program values statement, mission statement, goals, and scope of practice are presented. The chapter concludes with a discussion of the operation of a model SANE program and its impact on the community. What Is a SANE? SANC? SAFE? FNE? Since forensic nurse examiner programs began independently and functioned independently until the first meeting held in Minneapolis in 1992, different terminology has been used across the country to define the new role. The Minneapolis program used the term Sexual Assault Nurse Clinician (SANC) to denote a clinical nursing role that went beyond examination of the sexual assault victim. The SANC role in Minneapolis broadened the continuum of services provided to sexual assault victims, emphasizing crisis intervention and supportive counseling in the ER setting, and continuing with followup counseling by specially trained nurse counselors. To avoid a conflict in roles, the nurse counselor who provides followup services is a separate clinician from the SANC who provides services to the victim in the ER. The Memphis program, like many others, preferred the acronym SANE--Sexual Assault Nurse Examiner. Some newer programs have chosen to use the more generic term of Sexual Assault/ Forensic Examiner (SAFE) or Forensic Nurse Examiner (FNE). A program in Minnesota has chosen the SAFE terminology because they hope to move beyond examination of only sexual assault victims to the completion of evidentiary exams on domestic abuse victims, accident victims, and other populations where forensic evidence collection may be useful. Forensic evidence is all too often overlooked in busy medical facilities where the focus is on clinical treatment. At the October 1996 IAFN annual meeting held in Kansas City, the SANE Council voted on the terminology it wanted to use in the standards to define this new position. While there were some dissenting votes, the overwhelming decision was to use the title SANE, Sexual Assault Nurse Examiner. A Sexual Assault Nurse Examiner (SANE) is a registered nurse, R.N., who has advanced education in forensic examination of sexual assault victims. In some areas, the SANE is still referred to by other names, including Sexual Assault Nurse Clinician (SANC), and Sexual Assault Forensic Examiner (SAFE). While the preference for particular terminology may vary, for the purpose of this manual the term SANE is used. SANE Program Values, Mission, and Goals According to Peter Drucker there are five questions that must be answered to effectively assess the values, mission, and goals of a nonprofit organization (Rossum: 93). A mission statement should clearly and succinctly describe an organization's reason for being. To develop a mission statement begin by asking the following: 1. What is our business (mission)? What are we trying to achieve? What specific results are we seeking? What are our major strengths? What are our major weaknesses? After addressing the above question, focus on the following questions: 2. Who is our customer or client? Who is the primary customer (service users)? Who are our supporting customers (Board, volunteers, staff, law enforcement, prosecutor, other agencies)? Will our customers change? 3. What does the customer or client value? What do our primary customers value? What do our supporting customers value? How are we providing what our customers or clients value? 4. What have been our results? How do we define results? To what extent have we achieved these results? How are we using our resources? 5. What is our plan? What have we learned and what do we recommend? Where should we focus our efforts? What, if anything, should we do differently? What is our plan to achieve results? Answering these questions is a critical step in ensuring that an organization focuses on the activities that will achieve the desired results. The following are examples of SANE program values, mission statement, and goals. Values Statement The basis of a SANE program operation is the belief that sexual assault victims have the right to immediate, compassionate, and comprehensive medical-legal evaluation and treatment by a specially trained professional who has the experience to anticipate their needs during this time of crisis. As health care providers, the SANE has an ethical responsibility to provide victims with complete information about choices so victims can make informed decisions about the care they want to receive. A SANE program is also based on a belief that all sexual assault victims have a right (and responsibility) to report the crime of rape. While every victim may not choose to report to law enforcement, she has a right to know what her options are and what to expect if she does or does not decide to report. Those who do report also have a right to sensitive and knowledgeable support without bias during this often difficult process through the criminal justice system. Those who do not report still have a right to expert health care. In addition, a SANE program is based on the belief that providing a higher standard of evidence collection and care can speed the victim's recovery to a higher level of functioning, prevent secondary injury or illness, and ultimately increase the prosecution of sex offenders and reduce the incidence of rape. Mission Statement The primary mission of a SANE program is to meet the needs of the sexual assault victim by providing immediate, compassionate, culturally sensitive, and comprehensive forensic evaluation and treatment by trained, professional nurse experts within the parameters of the individual's State Nurse Practice Act, the SANE standards of the IAFN, and the individual agency policies. Program Goals This next step involves the development of specific goals and objectives. The following are examples of SANE program goals: --To protect the sexual assault victim from further harm. --To provide crisis intervention. --To provide timely, thorough, and professional forensic evidence collection, documentation, and preservation of evidence. --To evaluate and treat prophylactically for sexually transmitted diseases (STDs). --To evaluate pregnancy risk and offer prevention. --To assess, document, and seek care for injuries. --To appropriately refer victims for immediate and followup medical care and followup counseling. --To enhance the ability of law enforcement agencies to obtain evidence and successfully prosecute sexual assault cases. Based on the above values, mission statements, and program goals, each SANE program should develop a community-specific strategic plan or developmental plan of action. This process involves translating the values and mission statements into action. Where are we now? What do we have to do to get to where we want to be? This plan of action is the blueprint for obtaining financial support (See Chapter 6: A Look at Funding). SANE Scope of Practice A SANE program provides 24-hour on call services for all male and female victims of sexual assault or abuse. Medical Care The purpose of the SANE examination of the sexual assault victim is specifically to assess, document, and collect forensic evidence. In addition, prophylactic treatment of STDs and prevention of pregnancy are provided by the SANE following a pre-established medical protocol or with the approval of a consulting physician. While the SANE may treat minor injuries, such as washing and bandaging minor cuts or abrasions, further evaluation and care of any major physical trauma is referred to the ED or a designated medical facility. The SANE conducts a limited medical examination, not a routine physical examination, and clearly explaining this difference to the client is important. Obvious pathology or suspicious findings that may be observed are reported to the client with a suggestion for followup care and referral. Evaluation and diagnosis of pathology is beyond the scope of the SANE examination. Reporting and Victim Support While the SANE is not a legal advocate, she does provide the rape victim with information to assist her in anticipating what may happen next in making choices about reporting and deciding who to tell and to ensure that she gets the support she will need after she leaves the SANE facility. This usually includes a discussion between the victim and the SANE about reporting to law enforcement. If the victim has made a choice not to report, she needs to discuss why she may be hesitant to report. In most cases, the SANE encourages the victim to report the crime and makes referrals to legal advocacy agencies that can provide the support necessary to help the victim through the criminal justice process. The SANE also provides emotional support and crisis intervention. The SANE makes an initial assessment of the victim's psychological functioning sufficient to determine if she is suicidal, oriented to person, place, and time; or if she is in need of referral for followup support, evaluation, counseling, or treatment. Education, Training, Research, and Program Evaluation In addition, the SANE is active in training personnel from other health care and community agencies who provide services to sexual assault victims. Each SANE program also conducts ongoing program evaluation and periodic research studies to evaluate the impact, treatment needs, client outcomes and services provided to sexual assault victims. This should include a variety of program output, process, and outcome evaluation research activities. SANE Standards of Practice At the 1996 annual meeting of IAFN, the SANE Council voted and adopted the first SANE Standards of Practice. The standards incorporate the following: --Goals of Sexual Assault Nurse Examiners. --Definition of the practice area. --Conceptual framework of SANE practice. --Components of evaluation and documentation. --Forensic evaluation components. --SANE minimum qualifications. For a nominal fee, a copy of the SANE Standards of Practice may be obtained by telephoning IAFN at 609-848-8356 or writing to IAFN 6900 Grove Road Thorofare, NJ 08086-9447. While this guide was being developed, many State policies, protocols, or regulations have emerged. For example, based on the IAFN SANE Standards of Practice, the Virginia State Council of Forensic Nurses published their own Standards of Practice for Sexual Assault Nurse Examiners (1997). Always determine if there are State policies and standards relevant to the operation of SANE programs within your own State before implementing a SANE program in you area. You may request a copy of the Virginia Standards by contacting Kim Wieczorek, RN, BSN, FNE at telephone number 804-281-8574 or writing to: St. Mary's Hospital Emergency Department, Forensic Nurse Examiners, 5801 Bremo Road, Richmond, VA 23226. How a Model SANE Program Operates A SANE is usually available on call, off premises, 24 hours a day, 7 days a week. The on call SANE is paged immediately whenever a sexual assault or abuse victim enters the community's response system. If the protocol indicates a rape advocate should be called, the staff or SANE also will page the advocate on call. Hospital-Based SANE Programs If the SANE program is hospital-based, victims may enter the system in the following ways: --Calling local law enforcement who will transport them to the hospital emergency department or SANE exam clinic. --Going directly to the hospital emergency department or hospital clinic. --Calling the designated crisis line for assistance. During the time it takes for the SANE to respond (usually no more than 1 hour), the ED or clinic staff will evaluate and treat any urgent or life- threatening injuries. If treatment is medically necessary, the ED staff will treat the client, always considering and documenting thoroughly the forensic ramifications of the lifesaving and stabilizing medical procedures. If clothes or objects are removed from the victim by the ED staff, care should be taken utilizing forensic principles for handling and storage of the physical evidence. If medical necessity dictates treatment prior to the arrival of the SANE, ED staff will take photographs following established forensic procedures. However, it is preferable that the SANE take all forensic photographs. When the ED staff determines that the victim does not require immediate medical care, the victim is made comfortable in a private room near the ED. This area should enhance the victim's sense of safety and security and provide comfort and quiet in a sound-proof room with comfortable furniture, preferably a sofa that she can lie down on while she waits, a telephone, and a locked door. Family members who accompany the victim, with the victim's permission, should be allowed to stay with the victim while she waits. If there was no oral sex, she is offered something to eat or drink while she waits. If she has not yet filed a police report and she knows she wants to do so, the triage nurse will call the police to take the initial report at the hospital. If the victim is upset, and a hospital chaplain or social worker is available on site, with her permission, they will be called to wait with her until the SANE, advocate, or counselor arrives. Community-Based SANE Programs If the SANE program is community-based, victims may enter the system in the following ways: --Calling the local law enforcement where they will be triaged for injuries and, if only minor injuries or no injuries are present, they will be transported to the community-based SANE facility by law enforcement. --Going to the ED of a local hospital on their own, where they will be triaged for injuries, and if there are only minor injuries or no injury present, they will be transported to the community-based SANE program. --Going directly to the community-based SANE program during office hours. --Calling the designated crisis line for assistance and receiving a referral to the community-based SANE program. Community Response and Responsibilities In response to a sexual assault victim in the community, law enforcement is charged with initiating the investigation of the crime and determining if the client has serious injuries necessitating ED evaluation or care. If moderate to severe injury is detected, the victim is evaluated by paramedics and referred to the hospital ED. This occurs with less than 4 percent of rape victims, as rape seldom involves serious injury (Tucker, Ledray & Werner: 90). Life-threatening injuries indicate whether the client needs to go to the hospital ED first rather than to a SANE facility. When no injuries are suspected, the client is transported from the crime scene to the community SANE facility where she is met by the SANE within 1 hour. If the victim goes directly to a hospital ED, the staff will evaluate the victim for life-threatening injuries requiring immediate treatment. When these are present, the ED staff will admit the victim to the ED and notify the on call SANE to come to the hospital ED. The ED staff will evaluate and treat the injuries, always considering the forensic implications of the lifesaving and stabilizing medical procedures. Clothing or objects removed from the client are handled and labeled to maintain the proper chain-of-evidence. Photographs are taken of the injuries for forensic purposes by the ED staff. After the patient is stabilized medically, the SANE will collect the forensic evidence in the designated ED area. When the ED staff determines that the patient does not require urgent or lifesaving medical care, the victim is not admitted to the hospital. She is instead transported by law enforcement to the community-based SANE program facility. SANE Responsibilities Once the SANE arrives, she is responsible for completing the entire sexual assault evidentiary exam including crisis intervention, STD prevention, pregnancy risk evaluation and interception, collection of forensic evidence, and referrals for additional support and care. When the victim is uncertain about reporting. If the victim has not yet decided if she wants to report, the SANE will discuss the victim's fears and concerns with her and provide her with the information necessary to make an informed decision. If the victim does not want to report at this time, but is unsure if she will report at a future date, the SANE will make sure the victim is aware of her options and the limitations of reporting at a later date. The SANE will also offer to complete an evidentiary exam kit that can be held in a locked refrigerator for a specified time (usually 1 month or an appropriate period of time as mandated by State statutes if any exist) in case she chooses to report later. Mandatory reporting. In States with mandatory reporting laws for felony crimes or child abuse, the SANE will follow established protocol for reporting after explaining the process and her responsibilities to the victim or the victim's family when a child is involved and a parent is present. (NOTE: This is different from statutory rape laws which are discussed in Chapter 13: Policies and Procedures.) When the victim does not want to report. If the victim decides not to report and an evidentiary exam is not completed, the SANE can still offer her medications to prevent STDs, evaluate her risk of pregnancy, and offer pregnancy prevention for up to 72 hours post-rape. The SANE also will make referrals for followup medical care and counseling and provide the victim with written followup information. When a report is made. When a report is made or the victim is certain she will be reporting, a complete evidentiary exam is conducted following the SANE agency protocol. In most agencies, the complete exam is conducted within 36 hours of the sexual assault, and an abbreviated exam is completed between 36 and 72 hours post-rape (up to 96 hours in some States). (NOTE: Please see the Section on seminal fluid evidence in Chapter 11: SANE Program Operation, which describes the rationale for use of the complete versus the abbreviated exam.) After obtaining a signed consent, the SANE will conduct a complete exam including the collection of evidence in a rape kit, further assessment and documentation of injuries, prophylactic care for STDs, evaluation of pregnancy risk and preventive care, crisis intervention, and referral for followup medical and psychological care. Discharge. If the victim is alone, the SANE will talk with her about whom she would like to call and where she will go from the hospital. Every effort will be made to find a place for her to go where she will feel safe and will not be alone. When necessary, arrangements may be made for shelter placement. If she is intoxicated or does not want to leave until morning, arrangements may be made for her to sleep in a specified area of the hospital when this type of space is available. In many facilities, this will be an ED holding room or crisis center. If necessary, a community referral can be made to better meet her long-term housing needs. Community Impact and Benefit A SANE program cannot operate in isolation and be effective. Developing good community relationships must begin with the decision to consider developing a SANE program. When cooperating agencies are informed about the SANE model of care, they are more likely to see the benefits of collaborating with the SANE program to help victims. Working closely with community resources from the very beginning will encourage collaboration in the future. As a collaborative effort, the community can decide the type of SANE program which best meets the community needs. Change is often threatening because the results are unknown. It is common to have some resistance to any change including the implementation of a SANE program. Just because one may encounter resistance, even strong resistance, it does not follow that the idea is a bad one, or that it won't succeed. Chapter Five: Assessing the Feasibility of a SANE Program addresses the types of resistance others have encountered, along with information on how they were able to resolve these obstacles. The next chapter on developing a sexual assault response or resource team concentrates on developing and maintaining strong working community relationships. CHAPTER 4 SART: A COMMUNITY APPROACH No SANE program can operate in isolation. To be optimally effective and provide the best service possible to victims of sexual assault, the SANE must function as a part of a team of individuals from community organizations. They can be either formally organized as a Sexual Assault Response/Resource Team or as informal collaborators. Communities that have chosen to organize formally into a team have developed different concepts of a Sexual Assault Response/Resource Team (SART). One way is to work as a team of individuals who respond together to jointly interview the victim at the time of the sexual assault exam. Another way is to work independently on a day-to-day basis but communicate with each other regularly (possibly daily, and meet weekly or monthly) to discuss mutual cases and solve mutual problems thus making the system function more smoothly. Who Is on a SART? SART team members typically include the SANE, police or sheriff, detective, prosecutor, rape crisis center advocate or counselor, and emergency department medical personnel. The makeup of the SART team will vary from area to area, depending upon the community needs and resources. Ideally the team will include representatives from the community who can best help the victims. In some areas, it may include the SANE and the police. The SART team may also include an expanded range of professionals who work with specific victims populations: a school counselor, a battered women's advocate, a counselor who works with prostitutes, and any combination of representatives of programs in the community who are concerned about the problem of sexual assault. The team membership may change over time depending on the needs of the clients and the goals of the SART team. The Sexual Assault RESPONSE Team Model The original SART model, developed in California, involves a coordinated response. This SART concept is based on the belief that a team response helps prevent the victim from reporting the account of the assault repeatedly. It also helps prevent confusion among professionals trying to meet the needs of the rape victim as she progresses through the health care and criminal justice systems. In communities using the California SART model where multiple members of the SART respond to the emergency department together to conduct the sexual assault exam, the team usually includes law enforcement, the SANE, and a rape advocate. They are all present when the victim makes her initial statement so she only needs to tell the account once. How a Sexual Assault RESPONSE Team Operates When law enforcement is called to the scene of a sexual assault, they will protect the client from further harm, protect the crime scene evidence, and take a limited statement from the victim to determine if a sex crime was committed. They will then call the hospital ED triage who will page the SANE on call and the rape advocate on call. When the police and victim arrive at the hospital, the SANE will decide if the victim should be directed to the ED for medical evaluation by a physician, or directed immediately to the SANE area for forensic examination. The SANE will stay with the victim during any necessary medical evaluation and until she is cleared medically and transferred to the SANE examination area. If a client presents to the ED initially, law enforcement is called immediately to determine if a crime has been committed. The SANE and advocate may also be called to help facilitate the victim's admission to the SART system. In a limited number of communities, a prosecuting attorney also responds to the hospital as a member of the SART. The police are called initially in many areas to certify that a crime has been committed, because in these locales, the hospital is compensated for the medical evidentiary exam only if there is an accompanying police statement certifying that there was a crime. For a more comprehensive discussion of issues related to compensation, please refer to the section on SANE Program Funding Options in Chapter Six of this manual. With the advocate present to provide support, the SANE and police conduct an indepth interview of the victim after briefly conferring to coordinate questioning and reduce repetition. In California, the penal code gives the victim a right to have any two individuals of her choice present for support during police questioning. The advocate may be one of these two. Once the interview is completed, the police officer will wait outside the exam room while the SANE collects the evidence which is then turned over to law enforcement or locked in a secured area for law enforcement to pick up at a later time. With the victim's permission, the advocate will remain in the exam room to provide support during the exam as well. When the exam is completed, the SANE will make any necessary arrangements for followup medical care, and the advocate will make arrangements to contact the victim for followup supportive counseling and legal advocacy. Members of the SART may also meet regularly to discuss cases, or they may communicate informally after the initial ED experience. Sexual Assault RESPONSE Team Model Limitations While the coordinated effort of a SART certainly has some advantage, there are also some limitations to this approach. If the victim is uncertain about reporting, she may feel pressured to report when protocol requires law enforcement personnel to interview the victim before the SANE becomes involved. The advocate will support the victim in whatever decision she makes, even if the decision is not to prosecute. If the victim decides not to report, this also may result in a victim who cannot access health care for STD and pregnancy risk evaluation and prevention. If the victim decides not to report, the hospital care is then typically not paid by the crime victims compensation fund. When the police authorize reimbursement, they are more likely to require that a police report be made. In areas where payment is authorized through another agency, reporting is not necessarily a requirement for payment. Detailed information on compensation issues is provided in Chapter Six: A Look at Funding. In addition, while repetition of the account of the sexual assault is certainly an unpleasant experience that most victims want to avoid, the assumption that they will be better off if they do not have to do so is only a presumption. Research of treatment efficacy has in fact shown that repetition of the account of the assault in detail has a beneficial, desensitizing, healing effect (Foa: 97). The Sexual Assault RESOURCE Team Model Other parts of the country have modified the initial SART model to better meet the needs of their community while trying to maintain the team concept that the SART model fosters. In many of these other areas, while the team members meet regularly and communicate routinely about cases, they do not actually respond at the same time. They function cooperatively, not conjointly, which is why some choose to refer to themselves as a resource team, rather than a response team. In these areas, the police respond to the crime scene and take the initial report and then transport the rape victim to the hospital or SANE clinic. The SANE assumes responsibility for the care of the rape victim at the hospital or SANE clinic and completes the evidentiary exam. The police officer is not present during the exam and may not even wait at the hospital. Rather, the SANE will call the police when the exam is completed, and they will return for the victim. After discussing the exam findings with the SANE, the police may also take possession of the evidence and provide the victim with a safe ride home. If the victim comes to the hospital before contacting the police, with the victim's permission, the SANE may call the police to come to the hospital to take the initial report. The police may complete the report at the hospital, and the SANE may then be present during the interview. The rape center advocate may bring a victim to the hospital or be paged at the same time the SANE is paged. The advocate may also be contacted at a later point in time to provide followup advocacy and counseling. The advocate will likely go with the sexual assault victim when meeting with the sex crimes detective and prosecutor at a later point in time. Most areas also have a standing SART meeting to discuss broader concerns and to communicate informally about specific cases. The goal of this type of meeting is to gather the primary decision-makers, such as the directors or managers of the involved agencies, and resolve problems that affect the group as a whole. At this meeting, the nature of the SART's work is usually broader policy issues, rather than specific case issues. The Sexual Assault Resource Team needs to be aware of how the victim's testimony can jeopardize her case should she want to prosecute. For example, when the victim tells her account of the assault to the police, the SANE, the prosecutor, and the advocate at different times, her memory and the completeness of each account may vary somewhat. When present, these discrepancies must be addressed if the case goes to court. Therefore, all team members need to meet or communicate over the phone to discuss cases, issues, and concerns. While in many States, sexual assault advocates who have completed the required training cannot be subpoenaed to testify in court, both the SANE and law enforcement personnel will be called, and they need to have consistent facts about each case. Summary For a SANE program to be successful, all involved agencies must work together. It takes a coordinated community approach to deal with the multiple needs of the rape victim and to prosecute the offender. However the SART model operates, whomever is included on the team, whatever name is used to describe the team, the important concern is ensuring a coordinated community response with the needs of the victim as the primary focus. CHAPTER 5 ASSESSING THE FEASIBILITY OF A SANE PROGRAM The first step in determining the feasibility of developing a SANE program is to determine a community's need. If the need is there, then obstacles to SANE program development must be identified, and adequate support or resources to overcome these obstacles must be obtained. Needs Assessment A community needs assessment must be completed before making the decision that a SANE/SART program is appropriate for the community. Potential funders will ask for this information before they consider financially supporting the concept. Keeping an open mind during this initial assessment phase is important because a simpler change may be sufficient to provide adequate community services for sexual assault victims. On the other hand, it may be that, while there is need for implementing a SANE/SART program, sufficient community support may not exist. Perhaps all that can be accomplished initially is to plant the first seed of the idea that may take several years to germinate. Many communities have agencies who conduct needs assessments. If possible, identify such a local resource to work with because a properly done needs assessment can be very time-consuming and expensive. Even though a needs assessment may be a source of additional work, it is extremely beneficial, adding credibility to pleas to establish a SANE program. Identifying Allies Begin by talking to people in the community who work with rape victims or who are concerned about the problem of rape, such as personnel in law enforcement, hospitals, teen medical clinics, district attorneys' offices, and victim assistance organizations. Explain the SANE/SART concept to them and look for potential allies in program development and membership on a community resource team. Determining the Extent of the Community Problem of Rape While meeting with community players, determine the number of rapes that occur in the community each year. Getting a count of the actual number of rapes may be more difficult to determine than anticipated. At a minimum, talk with people from the local police department, rape crisis center, medical facility, and prosecuting attorney's office. Ask these people about who else should be contacted. Provide information about the SANE/SART concept to individuals who are interested in improving services to victims of rape. Use this information to identify one individual in each agency who is involved in providing care to sexual assault victims, who is knowledgeable about the current system, and who may be willing to work to try to improve those services. Offer to send them some information describing the SANE/SART concept and how it works, prior to the initial visit. The articles "Sexual Assault Nurse Clinician: A fifteen-year experience in Minneapolis" and "The Sexual Assault Examination: Overview and lessons learned in one program," in the Journal of Emergency Nursing, June 1992 (Ledray: 92a & 92b), are good choices because they are concise and easy to read and because they contain discussions about and demonstrate the advantages of the SANE concept for other agencies. They also summarize the most common obstacles and resistance to the development of a SANE program and provide accurate information to counter these concerns. Follow up these contacts with a personal visit to each agency. Assessing Community Services and Developing Community Support Law Enforcement Start by contacting the local police department. Ask if they have a special unit that investigates rape cases. If one exists, get the name and phone number of the police officer in charge of this unit. Call that person and obtain the following information: --What are the number of reported sexual assaults the unit receives each year? Ask for detailed clarification of the numbers. For example, some police departments include the number of indecent exposures in their sex crimes statistics; others may just include stranger rapes or only rapes that involve vaginal/penile penetration. Ask about the numbers of adult, adolescent, and child sexual assault victims. Remember, the literature suggests that the actual rate for sexual assaults is 5 to 10 times the number of rapes reported. --What percentage of rape reports do the police consider unfounded and how do they determine that a rape report is unfounded? --How efficient and effective do the police consider the current medical response? --Do officers have long waits after they take a rape victim to the hospital? --Where do they usually take the rape victims they see, and why do they go to that particular medical facility? --Is the medical evidence collected complete and is the proper chain-of-evidence maintained? --Is the medical staff cooperative in sharing information with them and helping them gain access to the medical records and maintaining contact with the victims? --Are the police familiar with the SANE/SART concept, and if so, do they think it could improve victim services in the community? Rape Crisis Center The local rape crisis center should be asked the following: --How many rape victims do staff see each year? --How many crisis calls does the center receive? --What are the victims saying about medical services? --What percentage of the victims have reported the rape to law enforcement? --What is the staff's assessment of the effectiveness of the current medical response? --What does staff believe are the strengths and weaknesses of the current health care response? --What percentage of rape victims, do staff believe, have rape exams completed? --Are staff familiar with the SANE/SART concept, and if so, how do they think it could improve community victim services? Medical Facility The next step is to identify which medical facilities in the community see most of the rape victims. Begin by calling the ED nurse managers and asking how many rape victims their facility sees each month and year. Try to identify a staff person, probably a doctor or nurse in the ED or women's clinic who works with the rape victims at each facility and who is particularly concerned about their care, and ask that person for the following information: --How many rape exams does the clinic (or ED) do each year? An estimate may be all that is available as hospitals often do not record the sexual assault as a primary diagnosis and if they do, they may include both victim and perpetrator exams. Consequently, the number of sexual assault victims seen may not be retrievable, and when cases are identified, the numbers may not be accurate. --How are exams done, and by whom? Ask for a copy of their protocol and ask if the doctors or nurses currently doing the rape exams are satisfied with the system. --Are they familiar with the SANE/SART concept, and if so, do they think it could improve services for victims at their facility? Prosecuting Attorney Talk to the prosecuting attorney who is most active prosecuting sexual assault cases. Larger jurisdictions often have a special sex crimes prosecuting unit. When available, the lead attorney in that unit will be the best person to provide the following information: --What are the number of rapes the prosecutor's office reviews each year? --What number do they charge, plea bargain, and take to trial? --What is their experience with the rape kit evidence? --Is the kind of evidence they need from the local medical facilities provided? --Do they work together with the medical staff to improve the evidence collection process? --Do they encounter problems in getting medical staff to testify? --What are the advantages of working together with the medical staff? --Are they familiar with the SANE/SART concept, and if so, how could it improve evidence collection? Other Agencies Ask the above contacts to identify additional agencies or individuals who they believe are key community players working with sexual assault victims. This could be a program in the school system, a pediatric clinic, a domestic violence program, a local women's group, or a church group. Be sure to include them in the assessment phase. Meeting with these agencies should provide a more accurate idea of the services available for rape victims in the area, the problems with the local system, the support for change that currently exists, and the resistance or obstacles to implementing a SANE/SART program that might be encountered. Identifying and Overcoming Obstacles Obstacles identified in the literature that SANE programs have had to overcome include the following: --The fear of physicians that the SANE would miss injuries in the initial exam (Ledray: 96a; O'Brien: 96a). --The concern of physicians that they will still be called to testify in court even though they did not complete the exam (Ledray & Simmelink: 97). --The belief of prosecutors that a physician must conduct the exam in order for the physical evidence to stand up in the court room (DiNitto et al.: 86). --The belief of prosecutors that the SANE will not be as credible a witness in court as the physician (Ledray:92a; AntognoliToland: 85). --Inadequate funding (O'Brien: 96a). --Narrow interpretation of old laws requiring a physician to collect the evidence for it to be used in court and for the cost of the exam to be reimbursable (Speck & Aiken: 95). Unfortunately, little hard data is available about the efficacy of the SANE model. Most of what is available is testimonial or anecdotal. On the other hand, no published data even suggests that the SANE model is ineffective or not preferable to the former model which involves a nurse and physician jointly completing the evidentiary exam. Concerns About Cost Starting and operating a SANE program costs money. Chapter 6: A Look at Funding deals with cost and funding issues more specifically. The amount of additional costs can vary greatly, depending upon how the program is structured. The treatment of rape victims by hospitals today is not free, but the costs are usually hidden. Having a SANE available on call may actually be more cost effective to the facility because it frees both the ED physician and nurse, saving an estimated 20 minutes of physician time and 3.5 hours of ED nursing time (Rambow et al.: 92). The costs for SANE programs are more modest than the costs in facilities with physicians completing even a portion of the exam (DiNitto: 86). Actual costs for the physician fee, use of the ED, laboratory fees, and medication costs often exceed the amounts reimbursed by the State. If there are no legal restrictions on billing the victim, or no special arrangements are made with the hospital, victims may be charged these additional expenses (DiNitto et al.: 86). Please see Chapter 6, under the section "VOCA Funding" for an expanded discussion of the reimbursement and billing of expenses. Having the nurses work on call has greatly reduced program costs, as has the ability to successfully train and utilize nurses without advanced degrees (Ledray: 96a). Fear of Interference There are numerous ways in which the SANE assists the police and the prosecutor. SANEs can ensure that the police get records of exams in a more timely fashion. They can interpret the findings for the police and prosecutor when necessary. Some SANEs routinely ask for the name, address, and phone number of friends or relatives with whom the victim might decide to stay, and through whom they may later be contacted. This information is often very helpful to the police (Ledray: 92a). Police generally prefer to work with a few forensically trained nurses, as opposed to dozens of different nurses and physicians in a busy ED because these nurses know what evidence to collect and how to maintain the proper chain-of-evidence, which makes the police officer's job easier (Yorker: 96). In EDs without a SANE program, victims sometimes encounter busy, insensitive staff, and as a consequence, victims may decide it is not worth the effort to report. However, with a SANE's support, more victims make a police report and follow through with prosecution (Arndt: 88). By providing the rape victim with additional assistance, resources, and support, SANEs facilitate the victim's followthrough with the legal process (Frank: 96; Ledray: 92a). This support results in more victims filing police reports (Arndt: 88). One program had an additional 15 percent of rape victims who reported after talking with a SANE even though the victims were initially hesitant to make a police report. The SANE is aware of the usual fears that keep victims from reporting and is thus able to give victims the needed information to make more informed decisions (Ledray: 92a). SANEs provide continuity of care from reporting to conviction (Ledray & Arndt: 94). SANEs also shorten the time a victim must spend in the ED (DiNitto et al.: 86). Unlike the ED physician who may be called away during the rape exam to see a more urgent ED case, the SANE is able to stay with the victim until the entire exam is completed (Frank: 96). In a client satisfaction questionnaire mailed to 201 victims 2 weeks after they were seen by a SANE for an exam, 93 percent of those returning the questionnaire were satisfied with the care they received. Unfortunately, only 33 (16%) returned the questionnaire (Speck & Aiken: 95). In most communities, having a SANE respond guarantees the availability of a female examiner which is important to many victims (Arndt: 88). Concern the SANE Will Not Do the Exam as well as the Physician The reliability of the evidence collected from a rape victim has been a prime concern in determining who would conduct the sexual assault exam. Until recently in England, only police surgeons, usually men, were allowed to collect evidence from rape victims. When a group of female general practice physicians decided they wanted to make their services available, their ability to develop the necessary forensic skills to collect evidence was challenged by the police surgeons. They have, however, proven their abilities and are now accepted (Wright, Duke, Fraser & Sviland: 89). This was a necessary first step before the police were willing to train nurses for this role in England (Holloway & Swan: 93). The real issue is one of training and experience, not professional background. Just as with any other specialized clinical skill, competency in the collection of forensic evidence and the completion of a sexual assault evidentiary exam entails training and experience. It does not necessarily require an advanced medical degree. Unfortunately, most medical and nursing schools do not teach forensic principles. Few physicians or nurses have the opportunity to complete a sufficient number of rape exams to develop or maintain proficiency, even if they have completed the training. A primary advantage of the SANE program is that a dedicated, limited number of nurses complete all of the evidentiary exams in a given hospital or clinic, which enables them to complete an adequate number of exams to develop and maintain proficiency (DiNitto et al.: 86). The SANE evidence collection process has evolved over the years because SANEs have historically met periodically with the prosecuting attorneys about the use of evidence in the courtroom. As a result of this history, today the evidence that is collected is more complete and useful in obtaining a conviction. For example, one program now routinely collects an extra tube of blood that can be held and run for drug or alcohol analysis if the assailant claims the victim was so drunk she doesn't remember giving consent or if he claims the sex was consensual because she exchanged sex for drugs (Ledray: 92a). Because SANE programs follow a case from the initial evidence collection through to prosecution, they have collected valuable data on the results of the evidence collected. These data have included information such as the likelihood of finding sperm at a specific site, at a specific point in time, and the likelihood of a rape victim being injured during the assault. This information has also been helpful to county attorneys who need to explain that the lack of injuries or the absence of sperm does not mean that the woman was not raped (Ledray: 92a). In a study comparing 24 sexual assault evidence kits collected by SANEs to 73 collected by non-SANEs, the SANE kits were overall better documented and more complete, and the SANEs always maintained proper chain-of-evidence, whereas the others did not. Thirteen (18%) of the kits completed by non-SANEs either had no indication of who had collected the evidence or the records were illegible thus making the available evidence useless. Overall, 48 percent of the non-SANE kits had some break in the chain-of-evidence compared to none of the rape kits collected by SANEs (Ledray & Simmelink: 97). Concern the SANE Will Not Be a Credible Witness in Court Concerns about SANE credibility are unfounded. In fact, there are several reports of prosecutors, who were initially concerned, later finding that the SANE is an extremely credible witness in court as a result of her extensive experience and expertise in conducting the sexual assault exam (Ledray & Barry: in press). SANEs are also more accessible and more willing to adjust their schedules to testify because it is an expected part of their chosen position (Ledray: 92a; Antognoli-Toland: 85). Prosecuting attorneys who have worked with SANEs know they can rely upon the competence of the SANE as a witness if the case goes to trial (Yorker: 96). The testimony of the SANE is backed up by solid credentials and impressive numbers of victims seen (Lenehan: 91). As a result of this solid SANE education, training, and experience, Tennessee more broadly interpreted its State laws to allow the SANE to testify in court (Speck & Aiken: 95). A common concern of physicians is that the physician will still be called to testify in court. In one community where thousands of rape cases have been completed by SANEs, not one case in which the testimony was given by the SANE alone ever required the prosecutor to subpoena the ED physician to testify about the evidence collected (Ledray & Simmelink: 97). When the physician is called to testify, it has always been about injuries that were treated. The Santa Cruz County Attorney believes that having the SANE collect evidence and be available to testify in court has resulted in more guilty pleas (Arndt: 88). In other communities, the SANE model is credited with an increase in conviction rates (Solola & Severs: 83). To date, two programs in operation for more than 10 years continue to have an impressive 96-percent conviction rate in cases in which the SANE did the exam (O'Brien: 96a; Smith: 96). In other communities, at the very least, there has not been the feared decline in convictions (DiNitto et al.: 86). Deciding to Proceed Based on the initial assessment, one of the following conclusions is likely: --The community system may be efficient and effective, and it may not need a major change to a SANE/SART system. --The problems in the system won't be fixed with the implementation of a SANE/SART program, but some other approach may be more helpful. --While the system is in drastic need of the type of restructuring a SANE/SART program could provide, there is currently too little support and too many obstacles to make the commitment to take on the project. --The community could indeed benefit from the implementation of a SANE/SART program, and there is at least enough support to take the next step toward overcoming any existing obstacles in the community in the hope of implementing a SANE program. Starting a Formal Task Force The next step is bringing together a group of interested individuals from the previously mentioned agencies to meet and discuss the possibility of implementing a SANE program. Be prepared to present the following: --A summary of the findings collected, including the best estimates available of the number of reported rapes and actual rapes in the community each year. --The positive and negative aspects of the current response to rape. --A brief description of how a SANE program operates. --The benefits of a SANE program for rape victims and each agency involved. If possible, list and respond to each concern presented by community agencies and solicit additional issues and concerns. To establish a SANE program, two primary task force goals must be achieved. The first primary goal is to establish an initial meeting with community leaders for an open discussion of the SANE concept and identification of additional concerns and information that will be needed. An additional goal is to get a commitment from each agency to meet again to explore further the possibility of starting a SANE/ SART program in the community or region. Getting community leaders to this first meeting is a big step. Getting them to come back again is even bigger. Respect their time by starting when scheduled and stopping on time. Have an agenda and stick to it. When meeting with the community, provide comprehensive information about the SANE program. When you do not have information, make a sincere effort to obtain it but do not promise information for the next meeting that is likely not available. Be honest about what is not known and not available. When unsuccessful in obtaining requested information, explain what efforts were made to obtain it and ask for suggestions or help getting the additional facts. To get community leaders to commit to meetings, be accommodating. For example, be flexible and creative in finding a convenient meeting time and place. If possible, get your agency to provide coffee and bagels or cookies. If individuals miss a meeting, send them a summary of what was discussed with the time and location for the next meeting. It is also important to call individuals who are unable to attend to let them know that they were missed and that you really hope they will be able to attend the next meeting. If possible, tell them what type of input would be helpful from them. If they don't attend, keep sending them minutes of the meetings so they are at least informed about the progress. Periodically reassess who should be included on the initial task force. Developing a SART Once a working committee is established, discuss becoming a SART even if developing a SANE program at the present time may not be possible. In all likelihood, the group of individuals brought together to discuss starting a SANE program are at least a major portion of a SART team membership (See Chapter 4: SART: A Community Approach). If the group decides to continue meeting as a SART, ask who else should be invited to the meetings. Continued communication among interested agencies may result in the development of a SANE program in the future or it may at least result in the improvement of victim services in other ways. CHAPTER 6 A LOOK AT FUNDING Funding is a vital issue often overlooked in the early stages of SANE program development. The inability to obtain needed funding for program startup costs has thwarted the past efforts of numerous nurses who wanted to develop a local SANE program. Many of these nurses were employed at medical centers and expected their medical center to incur the initial costs of SANE program development. While some were successful in making their case, many others were not. More often, these nurses were good clinicians who wanted to start SANE programs because they realized they were not providing victims of sexual assault with state-of-the-art clinical care in their institution. They were aware that there was a better way, the SANE way. Unfortunately, because their focus was on the clinical aspects of care, funding was an afterthought. To a great extent, the ability to obtain program funding is the test of program feasibility. If the necessary funding cannot be obtained, it will not be possible to develop a SANE program. The reality of the health care climate today is that it has become cost driven, and to a great extent, limited by cost. Most hospitals already provide services which do not produce revenues sufficient to cover costs. Understandably, hospital administrators are reluctant to develop an additional program that they perceive will increase costs and decrease profits. Hospital administrators may not understand that hospitals already assume many indirect and overhead costs associated with examining and treating sexual assault victims, such as physician and nursing time, supplies, and staff training. Furthermore, because the ED staff does not conduct these exams routinely, it takes these clinicians longer than a SANE. In addition, while ED staff is involved with a sexual assault exam, the ED may need additional staff to cover other cases in the ED and overtime may be required because staff cannot leave until the exam is completed. The ED must supply both a physician and a nurse to conduct the sexual assault exam so consequently both may be required to testify in court. If there is a delay in court cases, scheduling problems will arise in the ED. When promoting the establishment of a SANE program with hospital administrators, provide a cost-benefit analysis to administrators, demonstrating how a SANE program can provide some services in a more cost-effective manner. Less tangible, but equally important benefits should also be included in the discussion. Even though cost considerations drive many decisions in health care, intensifying competition in the ambulatory health care sector also focuses on the provision of quality, patient-centered care. Point out that the provision of SANE services would enhance the medical facility's reputation with the community, allowing the hospital to stand out among its competitors. Finally, hospitals and medical centers are increasingly interested in and involved with community wellness efforts. Explain how a SANE program, with its cadre of educated, experienced forensic nurse specialists, provides an invaluable resource for a hospital's community outreach and education initiatives. For example, the SANE can educate law enforcement and county attorneys about evidence collection and use of evidence. For the community, the SANE can raise the community's awareness about how secondary trauma is caused by sexual assault. However, even with the most favorable cost-benefit analysis, one cannot assume that a hospital will fund all the costs associated with an ideal SANE program. This is why SANE program costs and funding options must be an initial consideration, starting with the goal of developing a realistic and fundable program, not necessarily the ideal program. This chapter addresses both the cost of program development and program operation, including options when minimal funds are available as well as ideal options when funds are more readily available. (Many SANE programs start with minimal funds and are able to improve staff pay and benefits as well as extend program services after they have established themselves in the community and demonstrated the service need and benefit. It is essential to realistically anticipate all initial costs in order to obtain adequate startup and program operational funding.) This chapter also reviews the funding of SANE programs currently in operation. Lastly, it considers potential funding sources for program development and operation. Program Development and Operation Costs Program development and operation costs vary greatly. Surveyed programs indicated that initial startup costs ranged from $6,000 to over $50,000, and averaged $30,000 to $40,000. Much can be done to control and lower these costs when necessary (See Chapter 7: Starting Your SANE Program). Depending on the resources available, this section provides cost-saving options for consideration. It provides information on the minimum, unavoidable costs for those working with strict limitations, as well as options when more financial resources are available. The costs of program development are not all monetary; in fact, many of the costs are time commitments from personnel. Needs Assessment In most cases, the cost of the community and institutional needs assessment involves the time of a committed individual. In the early days, this was most often institutional employees who were aware of the inadequate services to sexual assault victims. The employees were typically nurses working in the ED or a clinic that saw rape victims, and they wanted to improve services for these victims. With the increased awareness of the SANE model, the needs assessment is now often provided by someone working with rape victims outside the hospital, such as the police, an advocate from the local rape crisis center, or staff at the prosecutor's office. Many State attorneys general and governors are now even taking leadership roles in promoting the SANE concept on a statewide level. While an interested institution may be willing to donate staff time, the hundreds of hours of needed time may have to be spread out over a full year or more. If there is an intense amount of interest, it is more likely that an agency or organization will provide a substantial amount of paid, experienced, professional staff time to determine program feasibility and startup activities. If an individual, rather than an institution, is the interested party, then a time commitment must be negotiated. While this person may be able to perform some of the tasks involved with the initial needs assessment and feasibility studies on institutional time, most efforts will be uncompensated, off-duty hours. If the interested individual's supervisor does not support compensated work hours for the development of a SANE program, the alternative is to find someone in the institution who does support the SANE project. Another possibility is to find support outside the institution, but this is not an optimal solution if the institution's support is vital to the SANE project. At this point, the feasibility of developing a SANE program needs to be carefully reconsidered. Another strategy may need to be developed, including postponing the development of the SANE program until more support can be generated. Facilities and Utilities Office space for the program director, secretary, and staff meetings are almost always located in space donated to the program. The only exceptions to this across the country are programs operated independently for profit. When the program is hospital-based, the hospital donates the space. Community-based programs are usually housed administratively with the sponsoring community agency. Office space should be negotiated either with the hospital where the services will be provided or with the sponsoring community agency. A SANE program provides the hospital or community agency with a valuable resource and a lot of community goodwill. Take advantage of the negotiating power this provides to avoid expensive office overhead. Supplies and Equipment Both office and exam supplies and equipment need to be included in the initial budget. Much like office space, however, it is often possible to get the sponsoring institution to donate supplies, at least for the first year of operation. It will be especially important during this first year to keep an accurate account of the actual supply costs. These cost records will be useful to negotiate for continued donation by the institution or to know the actual expenses if the program needs to assume them. Office equipment. In addition to the usual office equipment, a SANE program needs a computer with access to the Internet and facsimile (FAX) capabilities. The FAX capabilities can be part of the computer or a separate piece of equipment. The FAX equipment should have the capability of displaying the name and phone number of the receiving agency prior to pushing the send key. This allows staff the chance to double check that sensitive or confidential data are sent to the correct agency. To ensure data security, store client data in a computer separate from the computer linked to the Internet. Each SANE needs a long-range pager. Always try to get this cost donated, possibly by a paging company or a community agency, before adding it to the budget. Even $10 per month adds up when it is multiplied by 10 nurses and 12 months. Exam equipment. The hospital ED or clinic where the exams are being completed is often willing to donate exam supplies. In many States, the rape exam kits are provided by law enforcement at no charge. Standardized kits can also be purchased when they are not available free from law enforcement. Consult with the local State crime laboratory that will be analyzing the evidence collected before purchasing the kits. Since the price and contents of "standardized" kits vary greatly from manufacturer to manufacturer, ask to have a sample sent for review before making a decision to purchase a particular kit. The crime laboratory may know where to purchase standardized kits. They are available from a number of sources. (See Appendix C: Rape Kit Supply Resources). Law enforcement agencies often pay for this cost because use of standardized kits benefits law enforcement by promoting better evidence collection. Emphasize this benefit to the law enforcement agency when negotiating with them to provide these kits. A Polaroid camera and/or a 35mm camera will also be needed. Before making the purchase, check to see if the ED or clinic where the exams will be completed already has one available that SANE staff could access. Small 35mm cameras with automatic focus that are easy to operate and will take adequate pictures of injuries are available for as little as $100. A camera with a macro lens attachment will produce higher quality, closeup photos. Later, when the budget allows, the camera equipment can be upgraded. Don't be tempted to get camera equipment that is so sophisticated that the staff will have trouble using it effectively. Also, ensure that the cost of film and film development is covered in the budget if these costs, which can be considerable, are not reimbursed by law enforcement or the prosecutor's office. If the budget allows, consider purchasing a digital camera that can transmit photo evidence directly to the police department, if it is utilizing this technology. The police department may even be willing to provide the SANE program this equipment. One Minnesota police department offered to do so, recognizing the value to the investigative efforts of its department. Another consideration is photographic equipment which captures ultraviolet images. While more sophisticated, it is very effective in identifying and highlighting bruising, especially in women of color. While this technology was once controversial and its accuracy challenged in the courtroom, its scientific value is now widely accepted. The use of a digital camera, however, must be discussed with the local prosecuting attorney's office because digital imagery can be altered easily and, consequently, it may not be accepted by that office. An alternate light source will also be needed. Much like the camera, these light sources are typically available in the ED or clinic for eye exams. If the budget is tight, arrange to have access to the equipment rather than to purchase it. If the SANE program is located in a separate clinic, a pelvic examination table also must be acquired. A microscope may be necessary to observe wet mounts for motile sperm. Additional equipment that will soon become a standard, but which is still not available to many SANE programs because of the cost, are the colposcope ($10,000 to $15,000 for the colposcope alone); light staining microscope ($1,000 to $1,500); digital camera systems with direct computer links; and video equipment with print capabilities. Because of the excessive cost of the colposcope, some programs, especially those working with children, have chosen instead to purchase MedScope ($3,500; $11,500 including camera, internal lens, camera holder, monitor, printer, foot switch, VCR, and cart). It is currently being evaluated in a trial study funded by OVC. Exam paperwork. At a minimum, the SANE staff will need the following exam forms: --Sexual Assault Exam Report (with chain-of-custody). --Evidentiary Exam Consent which includes consent to release evidence to and communicate with law enforcement. --Pregnancy Prevention Consent. --Laboratory forms including a specimen chain-of-custody. --Program brochures. --Followup materials. Additional forms may include the following: --Medical and other referral forms. --Nursing Care Plan. --Medical History Forms. To avoid expensive printing of these forms, including the brochure, all can be produced on a computer. Several low cost computer printing programs are available from which to choose. Staff Advertising and Selection Advertising costs to recruit nurses for a SANE position can be reduced by posting the new SANE positions in local hospital EDs and clinics such as the obstetrics and gynecology clinic. Advertising in the local newspaper may also be necessary. This can cost hundreds of dollars. Ask the sponsoring institution if it will assume this cost; if not, advertising must be included in the budget. Media publicity associated with the development of the SANE program will not only alert the community of the program but may provide free advertising for interested nursing personnel. Sending flyers to the local nurses' associations, schools of nursing, and other local institutions is another less expensive mechanism for locating interested and talented nurses. Recruitment strategies should include recruiting for nurses who are sensitive and knowledgeable of diverse community populations and the issues involving sexual assault. Staff Training If the new SANE staff is sent to an established SANE training program the cost will run approximately $250 to $500 per person, plus travel expenses (See Appendix D: SANE Training Programs). If a trainer is brought in to provide training, the cost will be $1,000 to $1,200 per day, per trainer, for 5 or 6 days of training, plus travel expenses (See Appendix E: SANE Trainers). Program Media Promotion Media attention spotlighting the plight of rape victims can generate considerable public response. Use this community interest and support to elicit improvement of services to rape victims. Media attention is particularly effective if an individual victim is highlighted. Many victims are willing and even anxious to tell their story to the media when they do not believe their needs were properly addressed at the time of the rape. This can offer an opportunity to constructively focus their desire to effect a change in the system for future victims. Before a rape victim goes public, however, staff should discuss with the victim the potential responses, both negative and positive, that might follow public disclosure. Once the new SANE program is in operation, media attention can also be helpful in alerting potential clients to the availability of the service and how it can be accessed. The focus of this media coverage would include magazine articles, newspaper editorials, and television spots about general services and awards given to the program or a particular staff member. A testimonial from a rape victim would also be appropriate in this message. Staff Salaries Many variables influence the determination of staff salaries. Some variables are location of the SANE program not only geographically but also whether hospital-based or community-based. The number of sexual assault cases and the jurisdiction--urban or rural--affect the pay schedule. Please refer to Chapter 8: SANE Program Staff for a detailed discussion of SANE salaries. Current SANE Program Funding The survey of existing SANE programs found the following. Thirty programs were public nonprofit agencies, either associated with a nonprofit hospital, a nonprofit community program, or a government agency. Six were private, for profit, and one program characterized itself as a coalition. The yearly budgets ranged from $6,000 to $825,000 with an average of $122,000. It is rare to have all program funding from one source. Most programs rely on a variety of funding sources. Many SANE programs (N=20) are directly reimbursed for services by Federal money that is administered by a State or county agency. The rationale is that, since the exam is being completed to collect evidence, the State, not the victim or her insurance, should pay for the cost of the evidence collection. This money may be provided directly from a State agency, however, it is usually disbursed to the county and reimbursed on a per-case basis. Bills for each case are submitted by the SANE program for payment to a designated office, usually the law enforcement agency or the prosecutor's office. This reimbursement may be limited to a set maximum dollar amount that will be paid for each exam completed, ranging from as little as $75 per exam to $500 per exam. The reimbursement may also be payment of the actual charges for the evidentiary exam, without a set dollar limit. This reimbursement was found to cover a continuum of program costs ranging from 33 percent to as much as 80 percent of ongoing SANE program operating costs. Additional funding is provided through government agencies, at the State level (N=18), at the county level (N=5), or at the city level (N=2). State money is often received as a grant through the State Department of Corrections or through a State Crime Victims Assistance or Crime Victims Compensation Fund. An additional 11 SANE programs receive Federal grant money. SANE programs (N=44) also rely on donations from a variety of sources, including local foundations, corporations, businesses, churches, hospital foundations, women's groups, the United Way, universities, and individuals. Donations may support a specific clinical service, for equipment such as a colposcope or light staining microscope, or for ongoing operating expenses. Most hospital-based programs (N=47), or 94 percent of the total of 50 hospital-based programs, are fortunate to have the hospital assume responsibility for the remainder of their costs not covered by grants, donations, or reimbursement for services. Two additional SANE programs have a consortium of agencies that share the additional, nonreimbursed expenses. Two of the 9 nonhospital SANE programs, have similar relationships with their sponsoring agencies, the YWCA and a Violence Against Women's program. SANE Program Funding Options The literature indicates SANE programs have been started using Federal research grant funding (Ledray & Chaignot: 80), local community foundation grants, community fund-raising (Frank: 96; O'Brien: 96a), and fee-for-service reimbursement from the hospitals served, police, and/or the county attorney's office (O'Brien: 96a). Some hospitals have an in-house SANE programs because they serve large numbers of sexual assault victims. Other SANE programs are independent nursing programs or agencies that contract with the hospital to provide services on an on-call basis and bill the hospital on a per case basis for the exam (Burgess & Fawcett: 96; O'Brien: 96a). Where to Look for SANE Program Funding The best funding strategy includes approaching a variety of resources including local private foundations, State agencies, and Federal resources. The U.S. Department of Justice Response Center will place interested fund-seekers on a mailing list to receive updated information on funding resources for violence against women programs. Call 800-421-6770 to be added to the list. VOCA funding. The Victims of Crime Act (VOCA) of 1984 established the Crime Victims Fund, which is derived from fines and special assessments collected from Federal criminal offenders--not from tax dollars. The Crime Victims Fund is administered by the Office for Victims of Crime (OVC). Each year, OVC distributes approximately 90 percent of the Fund by formula to States to support victim assistance and compensation programs that provide services to Federal and State crime victims. All States and territories receive annual VOCA funding and, in turn, the States award VOCA Victim Assistance grant funds to local community-based organizations to provide services directly to victims of crime. A limited amount of VOCA funds is also awarded directly by OVC each year in the form of discretionary grants to improve and enhance the availability of victim services. These discretionary grant funds support a variety of nationwide initiatives, such as developing training curricula, training victim service providers and criminal justice professionals, and identifying and disseminating information about promising practices in victims services. OVC discretionary funds do not provide operational funding for victim services organizations. Community programs interested in obtaining a VOCA grant for operational funding should apply to the State agency designated by the Governor of their State to administer the State VOCA victim assistance grant monies. Appendix F contains a list of the State agencies that administer the VOCA Victim Assistance Funding. Each State has discretion to determine which organizations will receive funding based upon the VOCA victim assistance guidelines and the needs of crime victims within each State. Most States make awards on a competitive basis. Although many programs compete for this money, this is an excellent source of funding for sexual assault programs. States also receive VOCA funding for their victim compensation programs that may be used to pay for evidentiary exams given to victims of sexual assault. States may disburse funds to a variety of State or county agencies that conduct the exams--very often a police or sheriff's department. Law enforcement agencies are more likely to mandate that crime victims report their victimization and cooperate with the prosecution in order for the examination expenses to be reimbursed. Victim advocates should understand that States have some discretion in defining the nature and extent of "victims' cooperation with law enforcement." OVC's most recent VOCA Victim Compensation Final Program Guidelines recognize that there may be cultural or psychological factors that undermine a victim's willingness to report sexual assault or to report the crime in a timely fashion. Thus, the VOCA Guidelines allow States to "accept proof of the completion of a medical evidentiary examination such as a report, x-rays, medical photographs, and other clinical assessments as evidence of cooperation with law enforcement in cases involving sexual assault or abuse" (Final Program Guidelines, Victims of Crime Act FFY 1997 Victim Compensation Program, The Federal Register, 14 February 1997). To determine which agency is responsible for billing locally, contact an area hospital and ask whom they bill for the sexual assault evidentiary exam. Since the specific amount reimbursed and the services for which the SANE can be reimbursed typically vary from county to county, the SANE will need to contact the appropriate agency in her county and ask for a copy of the policy. If rape victims are examined from more than one county, a copy of the evidentiary exam reimbursement policy will be needed for each county. Reimbursement generally comes from the county in which the rape occurred, which will not necessarily be the county where the exam is completed. More information on VOCA formula and discretionary grant funding, as well as OVC, can be obtained via the OVC Homepage on the World Wide Web at the following address: http://www.ojp.usdoj.gov/ovc/. Reimbursement of costs associated with the forensic exam is a complex issue. According to a 1997 report by The Urban Institute prepared for the National Institute of Justice, "Medical costs and cumbersome restitution mechanisms in sexual assault cases continue to be a barrier for victims and discourage many women from seeking needed medical care and undergoing examinations to collect evidence needed for prosecution" (The Urban Institute: 97). In 1996, The Urban Institute conducted site visits to 12 States as part of its study of the S-T-O-P (Services, Training, Officers, and Prosecutors) grant implementation process. Most of the 12 States visited had long-standing State legislation that covered the waiver of charges for forensic examinations of sexual assault victims; others passed similar legislation during final congressional consideration of the Violence Against Women Act (VAWA), which was sponsored by Senator Joseph Biden and passed by Congress in 1994. The Urban Institute reported that hospitals incur substantial costs in conducting forensic examinations. Costs are around $800 if a physician conducts the exam; and substantially lower (between $200 and $300) if a trained nurse such as a SANE conducts the exam. The report continues as follows: State laws vary in the mechanism they specify for reimbursing hospitals and relieving victims of the burden of payment. Most of the 12 States visited by the State Institute had no State appropriation for covering these costs, and those that did usually did not appropriate enough funds to cover the need. One State had a backup fund that could pay for examination costs if other mechanisms failed. The various payment mechanisms, or lack of them, still leave victims with a financial burden in quite a number of States.... Most of the payment mechanisms established by the site visit States still leave some victims with either primary or secondary responsibility for payment because either they or the hospital have to apply for compensation to cover the cost of the exam. If the victim must apply, she must pay the hospital first and then seek reimbursement. Situations where hospitals may, and do, seek payment from victims include the following: --Low levels of reimbursement by counties do not cover most of the hospital's cost. --The victim has medical insurance that will cover the cost of emergency care. --Crime Victim Compensation Boards take years to pay claims, although they send an award letter relatively quickly. --Crime Victim Compensation Boards or county agencies reject victim claims for reimbursement because police reports indicate that a case is "unfounded" or because the victim "fails to cooperate with prosecution." Another reimbursement issue is that only part of the procedure is forensic; the rest is medical. Many women, according to The Urban Institute Report, seek medical care in emergency rooms after a sexual assault with no intention of reporting the crime to police. In at least two States, States paid for "evidence collection" but not "followup services." Hospitals then either covered the cost or attempted to bill the victim for these "additional services." VAWA funding. VAWA authorized a 6-year funding cycle for formula grants similar to the OVC victims assistance formula grants to the States. The VAWA funds are available to States to distribute to victim service agencies as well as prosecution, law enforcement, and the courts. Like the VOCA programs, most of the VAWA funding is distributed directly to the States through formula grants. The Violence Against Women Grants Office (VAWGO) is the Federal agency that administers the S-T-O-P Violence Against Women Formula Grant Program. Each State must allocate a minimum of 25 percent of S-T-O-P funds to nonprofit, nongovernmental victim services agencies. The State agency that administers the S-T-O-P grant determines the process for awarding subgrants. State are not required to competitively select recipient organizations. To be eligible for S-T-O-P funds, States must certify that they incur the full out-of-pocket cost of forensic medical examinations for sexual assault victims either by providing or arranging for free examinations, or by reimbursing the victim for the full cost of the examination. As discussed previously in this chapter in the section regarding VOCA funding, States utilize differing interpretations of what actions constitute victim cooperation with law enforcement to establish reimbursement eligibility. Twenty-five percent of each State's S-T-O-P falls into a discretionary category, and the purpose of this funding need not be strictly law enforcement, prosecution, or victim services, but must conform to the broad guidelines of VAWA. Discretionary funded projects must still fulfill at least 1 of the 7 purpose areas of this program. More information on VAWGO funding can be obtained via the VAWGO Homepage on the World Wide Web at the following address: http://www.ojp.usdoj.gov/VAWGO. The telephone number for VAWGO is 202-307-6026. Appendix F also contains a list of the State agencies that administer the S-T-O-P grant funds. Byrne funding. The Edward Byrne Formula Grant Program, administered by the Bureau of Justice Assistance of the U.S. Department of Justice, awards funds to States for use by States and units of local government to improve the functioning of the criminal justice system. As one of the 26 legislatively authorized purpose areas, government units may make awards to subgrantees to provide assistance to jurors and witnesses and assistance, other than compensation, to victims of crime. The Edward Byrne Formula Grant Program may be a potential source of funding for some services designed to assist sexual assault victims. Appendix F contains a listing of the State agencies that administer the Edward Byrne Formula Grant Program. Other Federal and private funding. There are other potential resources for SANE program funding beyond the U.S. Department of Justice. These include other Federal agencies such as the U.S. Department of Health and Human Services, private foundations, community foundations, grant making public charities, individual donors, and fundraising campaigns. The Foundation Center is an excellent source of information on the many grant funding resources. The Foundation Center does not make grants, rather, it provides information on those entities that do. In addition to maintaining libraries in Atlanta, Cleveland, New York City, San Francisco, and Washington, D.C., the Foundation Center has a nationwide network of affiliated libraries and nonprofit resource centers called Cooperating Collections. According to information provided by the Foundation Center on its Internet site, "These collections provide a core group of Center publications for public reference and some level of instruction on how to do funding research.... Every State has at least one Cooperating Collection, and many States have collections in more than one city" ("A Message to Grant-seekers" 1997, http://fdncenter.org/2onlib/2ufgall.html). The Foundation Center also publishes many useful reference directories. One of the most useful is The Foundation Directory (Renz, Baker & Read: 96). It is frequently updated and lists all of the private foundations by State. It provides information on trends in foundation giving, how much grant money each foundation has available, to what geographical area, and for what purposes. This is a valuable resource when applying for private foundation funding. Many Cooperating Collections of the Foundation Center also make available for public use a searchable database of funding resources called FC Search: The Foundation Center's Database on CD-ROM. The Foundation Center's main libraries and Cooperating Collections offer grant-seekers a myriad of services on site and on line, including access to publications, periodicals, training workshops, online tutorials on grant-funding research and proposal writing, online responses via e-mail to reference questions, and computerized databases. The Foundation Center is one of many resources available online and has links to other resources for grant-seekers on its Web site at: http://fdncenter.org/. A tremendous number of grant funding organizations now maintain their own site or homepage on the Internet including most agencies of the Federal Government. Fundraising Process The following processes are suggested for effective and efficient fundraising: --Make sure the type of funds needed is an integral part of the developmental plan: startup funds, capital expenditures, general operating expenses, special project funds, funds to increase organizational capabilities. --Gather information about potential program funding sources and support, including government, foundation, and local private donors; fundraising activities; professional organizations with grant opportunities; and in-kind gifts and services. --Analyze and synthesize the above information. --Decide which prospects are most promising. Match the organization's interests with those of potential funders. --Develop a time-line of proposal writing based on application deadlines, funding cycles, and program needs. --Cultivate potential donors in the private sector: rely heavily on professional contacts and personal networking, relationships of the Advisory Board, community stakeholders, etc. --Keep track of initial contacts made and potential donors' interests; invite potential donors to any and all events such as open houses, press conferences, exhibits, educational initiatives, public interest events. --Keep donors and potential donors informed of program progress through letters, memos, a newsletter, telephone contacts, or one-on-one meetings and informal lunches. --Focus on a distinctive characteristic of your project that sets it apart from other similar projects and that will appeal to and motivate a funding entity to support your program. The appeal might vary from one donor to the next. For government funding, a program might serve as a model; for a local business or organization, it could generate good will and promote the donor's community visibility, or provide an opportunity for unique collaboration. --Follow up with donors who provide support with thank you letters. Always respond to requests for information and don't forget to ask for additional support. Looking to the Future as You Begin Clearly SANE program affiliations have a significant impact on program funding. Fifty of the 59 programs surveyed are hospital-based. Survey respondents indicated that program costs that exceed the program income are paid by the sponsoring institution in 88 percent of the programs which are hospital-based, compared to only 22 percent of the programs that are nonhospital-based. This is probably due to more limited resources and budgets in community programs as compared to hospital organizations. It appears that the decision to affiliate a SANE program with a large institution, such as a hospital, may be an effective choice in ensuring ongoing program funding. Providing effective crisis intervention and preventive care for