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					   South Carolina Chapter

  International Association of
        Forensic Nurses


      State Standards for

Sexual Assault Nurse Examiners


             2006




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The information contained in this packet was created as a guide for hospitals and
individual programs who see and treat victims of sexual assault. The goal of this project
is to set minimum standards of practice for registered nurses who perform exams as a
sexual assault nurse examiners (SANE). As a state chapter, we feel it is of the utmost
importance to provide the best possible forensic care for victims of sexual violence. We
hope that the information contained here can be utilized to create programs across the
state that function at these minimum standards.

Special Thanks to those who contributed to these standards:

Terry Casto, RN, SANE-A, CFN                                   Danielle, Cluver, RN, SANE-A

Sabrina Gast, RN, BSN, SANE-A, CFN                             Pamela Driskell Belkwitz, RN, SANE

Angie Alexander, RN, SANE-A                                    Nadine Mulligan, RN, SANE

Kisha Ross, RN

Rebecca Eck, RN, MSN




"This project was supported by Federal Formula Grant #2005-VA-GX-0005 awarded by the Bureau of
Justice Assistance, U.S. Department of Justice through the South Carolina Department of Public Safety.
The Assistant Attorney General, Office of Justice Programs, coordinates the activities of the following
program offices and bureaus: Bureau of Justice Assistance, Bureau of Justice Statistics, National Institute
of Justice, Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. A
point of view or opinions contained within this document are those of the author and does not necessarily
represent the official position or policies of the U. S. Department of Justice."



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Introduction
    The purpose of the Sexual Assault Nurse Examiner is to meet the needs of sexual
    assault patient. Identifying and documenting injuries, assessing psychological needs,
    making community referrals and collecting evidence are the primary goals of the
    sexual assault nurse examiner. In order to meet these goals, policies, procedures and
    standards must be developed to guide practice. The standards provided are intended to
    give a minimum level of quality of care for this patient population.



Mission
    All patients who become a victim of crime deserve the quality care of a forensic nurse.
    These healthcare professionals serve as a connection between law enforcement, the
    judicial system and community resources. In addition to providing expert care to
    these patients, it is our obligation to educate individuals within the community
    regarding issues surrounding these crimes.



Goal
    Sexual Assault Nurse Examiners in South Carolina strive to provide quality care and
    expert evidence collection to victims of sexual violence.




Objectives
    Sexual Assault Nurse Examiners make every effort to provide care 24 hours a day in
    order to:

    1. Provide immediate crisis intervention to patients and their family

    2. Conduct a complete physical assessment and collect evidence when appropriate

    3. Maintain chain of custody for all evidence collected

    4. Provide community referrals to each patient

    5. Be available as an expert witness for court proceedings

    6. Educate the community and colleagues on issues of sexual assault




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Qualifications
    To practice as a Sexual Assault Nurse Examiner, extensive education outside basic
    nursing training is required. Knowledge from the Forensic Sciences is a necessity.
    The following are the basic fundamental requirements. Each locale has the option to
    add to these qualifications. The nurse must:

       1.   Be a graduate of an accredited school of nursing.

       2.   Hold a current license as a Registered Nurse in the State of South Carolina.

       3.   Demonstrate ongoing education in the Forensic Sciences with a minimum of
            12 hours each year for those forensic nurses who are non-active (not doing
            exams for a period of 1 year). For active forensic nurses (currently working in
            the forensic field) 6 hours of continuing education is recommended.

       4.   Have a minimum of 1 year with a recommended 3 years of nursing
            experience.

       5.   Demonstrate autonomous nursing practice.

       6.   Attend and successfully complete all didactic and clinical components of a
            Sexual Assault Nurse Examiner Training Program.

       7.   Must remain active in a SANE Program with no more than a lapse of 1 year.
            If there is a lapse of 1 or more years, the basic training must be repeated.



Continuing Education
    Continuing education is essential when practicing as a Sexual Assault Nurse Examiner
    and as a Forensic Nurse. Technology with regards to evidence collection and
    preservation procedures occurs on an ever-changing basis. To remain current, the
    Sexual Assault Nurse Examiner incorporates this into her/his practice. It is
    recommended that each SANE complete a minimum of 12 hours of continuing
    professional education each year and maintain proficiency in the performance of
    sexual assault examinations as determined by individual facilities. There will be
    individual accountability for maintaining continuing education. Documentation will
    be available upon request. Continuing education may be documented as:



       1.   Periodical reviews with presentation to team members

       2.   In-service education




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            a.   Presentation

            b.   Attendance

       3.   Seminars and/or conferences related to Forensic Nursing or the Forensic
            Sciences

            a.   Presentation

            b.   Attendance



Training
    Special training is required to become a Sexual Assault Nurse Examiner. The
    instructors for the course should be Nationally Certified SANE-A by the International
    Association of Forensic Nurses (IAFN).

    This training includes didactic components as well as required clinical rotations. Each
    must be completed satisfactorily, and a certificate of completion must be awarded
    before the nurse may practice as a SANE. The following have been designated
    requisites for the role of the Sexual Assault Nurse Examiner;

            1.   All individuals must complete a minimum of 40 hours of didactic training.

            2.   Didactic training will include, but not be limited to:

                 a. Role of the forensic nurse

                 b. The forensic/legal examination

                 c. Recognition, collection and handling of evidence

                 d. Courtroom testimony and proceedings

                 e. Documentation of the examination

                 f. Immediate crisis intervention

                 g. Introduction to forensic photography

            3.   A minimum of 40 hours of clinical rotations is required. The following
                 areas will include, but not be limited to:

                 a.   Pelvic examinations:

                      1.   identification of normal/abnormal variances of normal anatomy



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                    2.   identification of injuries

                    3.   evidence collection on at least 6 sexual assault patients

               b.   Courtroom observation, including expert testimony

               c.   Prosecuting Attorney’s office

               d.   Community referral agencies

               e.   Law enforcement



Quality Assurance
    The Sexual Assault Nurse Examiner participates in various evaluative processes
    to assure the quality of care to patients and the community. To maintain the level
    of proficiency of the SANE, auditing of various functions will be necessary. A
    minimum of 80% compliance is required for each item audited. If the level of
    compliance falls below the standard set, then education and re-auditing will be
    implemented. Categories for auditing may include the following:

    A.     Assessment

    B.     Discharge planning

    C.     Documentation

    D.     Chain of Custody


Expert Witness
    Sexual Assault Nurse Examiners are qualified by education, experience and
    training to be experts in the field of sexual assault in courts of law.




Routine Care for Sexual Assault Patients
    All patients should receive a comprehensive medical/forensic examination. The
    patient has the right to refuse any portion or all of the evaluation. A
    comprehensive examination may include, but is not limited to the following:




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       1. Patients with injuries, requiring immediate medical attention, will be referred
           to a physician for a medical evaluation and treatment prior to the forensic
           evaluation.
       2. The patient, parent, or guardian should sign consent for photographs, evidence
           collection and emergency contraception prior to the evaluation when
           applicable.
       3. Documentation of chief complaint.
       4. Complete vital signs
       5. Listing of present medications, allergies, and pertinent health history.
       6. Observation and documentation of emotional status.
       7. Observation and documentation of physical injuries:
               a. Written
               b. Diagrams
               c. Photographs*
       8. Observation and documentation of genital injuries through the use of:
               a. Toluidine Blue Dye
               b. Wood’s Lamp
               c. Forensic colposcopy with photography*
       9. Completion of the Sexual Assault Evidence Collection Kit (SLED).
       10. Use of microscope to detect motile sperm*
       11. Laboratory studies per facility protocols.
       12. The evaluation may include additional testing depending upon findings.
       13. Each patient will receive a discharge plan, which may include referrals,
           prescriptions, and follow-up care.

 *The use of photography, forensic colposcopy, and microscopy is facility dependant . It is recommended
   that SANE programs utilize these examination tools to better serve their patients.



Assessment and Documentation of the Forensic
Evaluation
       The Sexual Assault Nurse Examiner may assess and document the following
       information for a forensic evaluation:

       1.       Relevant history
                a. Sexual Assault
                               1. date, time, place
                               2. actual or attempted penetration
                                      a. vaginal
                                      b. anal
                                      c. oral
                               3. other intimate behavior
                               4. ejaculation of assailant
                                      a. use of condom
                                      b. location of ejaculate


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                   5.     any use of drugs or alcohol
                   6.     destruction of evidence
                             a. changing of clothes
                             b. bathing or showering
                             c. urination/defecation
                             d. vomiting
                             e. brushing teeth
                             f. eating/drinking
                             g. douche/enema
                             h. smoking
                     7. Associated Injuries
                             a. use of threats or violence
                             b. use of restraints
                             c. loss of consciousness
                             d. location of injuries
                             e. types of injuries
                     8. Bleeding
                             a. site
                             b. quantity
                     9.    Gynecological history
                             a. current use of birth control
                             b. last menstrual period
                             c. last consensual intercourse
                             d. tampon in place during assault
                     10. Health History
                             a.    medications
                             b.    tetanus status
                             c.    allergies
                             d.    recent illness/injuries
2.   Physical evaluation
        a. appearance of patient and clothing
        b. emotional behavior
        c. evidence of non-genital trauma
        d. evidence of genital trauma
        e. vital signs
3.   Psychosocial responses
4.   Potential for loss of support
5.   Recognition of injuries, areas of pain, and collection of evidence
        a. follow chain of custody
        b. photographs, if indicated
                           1. before removing clothing
                           2. obvious injuries
        c. forensic evidence kit (Sexual Assault Evidence Collection Kit)
        d. medical/ forensic examination
                           1. examination of injuries
                           2. documentation of injuries



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                                  3. collection of specimens for evidence kit
                                  4. utilization of appropriate tools
       6.     Laboratory studies (per facility protocol)
       7.     Discharge package
                 a. Prescriptions (offer emergency contraception when appropriate)
                 b. Medication instructions
                 c. HIV testing referral or follow-up
                 d. Sexually Transmitted Disease information/ follow-up
                 e. Information on victim/witness assistance program
                 f. Information on Crime Compensation Fund
                 g. Follow-up information/ referrals

Pediatric Sexual Assault Nurse Examiners
A medical/Forensic sexual assault examination of the pediatric population requires
specialized training and monitoring. In order for nurses to perform sexual assault
examinations on children 11 years and younger the following criteria must be met:

   1. Must have successfully completed didactic and clinical requirements for
      adult/adolescent Sexual Assault Nurse Examiner Training.
   2. Attend and successfully complete a didactic training on pediatric sexual assault
      examinations that has a minimum of 18 hours CEU’s, followed by a fellowship
      with a forensic physician. Number of precepted examinations will be set by
      physician and done to proficiency.
   3. Have a physician who has specialized training in child abuse and child sexual
      assault who will act as medical director for reviewing each case presentation.
   4. Clinical requirements for successful completion of a pediatric training must be set
      according to each programs guidelines and standards.
   5. Policies regarding testing of STD’s and prophylactic treatment of STD’s must be
      made according to facility standards.
   6. Have protocol in place for pediatric follow up examinations.


Nursing Diagnosis and Patient Outcomes
The following nursing diagnoses may be used in each patient’s plan of care

       1.     Anxiety
       2.     Pain
       3.     Rape Trauma Syndrome
                 a. acute
                 b. delayed
       4.     Knowledge deficit

Patient outcomes may include



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1.   Anxiety related to sexual assault
     Reduced anxiety as evidenced by:
      a. calm relaxed facial expressions and body position and movement
      b. patient able to verbalize feelings and fears
      c. patient able to cooperate with examination and procedures
      d. vital signs normal for patient who is hemodynamically stable

2.   Pain related to injuries sustained during sexual assault
     Pain relief indicated by:
      a. fewer complaints of pain
      b. verbalization of relief of pain
      c. calm, relaxed facial expressions and body movements
      d. vital signs normal for patient who is hemodynamically stable

3.   Rape Trauma Syndrome: Acute related to sexual assault
     Indications of limited, appropriate decision making, self control and
     cooperation as evidenced by:
       a. exhibits decreased anxiety
       b. focuses on tasks, procedures
       c. cooperates and participates in verbal dialogue
       d. assists with plan of care
       e. demonstrates coping reactions that are appropriate for events
       f. accepts offer to call support person
       g. demonstrates understanding of referrals
       h. is discharged with an escort
       i. decides to inform others


4.   Rape Trauma Syndrome: Delayed related to sexual assault
     Acknowledgement of status and limited decision making as evidenced by:
      a. Acknowledges changes in lifestyle and behaviors since sexual assault
         ie: change in residence, change of job, change of marital status
      b. Accepts referrals

5.   Knowledge deficit related to biopyschosocial follow-up care
     Acknowledgement of follow-up options as evidenced by:
      a. Accepts discharge information packet of instructions and available
         resources
      b. Verbalizes understanding of contents of discharge packet
      c. Acknowledges potential for reactions related to rape trauma
         syndrome (fear, anxiety, somatic complaints, loss of support, grief)




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