Negotiating the challenges of multidisciplinary responses to sexual assault victims: sexual assault nurse examiner and victim advocacy programs

Support or justice: a triangulated multi-focal view of sexual assault victim support in a UK sexual assault referral centre (SARC)

BACKGROUND

Despite vast levels of underreporting, sexual assault remains an issue at scale in the UK, necessitating the presence of statutory and voluntary organisations in the support of victims. Understanding the experiences of all parties within this context is important for the resilience of support that can be provided at a systems level. This study examines the barriers faced by service providers when working with victims of sexual assault.

METHODS

Semi-structured interviews took place with eleven professionals working in or in conjunction with a Sexual Assault Referral Centre (SARC) in Southeast England, which were subsequently analysed using inductive thematic analysis.

RESULTS

Five themes were identified exploring SARC staff's experiences with (i) communication breakdowns with external services; (ii) delivering support in an underfunded system; (iii) tailoring support to survivors' needs; (iv) the Criminal Justice System fails victims of sexual assault; and (v) reckoning with burnouts and vicarious trauma.

CONCLUSION

Significant gaps in UK service provision for sexual assault victims are identified, particularly within the criminal justice system, where legal and investigative processes are cited as retraumatizing. The results emphasize the urgency of enhanced training, coordination, resources, and trauma-informed practices across organizations to better serve victims and support overwhelmed providers. Prioritizing systemic improvements is crucial to address the complex needs of both victims and service professionals.

The Working Relationship Between Emergency Room Nurses and Medical Rape Victim Advocates: A Qualitative Examination of Nurses' Perceptions of the Influence of Nurse Training and Experience on Nurse-Advocate Interactions

Nurses and medical advocates respond to sexual assault survivors seeking hospital services. Ideally, both providers work collaboratively. However, this does not always happen. Extant research on the nurse-advocate relationship focuses on Sexual Assault Nurse Examiners (SANEs). This study examines how ER nurses perceive their training and experience influence the working relationships between emergency room (ER) nurses (not exclusively SANEs) and medical advocates. Key findings indicate nurses perceive increased training improves (a) role understanding, (b) trust, (c) respect, (d) rapport, and (e) appreciation. Less training was associated with poorer role understanding and trust.

Sexual Assault Nurse Examiner (SANE) program: Long-term impact on confidence and attitudes on SANE trainees

AIM/OBJECTIVE

The current study examined the long-term impact of SANE programming on the confidence of SANE trainees and on their attitudes toward the SANE role after obtaining SANE certification.

BACKGROUND

Nationally, sexual assault examiners (SANEs) are in short supply. However, the shortage of SANE nurses takes on a special meaning in the medically underserved United States- Mexico border region where human trafficking is seen as a threat in the region and sexual assaults may be less likely to be reported. In recent years, SANE training programs have established across the country to address the shortage of SANEs. Although positive outcomes have been reported among SANE training programs, the long-term outcomes of programming for trainees are not known.

DESIGN

A descriptive longitudinal study with repeated measures was conducted.

METHOD

A total of N = 66 registered nurses who had more than 2 years of nursing work experience were recruited to participate in a SANE training program. The current study included only n = 27 participants who completed the questionnaire at 3 points (Time 1) baseline, (Time 2) 6 months after SANE certification, and at (Time 3) 12 months after SANE certification. General linear modeling and repeated measures analysis of variance were used to analyze the data. Type 1 error was set at p = 0.10. An original 43-item questionnaire was developed to measure the SANE trainees' confidence and their attitudes toward the SANE role.

RESULTS

Initially, an increased sense of self-confidence was found among trainees at least six months after completing SANE certification; however, this slowly diminished after one year. Likewise, attitudes toward the SANE role deteriorated six months after obtaining SANE certification.

CONCLUSION

Lack of support and infrastructure to integrate SANE into the wider medico-legal community could explain the diminishing confidence and attitudes of SANE toward the role. The findings of this study have implications for the establishment of support infrastructures in the workplace and community to enhance the recruitment of nurses in SANE programs, the retention of SANEs in the workforce, the sustainability of SANE programs in underserved communities, and the establishment of protocols to integrate SANEs into sexual assault response teams (SARTs), especially in medically underserved US-Mexico border regions.

Views on Interprofessional Collaboration in a Dutch Sexual Assault Center: A Qualitative Study Among Workers

Purpose

As the response to sexual assault victims proved to be shattered and substandard, sexual assault centers were set up to improve care by providing the victims with medical, psychosocial and legal care. The Dutch Centers for Sexual Assault were launched in 2012. We wished to examine the challenges in interprofessional collaboration experienced in a long-running Dutch Sexual Assault Center.

Methods

In this qualitative study, data was collected via semi-structured explorative interviews which were analyzed using thematic analysis in an iterative process. The semi-structured interviews were held with fifteen professionals from medical, psychosocial and legal disciplines. An interview guide was developed based on expert opinion and the Bronstein Index of Interprofessional Collaboration. Qualitative analyses were done using the method of thematic analysis in ATLAS.ti and were reported according to the COREQ criteria. The themes of the experienced challenges in interprofessional collaboration were further clarified using quotations.

Results

Participants mentioned three themes that challenged interprofessional collaboration: 1. discrepancies in professional involvement, 2. conflicting goals and 3. a lack of connection. Discrepancies in motivation and affinity to work with victims of sexual violence between professionals proved to be the most pivotal challenge to collaboration, leading to disturbing differences in professional involvement. A low caseload and time restraints complicated gaining expertise, affinity and motivation. Conflicting goals and confidentiality issues arose between the medical and legal disciplines due to their contrasting aims of caring for victims versus facilitating prosecution. Some professionals felt a lack of connection, particularly due to missing face-to-face personal contact, which hindered the sharing of complex or burdensome cases and gaining insight into the other discipline's competences.

Conclusion

Building collective ownership and equal professional involvement are crucial for interprofessional collaboration. Professional involvement should be increased by training courses to clarify conflicting goals and to improve reciprocal personal contact between professionals. Training courses should be facilitated with organizational financial support.

Rape Crisis Victim Advocacy: A Systematic Review

While rape crisis center (RCC) advocacy is generally regarded as valuable, there are no prior systematic reviews of the advocacy literature. This review examined RCC advocacy service provision, perceptions and impact of advocacy, and challenges and facilitators to effective service provision. Databases related to health and social sciences were searched including Academic Search Complete, PsychINFO, PubMed, CINAHL, ProQuest, Science Direct, OAlster, WorldCat, and MEDLINE. Empirical articles written in English that examined RCC advocacy service provision and/or impact in the US were included. The researchers reviewed abstracts and titles, and then full texts. Forty-five articles met criteria, were summarized, and double checked. Findings demonstrate advocacy is multi-faceted, beneficial, and challenging. Advocates work directly with survivors and interact with other responders on behalf of survivors. Specifically, advocates provide emotional support, safety plan, support survivors in making decisions, and assist them in navigating other systems. While advocates are generally regarded positively by survivors and responders, some responders have concerns about advocates. In addition, advocates sometimes report victim-blaming and being ill-equipped to meet survivors' needs. Finally, advocates face specific challenges in their work with survivors and responders. Future research using diverse methodological approaches is needed to understand advocacy utilization and reach; survivors' perceptions of advocacy; marginalized survivors' experiences; connections between specific services, implementation, and outcomes; and effective strategies for advocates' interactions with other responders. Additional resources to help advocates serve all survivors effectively and equitably; to support evaluator-practitioner partnerships; and to share unpublished data on advocacy may help contribute to improvements in advocacy practice.

Patient Advocates' Perspectives on the Care of Sexual Assault Survivors in Chicago-Area Emergency Departments

Emergency departments (EDs) providing care and forensic examinations for sexual assault (SA) survivors are often supported by SA patient advocates. This study explored advocates' perspectives regarding problems and potential solutions in SA patient care through a focus group with 12 advocates. Thematic analysis identified two major themes: provider-patient interactions and ED-hospital systems. Challenging aspects of provider-patient interactions included (a) provider attitudes and (b) disempowering behaviors. Within ED-hospital systems, themes included time constraints, efficiencies, and hospital preparation. Advocates surveyed were optimistic about an increased presence of SA nurse examiners and enhanced protocols and provider training to improve survivors' experiences.

Improving Access to Postassault Healthcare for College Students: Creating a Campus-Based Sexual Assault Nurse Examiner Program

National prevalence data indicate that college students are at a high risk for sexual assault, but most institutions of higher education do not provide postassault medical forensic examinations as part of student-facing healthcare services. College sexual assault patients might have access to sexual assault nurse examiners (SANEs) in local hospitals, if they are available where they are attending school, but unfortunately, many student victims do not have options for postassault health services. Creating campus-based SANE programs could address this gap in services and increase access to healthcare. In this article, we describe how we created a free-standing, campus-based SANE program at Michigan State University. We worked with a multidisciplinary community advisory board to identify core guiding principles to inform stakeholder engagement, program location decisions, program policies, training protocols, staffing plans, and collaborative partnerships with other disciplines (e.g., advocacy, law enforcement, prosecution, forensic sciences). We discuss how we navigated opening the program in the midst of the global COVID-19 pandemic and share lessons learned for creating campus-based SANE programs.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

"Just Bring Us the Real Ones": The Role of Forensic Crime Laboratories in Guarding the Gateway to Justice for Sexual Assault Victims

Throughout the United States, hundreds of thousands of sexual assault kits (SAKs; also termed "rape kits") have never been submitted by law enforcement personnel to a crime laboratory for forensic DNA testing. Prior research indicates that negative stereotypes about victims influence police decisions to submit kits for testing, but forensic crime laboratory personnel may also be involved in SAK submission decisions. The purpose of the current study was to explore the communication and collaboration between police and crime lab personnel regarding SAK submissions within a community with large numbers of unsubmitted rape kits. Drawing from 3 years of ethnographic observations and longitudinal qualitative interviews, we found that the police department's crime lab did not have sufficient resources to test all rape kits in police custody, which is a problem forensic laboratories are facing throughout the United States. However, we also found that access to this limited resource was controlled by crime lab personnel and their rape myth beliefs about which victims and which cases were considered worthy of the time, effort, and attention of the criminal justice system. Lab personnel emphasized that police should only submit "real" cases for forensic DNA testing, which they typically defined as physically violent stranger-perpetrated sexual assaults; "shady" cases did not merit testing, which they defined as known-offender assaults, reports made by adolescent victims, and cases in which the victim may have been engaged in sex work. We noted marked similarities in police and lab personnel's rape myth acceptance, and stakeholders readily agreed that they did have a common understanding about which victims were not credible and therefore which SAKs did not merit testing. We discuss these findings in light of recommendations from the National Academy of Sciences for the independence and autonomy of the forensic sciences from law enforcement.

Examining the Implementation of the National Protocol for Sexual Assault Medical Forensic Examinations

The National Protocol for Sexual Assault Medical Forensic Examinations, Adult/Adolescent, 2nd edition, or SAFE Protocol, is a voluntary guide that assists local and state jurisdictions with their responses to sexual assault by institutionalizing best practices around survivor care and evidence collection, particularly for sexual assault nurse examiners (SANEs) completing medical forensic examinations. We examined the uptake of the SAFE Protocol in communities across the United States by analyzing data from a set of national surveys of forensic nursing programs and victim advocates within the same communities. We studied four implementation outcomes: the acceptability, adoption, reach, and sustainability of the SAFE Protocol. SANEs and advocates reported that stakeholders responding to sexual assault-including forensic nurses, advocates, law enforcement, and prosecutors-have high implementation of the Protocol, which indicates how important individual stakeholder engagement is in actively facilitating the adoption of it. However, when information from SANEs and advocates from the same community are compared, the extent to which the SAFE Protocol is reported to be implemented with fidelity across U.S. jurisdictions is mixed.

Possible Factors Supporting Cross-Agency Collaboration in Child Abuse Cases: A Scoping Review

Cross-agency collaboration for responding to child abuse cases is critical for the safety and wellbeing of children. However, working effectively across organizational boundaries can be difficult, especially where there are considerable disciplinary differences. Accordingly, many jurisdictions have put in place policies and processes to support cross-agency collaboration across groups responding to severe child abuse. The aim of this scoping review was to highlight key factors that may influence the quality of cross-agency collaboration in severe child abuse cases. A systematic search comprising 57 empirical studies examining the facilitators and/or barriers to cross-agency collaboration in child abuse cases was undertaken identifying eleven factors. This review found the most commonly cited factor was the need to reconcile the different roles/mandates of workers with their roles in a cross-agency response. A clear cross-agency protocol that establishes agreed procedures was also a commonly cited factor, along with cross-agency training, and communication and information sharing practices. This scoping review highlighted the lack of high-quality evidence that could be used to assess the effectiveness of policies and processes to support cross-agency collaboration for child abuse cases, and targeted areas for future research to enhance the quality of evidence for this common type of program/intervention.

Minimising trauma in staff at a sexual assault referral centre: What and who is needed?

INTRODUCTION

This study investigates staff's perspectives on the characteristics required to work in a sexual assault referral centre and the support and training they believe sexual assault referral centres should provide to minimise the negative impacts of the work and provide a supportive working environment.

METHODS

Semi- structured interviews were conducted with 12 staff, and a focus group was held with a further four staff of a sexual assault referral centre. The data were examined using thematic analysis.

RESULTS

Findings indicated that to work in a in sexual assault referral centre staff need to be understanding, empathetic, non-judgemental, supportive, flexible and resilient as well as having coping skills. The support structures and processes staff reported as being essential to creating a supportive working environment and reducing vicarious trauma were: supervision; training; peer support and shadowing.

CONCLUSIONS

Working in a SARC is stressful and emotionally difficult work. This study provides valuable insights about the individual and environmental factors SARC staff believe are required to have a happy and healthy workforce delivering a gold standard of care to victim-survivors of sexual violence.

Establishing Sexual Assault Care Centres in Belgium: health professionals' role in the patient-centred care for victims of sexual violence

BACKGROUND

Having ratified the Convention of Istanbul, the Belgian federal government commits itself to the foundation of Sexual Assault Care Centres (SACC). In the light of researching the feasibility of these centres, this study aimed to evaluate the care for victims of sexual violence (SV) in Belgian hospitals anno 2016 as well as to formulate recommendations for the intended model.

METHODS

Between April and October 2016, a questionnaire was distributed to 159 key health professionals active in 17 different hospitals attached to an AIDS Referral Centre. The survey covered four parts, i.e. the health professionals' profile, their knowledge, attitude and practices, an assessment of the hospital's policy and the caregivers' opinion on the care for victims of SV and on the intended SACCs. Subsequently, a descriptive analysis using 'IBM SPSS Statistics 23' was performed.

RESULTS

A total of 60 key health professionals representing 15 different hospitals completed the questionnaire resulting in a response rate of 38%. The results showed a lack of knowledge and practical experience of caregivers' regarding the care for SV victims. Approximately 30% of responders face personal or professional difficulties upon provision of care to victims of SV. Participants evaluate the current care as good, despite the limited psychosocial support, follow-up, insight for the needs of vulnerable groups and support for family, relatives and health professionals. Yet, the majority of health professionals appraise the SACCs as the best approach for both victims and caregivers.

CONCLUSIONS

By introducing a SACC, the Belgian federal government aims to provide holistic and patient-centred care for victims of SV. Essential in patient-centred health care is an extensive and continuous education, training and supervision of health professionals concerning the care for victims, support for family, relatives and caregivers. At the end and as a result of a participatory process with many professional experts as well as victims, a specific Belgian model, adjusted to the health care system anno 2016 was developed for piloting. The main challenges in establishing SACCs are situated at the institutional and policy level. Collaborating with other institutions and further research are herewith required.

Structural, Organizational, and Interpersonal Factors Influencing Interprofessional Collaboration on Sexual Assault Response Teams

Sexual Assault Response Teams (SARTs) are multidisciplinary teams that coordinate multiple systems (e.g., medical, law enforcement, prosecutors, and rape crisis center advocates) to provide comprehensive care to victims and to collect high-quality forensic evidence to facilitate investigation and prosecution. Relatively little guidance is provided about effective teamwork strategies in resources on forming SARTs. Using in-depth surveys with the SART coordinators and telephone surveys (including close-ended and open-ended questions) with 79 professionals involved in three active, formal SARTs in one state, this study examined structural, organizational, and interpersonal factors that influence interprofessional collaboration on SART. Study findings indicate that perceived structural factors and interpersonal factors were significantly associated with SART members'/responders' perceptions of the quality of interprofessional collaboration on their SART. Findings suggest that individuals' perceptions of professionalization and power disparities between professions pose challenges to perceived interprofessional collaboration on SART. Compared with criminal justice and medical professionals, victim advocacy rated the level of collaboration on their SART significantly lower. The overall picture from the data was that SART professionals perceived mutual respect, trust, and commitment to collaboration to be pervasive on their SARTs, even though recognition of professional conflicts was also prevalent, suggesting that professionals understood that interpersonal conflict was distinct from professional conflict. Initial SART trainings should address the benefits of the team response, professional roles, and communication and conflict resolution skills, and ongoing training should provide professionals the opportunity to raise positive and negative examples of their collaborative efforts to explore existing tensions and constraints on the team for conflict resolution.

Exploring the Sexual Assault Response Team Perception of Interprofessional Collaboration: Implications for Emergency Department Nurses

There is little research on the dynamics of the sexual assault response team (SART) members' interprofessional collaboration (IPC) practice. The study purposes were to (1) explore the perceptions of IPC among SART members; (2) evaluate the use of Perception of Interprofessional Collaboration Model Questionnaire with the SART; and (3) discuss the implications of the Interprofessional Core Competencies for emergency department nurses and sexual assault nurse examiners. This cross-sectional mixed-methods study (n = 49) was implemented using 4 SART teams in a mid-Atlantic state. There were no statistically significant differences in the subscales within the group level using analysis of variance but offered some valuable insight and content analysis. Emergency department nurses collaborate with different agencies and discipline within their working environment. Understanding the basics of IPC and the perception of IPC within the SART may open doors to further appreciate the dynamics of this team.

Contested Discourses in Multidisciplinary Sexual Assault Response Teams (SARTs)

This qualitative study explored how law enforcement officers, forensic nurses, and rape crisis advocates who are members of coordinated service delivery models such as Sexual Assault Response Teams (SARTs) describe their process of engaging with one another and managing their differences in professional orientation, statutory obligations, and power. Using semi-structured interviews with 24 SART responders including rape crisis center advocates, law enforcement, and medical personnel, we examined the ways that SART members discursively construct one another's role in the team and how this process points to unresolved tensions that can manifest in conflict. The findings in this study indicate that interdisciplinary power was negotiated through discursive processes of establishing and questioning the relative authority of team members to dictate the work of the team, expertise in terms of knowledge and experience working in the field of rape response, and the credibility of one another as qualified experts who reliably act in victims' and society's best interests. Implications of these findings for understanding and preventing the emergence of conflict in SARTs are discussed.

Creating a Victim Notification Protocol for Untested Sexual Assault Kits: An Empirically Supported Planning Framework

In cities throughout the United States, hundreds of thousands of sexual assault kits (SAKs) have not been submitted by the police for forensic DNA testing. Given recent media attention and public outcry about this problem, many jurisdictions with large numbers of untested SAKs are deciding to test all previously unsubmitted SAKs, which raises complex issues regarding when and how victims ought to be notified about what has happened to the kits that were collected during their medical forensic examinations. In this project, we collaborated with one community that has had large numbers of untested SAKs-Detroit, Michigan-to develop an empirically supported planning framework for how to create a victim notification protocol. This planning tool presents 12 discussion questions that can guide communities through the process of creating a victim notification protocol tailored to the needs of their local jurisdiction. In this article, we review the evidence (both practice and research based) that can inform discussions about each of these 12 key questions.

Is there a role for paediatric Sexual Assault Nurse Examiners in the management of child sexual assault in Australia?

In Australia, paediatricians and Child Protection Specialists provide the medical and forensic examinations of child victims of sexual assault. There are workforce challenges in the recruitment and retention of doctors to undertake child sexual assault (CSA) work particularly in remote and rural areas. Pediatric Sexual Assault Nurse Examiner (PSANE) programs have existed in the USA and the UK for many years. Using Rapid Evidence Assessment (REA) methodology, a systematic search of the literature was performed to ascertain what is known about SANE programs, to evaluate the evidence for their effectiveness across a number of domains (accessibility, health and legal outcomes and cost effectiveness) and to inform policy on models of care and elements of best practice which may be appropriate for local implementation in Australia. This review showed that despite the limited evidence available and significant gaps in the evidence, SANEs provide a high standard of medical care and are not detrimental to the legal process. By providing recommendations regarding the potential value, effectiveness and feasibility of establishing a PSANE program in Australia, this article may be of interest to other high income countries facing similar workforce challenges in meeting the needs of children with alleged sexual assault.

The Sexual Assault Nurse Examiner's Interactions Within the Sexual Assault Response Team: A Systematic Review

Many emergency department nurses care for the sexually assaulted victim, when sexual assault nurse examiner (SANE) programs are not available. Therefore, it is important for emergency department nurses to understand the roles of both the SANE and the sexual assault response team (SART). The purpose of this systematic review was to identify the current research on the integration of the SANE among the SART and evaluate the gaps in research of the SANE's role, attitude, behavior, and satisfaction within the collaborative SART. Studies published between 2004 and 2014 using key words were evaluated. A 3-stage search strategy revealed 582 articles. The articles were assessed and categorized according to Level of Evidence definitions. Twelve qualitative and mixed-methods studies were identified. Studies ranged from SART protocols or responses to situational factors to SANE relationships with other SART members. The review reflected the need for more research within the collaborative atmosphere of this multidisciplinary and interagency team that defines the SART, and the individual member's perceptions. Further studies are needed on the SANE's impact on patient outcome and the emergency department nurses role when a SANE or SART program is not available.

"Catching flies with honey": the management of conflict in Sexual Assault Response Teams

Sexual Assault Response Teams (SARTs) are models of service delivery characterized by coordination between rape crisis, health care, and criminal justice sectors. Expanding on research documenting the extent and nature of conflict in SARTs, this study qualitatively explores the strategies used to manage conflict and variations in the use of strategies between professions. Analysis of interviews with SART members (n = 24) revealed five types of strategies: (a) preventative strategies sought to prevent conflict and build capacity for resolving conflict, (b) problem-solving strategies identified and responded directly to conflicts, (c) forcing strategies involved one person attempting to force a perspective or solution on others, (d) unobtrusive strategies covertly worked toward change, and (e) resigned strategies limited direct responses to conflict to protect the coordination. Rape crisis advocates talked the most about conflict management strategies and were almost exclusively responsible for unobtrusive and resignation strategies.

Sexual Assault Response Teams (SARTs): mapping a research agenda that incorporates an organizational perspective

Multidisciplinary coordinated Sexual Assault Response Teams (SARTs) are a growing model of providing health, legal, and emotional support services to victims of sexual assault. This article conceptualizes SARTs from an organizational perspective and explores three approaches to researching SARTs that have the potential of increasing our understanding of the benefits and challenges of multidisciplinary service delivery. These approaches attend to several levels of organizational behavior, including the organizational response to external legitimacy pressures, the inter-organizational networks of victim services, and the negotiation of power and disciplinary boundaries. Possible applications to organizational research on SARTs are explored.

Interdisciplinary team communication among forensic nurses and rape victim advocates

Victim advocates and forensic nurses provide integrated care to address the complex legal, medical, and mental health needs of rape survivors. Research suggests that conflict exists between nurses and advocates, but it remains unknown how their communication patterns contribute to or resolve these conflicts. Utilizing a qualitative case study approach, the current study interviewed 24 nurses and advocates from a Midwest organization to better understand team communication patterns when addressing conflicts. The findings suggest that most nurses communicate concerns directly while advocates avoid direct communication. Factors that influenced direct and indirect communication and their implications for practice will be discussed.

Prosecution of adult sexual assault cases: a longitudinal analysis of the impact of a sexual assault nurse examiner program

Most sexual assaults are never reported to law enforcement, and even among reported cases, most will never be successfully prosecuted. This reality has been a long-standing source of frustration for survivors, victim advocates, as well as members of the criminal justice system. To address this problem, communities throughout the United States have implemented multidisciplinary response interventions to improve post-assault care for victims and increase reporting and prosecution rates. One such model is the Sexual Assault Nurse Examiner (SANE) program, whereby specially trained nurses (rather than hospital emergency department [ED] physicians) provide comprehensive psychological, medical, and forensic services for sexual assault victims. The purpose of this study was to examine whether adult sexual assault cases were more likely to be investigated and prosecuted after the implementation of a SANE program within a large Midwestern county. A quasi-experimental design was used to compare criminal justice system case progression pre-SANE to post-SANE. Results from longitudinal multilevel ordinal regression modeling revealed that case progression through the criminal justice system significantly increased pre- to post-SANE: more cases reached the "final" stages of prosecution (i.e., conviction at trial and/or guilty plea bargains) post-SANE. These findings are robust after accounting for changes in operation at the focal county prosecutors' office and seasonal variation in rape reporting. Implications for policy and practice are discussed.

Sexual assault nurse examiners' perceptions of their relationship with doctors, rape victim advocates, police, and prosecutors

In response to the negative and inefficient treatment of rape victims by emergency room personnel, the first Sexual Assault Nurse Examiner (SANE) programs began in the late 1970s. While SANEs, doctors, rape victim advocates, police officers and prosecutors work together to ensure the most comprehensive and sensitive care of rape victims, they all have very different roles and objectives. This research explores SANEs' perceptions of their relationships with other professionals who treat or interact with rape victims. Data from interviews with 39 Sexual Assault Nurse Examiners from four East Coast states indicate positive relationships are marked by open communication, respect shown towards SANEs as well as rape victims, and a sense of appreciation among SANEs. On the contrary, negative relationships result when SANEs believe police treat victims poorly, when advocates overstep boundaries and question SANEs about evidence collection or the exam, and when prosecutors fail to properly prepare them to testify during a trial.

Adult sexual assault survivors' experiences with sexual assault nurse examiners (SANEs)

Sexual assault survivors often feel traumatized by the care received in traditional hospital emergency departments. To address these problems, Sexual Assault Nurse Examiner (SANE) programs were created to provide comprehensive medical care, crisis intervention, and forensic services. However, there is limited research on the actual experiences and emotional impact of sexual assault survivors who seek treatment from SANEs. This qualitative study examined twenty rape survivors' experiences with forensic nurse examiners of a Midwestern SANE program. Findings suggest that SANEs provided survivors with care and compassion, clear explanations, and choices. Taken together, these positive experiences were perceived as "humanizing". However, some survivors perceived forensic nurses as hurtful when they were not provided with choices, explanation, and/or acted cold and distant. Implications for future research on SANE care and practice are discussed.

Victim confidentiality on Sexual Assault Response Teams (SART)

The purpose of this study is to examine how professionals and paraprofessionals involved with a Sexual Assault Response Team (SART) understand and navigate different professional statutory requirements for victim confidentiality. Telephone surveys are conducted with 78 professionals: medical (27.8%), criminal justice (44.3%), and victim advocacy (27.8%). The majority of participants (58.2%) disagree with the statement that maintaining victim confidentiality posed a challenge to coordination on SART, 10.1% were neutral, and 31.7% agreed with the statement. Significantly more victim advocates than criminal justice and medical professionals perceive that maintaining victim confidentiality posed a challenge to coordination on SART. Consensus on how best to conceptualize victim confidentiality within SART has not been attained. Findings show that not all criminal justice and medical professionals understood the statutory provision of privilege to communications between rape crisis victim advocates and victims. Implications for practice and research are discussed.

Interprofessional collaboration on Sexual Assault Response Teams (SART): the role of victim alcohol use and a partner--perpetrator

The purpose of this study was to examine the role of victim alcohol use and partner-perpetrator on interprofessional collaboration on Sexual Assault Response Teams (SART). Telephone surveys with 78 medical, criminal justice, and victim advocacy professionals were conducted. When asked to identify case factors that pose challenges to interprofessional collaboration, 48.7% mentioned victim characteristics and 28.2% mentioned situation characteristics. Significantly more victim advocates identified aspects of the victim's behavior before the sexual assault as a challenge to collaboration compared to criminal justice professionals. Using vignette methodology, professionals anticipated more disagreement between SART professionals on the hypothetical case involving victim alcohol use and a partner-perpetrator compared to a hypothetical stranger/no alcohol case, with victim advocates rating agreement significantly lower than other professionals. Finally, professionals who perceived of more disagreement between professionals when discussing the vignettes also perceived of lower interprofessional collaboration on their SART. Implications for practice and research are discussed.