Evaluating SANE Programs

Sexual Assault Nurse Examiner (SANE) programs were created by nursing professionals to address the under-reporting and under-prosecution of adult sexual assaults by providing comprehensive medical care to survivors and expert forensic evidence to the legal community.

To date, there are more than 600 SANE programs in every state in the country, addressing the unique and often complex needs of sexual assault victims, according to the International Association of Forensic Nurses (IAFN). And while SANE programs are held up as the model for best practice in the case of sexual assault victims, only a handful of programs have been evaluated rigorously.

Rebecca Campbell, PhD, professor of community psychology and program evaluation at Michigan State University, says SANE programs caught on and spread quickly throughout the United States and internationally, but they did so with little evaluative data to guide implementation. 

Studying SANE

Campbell’s research focuses on sexual assault and how the legal, medical, and mental systems respond to the needs of rape survivors. She and her team conducted a series of research studies on how SANE programs impact adult sexual assault prosecution, including the following:

• By analyzing criminal case outcomes five years prior to the launch of a SANE program and during the first seven years of SANE programs, one study found that more sexual assault cases moved through the legal system and raised guilty pleas or trial convictions from 24% to 29% after the implementation of a SANE program. 

• An examination of SANE program goals and philosophies and how they influenced patient care practices for sexual assault victims found that programs with a primary goal of case prosecutions lacked comprehensive victim services, including education that impacts a victim’s long-term well-being.

• A national random sampling of 110 SANE programs found consistency in forensic evidence collection, sexually transmitted infection prophylaxis, information on HIV and pregnancy risk, and referrals to community resources.

Several SANE studies have confirmed that the criminal justice system benefits from SANE programs through quality evidence collection, expert testimony, and improved communication with law enforcement. The common thread in these studies is that SANE programs lead to increased arrest rates, charges, convictions, and sentences in sexual assault cases. 

These studies also noted the impact of SANE nurses is felt on many levels:

• SANE nurses attend to the medical, forensic, and psychological needs of sexual assault victims;

• SANE nurses have extensive training and experience in forensic evidence collection;

• SANE programs may increase prosecution rates in their communities by collecting forensic evidence that increases the likelihood of case referral by police;

• SANE programs contribute to the recovery gains made by victims.

But a number of studies, including a 2007 study from the University of Kentucky, pointed out that only a small number of programs had a formal reporting system in place that communicates case outcomes, including arrests, prosecutions, and convictions. Knowledge of case outcomes, study authors noted, provides a learning experience by identifying strengths and weaknesses at both the law enforcement and medical community levels. 

At the first national SANE Coordinator Symposium in 2009, the group called for additional research in several areas, including developing best practice for SANE programs and compiling SANE models used nationally.

SANE Toolkit

Campbell and her team used a competitive grant from the National Institute of Justice to develop a practitioner toolkit for evaluating the work of SANE programs. The toolkit offers three evaluation designs:

• Pre-SANE/post-SANE evaluation—compares how far cases progress through the criminal justice system before and after the implementation of the SANE program;

• Post-SANE-only evaluation—compares how far cases progress through the system after launching a SANE program;

• Ongoing evaluation—charts prosecution outcomes from this point forward.

The toolkit walks users through a six-step evaluative process and offers ideas for using those findings to improve best practices, as well as reporting, investigation, and prosecution of sexual assault cases. The goal of the toolkit is to assist SANE program staff in evaluating how their program affects the progression of sexual assault cases through the criminal justice system.

The four main sections of the toolkit include a basic overview for conducting a program evaluation, an introduction of how SANE programs create change in communities, a step-by-step explanation of the three types of evaluations a program can use, and an illustration of how to create community action by determining what works and what needs to be improved in a particular SANE program. 

The pilot program evaluated six SANE sites—two rural, two mid-sized, and two urban programs. The pilot found that most sexual assaults reported to law enforcement (80% to 89%) were never referred by police to prosecutors, or there were no charges filed by the prosecutor’s office. None of the programs had a statistically significant increase in prosecution rates pre-SANE to post-SANE, but cases processed post-SANE were 80% more likely to achieve convictions or guilty pleas.

Campbell said the evaluative results of the six programs are representative of SANE programs nationwide. “Nationally, this is very typical,” she says. “We’ve seen a lot of studies where most sexual assaults reported with forensic exam do not end up in successful prosecution. That’s what the six programs in this study highlights. 

“This continues to be an issue, a problem.”

Campbell says the toolkit did what her team hoped it would do—it got people talking and looking at data to see what’s really happening in their communities, in regard to sexual assault cases. She says the toolkit resulted in communities applying for new grants to form new programs or to revitalize existing sexual assault response teams. 

The toolkit and materials are available for public distribution through the National Criminal Justice Reference Service, and other SANE programs are starting to use it, according to Campbell. She says she hopes to secure additional grant funding to create a more interactive, web-based version of the toolkit.

“There is only so much one organization—one discipline—can do in terms of trying to address the problem of under-prosecution of sexual assault,” Campbell says. “Nursing programs focused on patient care and forensic work should continue to focus on good patient health outcomes, because it’s a crapshoot on what happens in the legal system.”

Creating a SANE Program

Diane Daiber, RN, SANE-A, a forensic nursing services coordinator at the Cleveland Clinic in Ohio, was working as a staff RN and case manager in the emergency department setting for 19 years when she realized there was a disconnect between health care and patients touched by violence. 

“Many nurses will describe taking care of a patient who has experienced sexual assault and not having the understanding or knowledge about sexual violence to provide optimal care,” says Daiber, adding that most nurses have no training in assessment of sexual assault or in the collection of evidence. “I cannot think of any other diagnosis that is handled that way. I knew there must be a better way of caring for patients who have experienced violence, and took the SANE training.”

She took her initial SANE class in 2001 with two other nurses and was granted the opportunity by her employer to develop a SANE program at Hillcrest Hospital in the Cleveland Clinic system. Today, the SANE program employs four SANE-A (adolescent/adult), two of whom have dual certification in SANE-P (pediatric). 

Daiber says once the program was developed, the benefits became clear. The Cleveland Clinic SANE practice evolved to forensic nursing, with SANEs responding to domestic violence and other forms of maltreatment and trauma, as well as sexual assaults.

“As nurses, our priority is the health and welfare of our patient. We provide one-on-one, holistic, patient-centered care,” says Daiber. “Sexual assault has short- and long-term health consequences. We understand the neurobiological effects of trauma.

“Our goal is to decrease the effects of that trauma and begin the healing process from the moment we meet this patient and their family or significant others.”

The Cleveland Clinic’s SANE practice is hospital-based, with most patients seen in the emergency department. But SANEs will travel to other nursing floors for consultation, and forensic teams travel to other hospitals in the Cleveland Clinic system if the patient’s medical condition prohibits her or his transport to a SANE.

Daiber says there is great interest in the field, but the on-call structure of most departments makes it challenging for nurses to maintain a commitment. She explains that expanding the patient population to include domestic and teen dating violence, child and elder maltreatment, liability-related issues, and trauma patients will ensure the most comprehensive use of the clinical skills of the forensic nurse.

“The key is that forensic nurses have trauma-informed care skills to provide care to patients that have experienced all forms of trauma and abuse,” says Daiber. 

Preparing Tomorrow’s Forensic Nurses

More and more schools of nursing are adding forensic nursing certificate and degree programs to address the increased interest.

“There is no specific path to getting into the field,” says IAFN President Polly Campbell, RN, BS, BA. “Some nurses seek out the forensic nursing role through their workplace; others discover the role through reading, webinars/educational sessions, or colleagues; others pursue it through higher education.”

Educational opportunities in forensic nursing have increased significantly in the last 10 years, says Jennifer R. Campbell, program coordinator and assistant director of the University of California, Riverside Extension, which offers a Forensic Nursing Certificate through an online degree program that focuses on victim advocacy and investigative sciences. 

Mary Kozub, PhD, RN, assistant professor and forensics advisor at Xavier University School of Nursing in Cincinnati, Ohio, says television and media are driving a societal and cultural fascination with forensic sciences. She jokes about writing a letter to the crime drama CSI to suggest adding a forensic nurse to the team to educate the public about their work.

Xavier offers an MSN forensic nursing concentration, in addition to a dual degree option with the Criminal Justice Department. As a nurse at Cincinnati Children’s Hospital Medical Center for six years, Holly Shively saw everything from trauma to gunshot wounds in the operating room. When she was looking for advanced educational opportunities, she found the forensic nursing program at Xavier University and refocused her career goal on working in homicide and, potentially, a coroner’s office.

“I would like to do evidence collection and expert witness testimony in the court system,” says Shively, adding that she worked with the local police homicide unit and the coroner’s office through the Xavier program. “I was able to do anything they were doing at any of the crime scenes, including collecting evidence, taking pictures, interviewing suspects and witnesses. I actually went into the crime lab and learned to do fingerprinting. They taught me their skills.”

Susan M. Schmidt, PhD, BSN, MSN, CNS, COHN-S, CNL, director and professor/epidemiologist in the Xavier University School of Nursing, says she worked with the Criminal Justice Department at the university on the dual degree option because health care workers do not understand crime scenes and the importance of protecting evidence, as well as how to treat a criminal and a victim with respect and dignity.

“A nurse could bring a lot to that crime scene,” says Schmidt. “We’re moving as a nation into a whole new area of the Affordable Care Act. With that, we’re moving into population health and away from taking care of sick people, trying to take care of well people and keep them from getting sick.

“Forensic nursing will help one of the leading causes of ill health in our nation turn around.”

Job Outlook

While SANE programs—and the forensic nurses behind them—are making an impact and interest in the field is growing among nursing professionals, finding a job in this relatively new and still evolving field can be a challenge.

In the United States, most forensic nurses practice in hospitals, but they can also work in child advocacy centers, universities, community anti-violence programs, coroners’ and medical examiners’ offices, corrections institutions, and psychiatric hospitals. They also may be called in on mass disasters or to help out during community crisis situations.

According to the US Bureau of Labor Statistics, there were 2.7 million registered nurses in the United States in 2010. Job growth for RNs is expected to grow by 26% through 2020. 

The IAFN’s goal is to have a forensic nurse in every hospital and venue where her or his skills are needed. But because it is a relatively new specialty in nursing, there aren’t many jobs out there. Typically, a forensic nurse creates a job that is then recognized in the work setting. But Polly Campbell says there is a growing value and recognition of the skills forensic nurses bring to the table, and she is confident opportunities will grow with time.

“As is often the case, a forensic nurse must often pioneer her first position in a hospital or community since there is so little awareness of the role and what the specialty has to offer,” says Polly Campbell. “Changes in attitudes and beliefs, federal and state laws, and caring health care providers have all contributed to an improved standard of care for victims and perpetrators of violence. Forensic nurses are change agents, leading the way for all practitioners.” 

Kimberly Bonvissuto is a freelance writer based in Cleveland, Ohio.