By Joshua Vickers
Tucked away at the end of the third floor hallway in the Allen Riddle building at Newton-Wellesley Hospital are the three offices that make up the Massachusetts Sexual Assault Nurse Examiner (SANE) program’s first TeleNursing Center.
“The first thing we did was pick wall color in here,” said Chris Murphy, project manager for the Massachusetts SANE program. “We literally started with nothing.”
Designed and implemented by the Massachusetts SANE program over the last two years, the TeleNursing Center is the product of a grant issued by the federal Office for Victims of Crime (OVC) to bring the SANE program to military, rural and tribal locations.
The SANE program provides registered nurses who have received specialized training in treating victims of sexual assault while properly documenting forensic and historical evidence of the attack. The quality of the evidence collected by SANE nurses has proven to be beneficial in identifying and prosecuting offenders.
“I’m a big proponent for what they do,” said Lieutenant Detective George Juliano of the Boston Police Department’s (BPD) Sexual Assault Unit. “We’ve got one shot to get it right. When you say that to a SANE nurse, they understand that.”
Juliano has been with the BPD’s Sexual Assault Unit for seven years. In his experience, the level of detail in the historical and physical evidence collected by a SANE nurse provides a great starting point for a police investigation without adding the stress of a police interview to the victim’s experience.
“It’s a victim empowerment model,” Juliano said. “Any time you can lower the anxiety of the victim or the patient in our case, you’re going to have better results.”
But while the SANE program works closely with law enforcement to provide the best evidence possible for prosecution, its primary goal is to always do what is best for the patient, whether the patient chooses to allow the collection of a rape kit or not. “The mission is providing compassionate, comprehensive, coordinated forensic expertise,” said Joan Sham, director of the Massachusetts SANE program. “So we are doing our best to ensure that it’s trauma-informed, patient-centered, patient-sensitive. We’ve put a lot of focus on building that up front,” she said.
After sexual assault victims are medically cleared by an emergency room practitioner, they have the choice in consenting to an exam by a SANE nurse in which a rape kit is collected. Accompanied by an advocate from a local rape crisis center, SANE nurses only focus on one patient and can take up to eight hours to do a thorough exam, said Cheryl Re, project co-director and SANE nurse.
SANE nurses in Massachusetts are on-call 24/7 to treat adult and adolescent victims of sexual assault in 27 hospital emergency rooms across the state. They also provide pediatric care to young children in seven advocacy centers, Sham said.
But not all states have a centralized SANE or similar program that provides specialized care for sexual assault patients. This is especially true in rural or tribal areas where there are fewer, less advanced hospitals. But what is also similar among the target populations for the TeleNursing Center is the high levels of reported and unreported sexual assaults, according to the Massachusetts Department of Public Health (DPH).
The ability of SANE nurses to properly care for sexual assault victims is something that the SANE program and the DPH indicates will help more victims in the target populations feel comfortable reporting their attack, especially in the military.
“If they’re truly successful in making their ranks feel as though there is a better response, there is more support, more protection for them, then you should see the numbers go up because they should more readily come to disclose,” Re said.
The effectiveness of the SANE program has led federal and state governments to take steps to bring programs like SANE to as many hospitals as possible.
In August of 2013, the Texas senate approved a bill requiring that all emergency rooms staff at least one nurse that has received a minimal level of specialized training in treating sexual assault victims and evidence collection.
In December of 2013, both the US House and Senate approved the National Defense Authorization Act which included a stipulation that all US military hospitals operating a 24-hour emergency room must staff at least one full-time SANE nurse.
With its grant, the OVC sought to pilot the use of TeleNursing to bring the SANE program to places that lack a significant program that can train and coordinate SANE nurses. The Massachusetts SANE program was one of 11 applicants to receive the OVC’s grant and was chosen because it is the most organized program in the nation, Sham said.
“We feel like we have a gold-standard model in a lot of ways,” Sham said. “We’re the only statewide SANE program in the country where everything is centrally managed. So we have statewide protocols, we have statewide training curriculum, we have statewide evidence collection kit.”
While the OVC’s three-year grant provided the funding for the TeleNursing Center, Sham and her colleagues had to put it together themselves with no existing standard or model to work from.
“It was like building a plane while you’re trying to fly it,” Re said.
Since October of 2012, Sham said, she and her colleagues have found a location for the TeleNursing Center and designed and tested all of the protocols that will be followed by nurses participating on both ends of the communication line. They also put together a curriculum to provide 32 additional hours of training for Massachusetts’ SANE and 16 hours for Navy nurses, including role-playing and mock-trials to give nurses a chance to practice for the real thing.
Two Navy pilot sites in Twentynine Palms, California and Jacksonville, Florida will be the first locations the TeleNursing Center will be working with once the project begins operation. Operations have been delayed since the TeleNursing Center’s scheduled opening last October because the Navy has yet to approve Massachusetts nurses to practice in those states, Sham said. Repeated attempts to get comments from the Navy’s Bureau of Medicine and Surgery on this matter were unsuccessful.
The TeleNursing Center will be using live video technology provided by American Doctors Online that will be routed through the Department of Justice and the Department of Defense to have the highest level of network security, said Stacy Garrity, the Education and Outreach Manager for the project.
Every patient will have the on-site clinician, a nurse or otherwise, to conduct the exam along with a local victims’ advocate for support. The SANE nurses at the TeleNursing Center will guide them through the exam and offer support to the clinician in the room with the patient.
The goal is to bring the Massachusetts SANE program’s expertise to clinicians that are not as experienced with treating sexual assault. As they already do for SANE nurses in their own program, the Massachusetts SANE nurses will also provide debriefing for the remote clinicians after the exam. Providing that kind of support to the nurses is one of the most important parts of the program for Sham and her colleagues.
“Really, we’re trying to increase the level of expertise, whether or not they’re SANE nurses, in a sense of support for them so that they’re feeling confident and competent and don’t get burned out from doing this work,” Sham said.
Sham explained that nurses from all over the state of Massachusetts volunteered to participate at the TeleNursing Center. She and her colleagues selected 22-25 nurses that will be volunteering 2-4 shifts a month in 8-12 hour shifts to keep the TeleNursing Center staffed 24/7.
With no word yet as to when the TeleNursing Center will begin operations, Sham and her colleagues keep preparing themselves and their nurses, eagerly awaiting the chance to take the next step in treating sexual assault. It will be the culmination of a career-long commitment for many of the nurses involved, 40 percent of which have been with the Massachusetts SANE program for ten years or more, Sham said.
“Theres a huge passion of the women that are doing this work,” Sham said. “It’s not a well-paid, well-known profession and people aren’t doing it for those reasons. They really want to be making a difference.”