WHAT IS A SAFE NURSE?

Forensic nursing with a sub-specialty in sexual assault is a relatively new field in the US. Definitions of sexual assault are not standardized yet. The CDC is currently working on this. The name of the nurse specializing in the treatment of sexual assault is also not standardized. The job description and the qualifications for it vary with the legal jurisdiction and hiring institution. I am dealing only with Maryland based definitions, as this is where I live, train and work.

I am aware of the at least 3 titles. There are likely more.

SAFE = Sexual Assault Forensic Examiner (Maryland's former acronym)
SANE = Sexual Assault Nurse Examiner
FNE = Forensic Nurse Examiner (This is the particular acronym Maryland has now adopted as of 2003).

The various acronyms all mean nurses with specialized training and practice rights to assess and treat sexual assault victims/survivors who plan to press charges and who have police involvement in the emergency room.

WHERE DO SAFE NURSES WORK?

The way a SAFE nurse is made available varies by the hiring institution’s practice. In my particular hospital every sexual assault patient coming into the Emergency Room is assigned to a regular staff ER nurse and a SAFE nurse. The ER nurse is there from the beginning and calls in the SAFE nurse and the rape crisis center patient advocate. If the police are not yet there the ER nurse also calls the police. In our hospital, we have a SAFE nurse “on call24/7. Our on call time is scheduled and posted in the ER so the ER nurse knows whose pager to call. When we are the SAFE nurse on call we are expected to be ready and able to report to the ER as soon as possible, but always in less than 45 minutes of being paged. We are paid for being on call and paid additionally if we see a case and for our time in court. We do not see other patients while working as a SAFE nurse. In some other settings within Maryland a SAFE nurse is always on duty as a member of the 24/7 ER staff. If there is not a need for them in that capacity they may work as regular ER staff or on other aspects of their job as a SAFE nurse, such as education, statistics or research projects. These specifics depend on the hiring institution’s job descriptions. Not all hospitals in Maryland have SAFE nurse programs. In some areas this is a real deficit, in other areas certain hospitals take all the local cases and do the job very well, doing many cases, gaining wide experience and conducting training and outreach programs. For example, Mercy hospital takes all adult sexual assault cases in Baltimore City.

SAFE nurses document injuries and collect evidence from the body of accused offenders in some settings. The examination of the accused offender may take place in the setting of the emergency room or in the setting of a jail or correctional facility. Either way, the SAFE nurse’s job is still the objective collection of evidence and documentation of injury.

WHAT ARE THE ADVANTAGES OF A SAFE NURSE PROGRAM?

There are many advantages to having a SAFE/SANE/FNE nurse program in the emergency room. With a SAFE nurse as much as possible of the patient’s treatment is done by one person, minimizing patient distress and confusion. The SAFE nurse has specialized training and a desire to do this work. The SAFE nurse has the time to do the job right. Sexual assault forensic exams typically take 1 to 3 hours of direct patient contact. Many doctors and nurses in the emergency room are not comfortable with treating victims of sexual assault and have had little or no training to do so. They may be reluctant to be drawn into the legal system especially with the need to testify in court. The regular emergency room staff is responsible for triaging of all emergency patients and the person with more severe physical trauma or medical needs will obviously and appropriately take precedence over the typical sexual assault patient. Before the advent of SAFE nurse programs many sexual assault patients were forced to deal with multiple delays and far too many caregivers while in the ER. While waiting for examination the patient is not supposed to use the bathroom or eat or drink anything. Imagine needing to pee and being told “no”, “you must hold it” while your nurse sees another patient and if you can’t; knowing your simple act of urination may cause your case to be lost in court. Perhaps one of the most important advantages of the SAFE nurse is the proven increase in successful prosecution and conviction of the crime when SAFE nurses are involved. With fewer staff involved and with more time and training SAFE nurses do a better job of collecting and preserving forensic evidence and in protecting the chain of evidence. Patient satisfaction with their ER medical treatment has also been shown by research to be higher when said treatment is managed by a SAFE nurse. I would speculate (this is not research based) that a person who is more satisfied with their initial medical/forensic treatment/exam would also be able to better negotiate the psychological and legal hurdles that will be faced in the future. I would hope that this would help to reduce the incidence of re-victimization that we know occurs. A victim of sexual assault is statistically more likely to experience sexual assault again than a person who has never been sexually assaulted (this is research based).

Obviously the potential for increased stress to the patient is high. I believe that handled sensitively, the sexual assault forensic exam can be the beginning of the patient’s healing process instead of increasing the trauma. The patient’s body has become, in essence, a crime scene. A good examiner will be able to do efficient and effective collection of evidence from that “crime scene” while still being constantly aware of and dealing with that body as a person who has screaming needs and fears. Victims of sexual assault suffer from higher levels of dissociative disorders as well as depression and anxiety disorders that the average population. My hope is that at the conclusion of a sexual assault forensic exam the patient’s body and the mind are beginning to reintegrate, that the sexual assault forensic exam can be the beginning of the process of moving from victim to survivor as well as an aid to the criminal justice system.

WHAT DOES A SAFE NURSE ACTUALLY DO?

WHEN EXAMING A VICTIM OF AN ALLEGED SEXUAL ASSAULT, the SAFE nurse does a forensic history and explains the examination that will follow. She (or he) obtains permission from the patient to proceed. She will usually have a pattern she prefers to follow when doing the exam. This minimizes omissions and backtracking, in other words makes the exam more efficient and through. Typically the SAFE nurse will draw the patient's blood very early in the process. Pregnancy test results are needed before any prophylactic can be administered. Most rape drugs metabolize very quickly so it is important to draw blood for them early. The patient's history of the assault and the aftermath and the patient's immediate needs for food/drink/urination will also influence how the exam proceeds. But, with some variations in timing and sequencing the SAFE nurse basically observes and documents patterns of injuries and collects and preserves physical evidence from patient’s body and/or clothing. The entire body is examined clothed then nude. Clothing may be kept as evidence. A focused exam of any injuries or areas with potential evidence and/or the genitalia is performed. A speculum-assisted exam is usually done on adult females who report penetration but not on young girls. A detailed examination of the mouth or anus may be performed, depending on the report by the patient of what took place during the assault. The person (In Maryland 95% females) is examined for obvious and less than obvious and at times nearly microscopic, injuries. Special lamps, dyes and magnifying devices are used to locate, highlight and document the presence of injury and/or evidence.

Types of injury and the location(s) of evidence and/or injuries are documented with written descriptions, sketches, photographs and/or videotapes. Evidence may be bodily bits (semen, blood, hair, skin cells, saliva), or bits and pieces of “stuff” such as fabric, dirt, or debris from the crime scene still stuck to the patient or her clothing. SAFE nurses examine suspected semen microscopically for the presence of sperm and send samples for DNA analysis. Knowing in a timely manner if the suspect fluid is indeed semen may guide the immediate police investigation. DNA analysis results, while extremely valuable in the courtroom take a much longer time to obtain and are not as immediately useful.

The SAFE nurse does routine but limited medical treatment, teaching and counseling in the emergency room setting. We have standard protocols mandated by our licensing board to test for and dispense medications for sexually transmitted diseases and potential pregnancy. SAFE nurses use standard protocols for the prophylactic treatment of STDs and the morning after pill, as the patient desires. We work under the supervision of a emergency room physician although in reality if all is routine the physician is just signing off on our protocols and may only see the patient for minutes. The is the way most advanced practice nursing works, routine protocols for routine problems in the area of specialization and anything outside of routine also seen by the supervising physician. The SAFE nurse may treat very minor injuries (as could any nurse) but anything outside her area of practice is deferred to an emergency room physician for additional treatment and/or orders for treatment. Depending on her broader experience and qualifications and her specific institutional job description the SAFE nurse may then follow those orders or defer them to another ER nurse. For example, in my case, I am not an experienced ER nurse, my experience as a nurse is mostly with new mothers and babies. I would not clean and dress any wound beyond a minor one. I would ask the more experienced ER nurse assigned with me to care for the patient to do the wound treatment instead.

Priorities must be set to maximize the collection of forensic evidence AND the patient’s comfort and security. Police remain in the ER for the entire exam but are not in the exam room. The earlier the exam is done following the assault the better. Blood work should be drawn ASAP so results are back ASAP and to maximize the capture of possible drugs. It is better if the genital exam is done prior to the patient using the bathroom. If there has been oral contact the mouth exam should be done before the patient eats, drinks or brushes her teeth. In most cases a forensic exam is not valuable for evidence collection over 72 hours from the time of the assault but the patient may still require medical treatment. There are exceptions to the 72-hour "rule" but most injuries heal quickly and most evidence is long gone after 3 days. If "just" medical treatment is required a SAFE nurse doesn't get involved and the medical treatment is handled by regular emergency room staff. SAFE nurses are only involved when evidence collection for potential legal prosecution is planned. We must have a police case number to proceed. The state of Maryland pays for our services, not the patient or her insurer. In fact it is illegal to bill the patient for these services. The patient’s level of distress and ability to understand must be factored into the teaching and counseling as well as to the obtaining of consent. If a victim is too drugged or drunk she may be admitted and left to sleep it off until her blood alcohol levels drop enough to allow her to make an INFORMED consent for the forensic exam. This may reduce the value of the exam because it delays it but must be done because the exam can only be done with the patient's (or legal guardian’s) informed consent.

Appropriate follow up must be assured. Most SAFE nurses team with a rape crisis center and in my hospital a patient advocate from the center is almost always present during the exam. The patient can decline having an advocate but most appreciate them. Working collaboratively with police, the district attorney, a rape crisis center and other ER staff or community based health care providers allows the SAFE nurse to do the exam and early medical treatment efficiently and compassionately. It allows the police investigation and if deemed appropriate the prosecution of the crime to proceed smoothly. It begins the longer-term therapeutic relationship(s) the patient may later use for further counseling with the rape crisis center or other health care provider(s).

As needed, upon completion of the exam and treatment the patient should also be offered something to eat and drink, clean clothing, the place and time to clean up and be assured of immediate safety and support upon leaving the emergency room. The SAFE nurse should know how the patient is going to get home or to a safe location, what provisions are being made to assure her immediate safety and who will be with her. This is of course done in collaboration with the police and the rape crisis center. We even have a mobile crisis unit that can be called in for complicated cases.

Family and/or friends of the patient are also often present. They are often secondary victims and may also require counseling and assistance. They are a mixed bag and may confuse the forensic aspect of the exam. It is usually best for only the patient advocate and the SAFE nurse to be in the exam room with the patient during the actual physical examination.

WHEN EXAMING AN ALLEGED OFFENDER, the SAFE nurse’s job is still the objective collection of evidence and documentation of injury (scratches, bites, nail scrapings, etc.). This may involve drawing blood or doing penile or other skin swabs or collecting hair and/or finger nail scrapings. This is always done with a police guard and a legal subpoena. It should also be done with a professional attitude. We do not know the ultimate outcome of the case. We do not medically treat accused offenders as SAFE nurses although some SAFE nurses may overlap jobs and be working as an emergency room nurse or a corrections facility nurse and might then (under the other job title) also do some normal nursing treatment(s) as medically ordered.

WHY EMPHASIZE BEING “OBJECTIVE”

SAFE nurses are patient advocates, as are all good nurses, but must remain objective on the job. We do not know the ultimate legal outcome of the case at the time of the exam. The evidence we collect may incriminate or exonerate an accused offender. Even when it seems “obvious” that a crime has taken place if the SAFE nurse loses objectivity she reduces her credibility as a potential witness in court. We are most useful to the prosecution when declared an "expert witness" as that allows us to express an opinion, not just facts. If we are not objective it is unlikely we will qualify as an "expert witness". Whether the person being examined is a patient and the victim of an alleged sexual assault or is the alleged offender being objective is essential to the forensic aspect of the job.

Being objective does not exclude having empathy for the patient/victim, whom we also treat and counsel. It doesn’t stop a therapeutic relationship from developing over the 2 to 4 hours the nurse and patient spend together.

Being objective and maintaining an attitude of professionalism and respect toward an alleged offender can be difficult. We may really believe this person did the crime and we may have been the one to examine the victim as well. Still, it is the right thing to do. Because it is so difficult we need to examine our ability to do the job. We may need to allow another SAFE nurse to take over if we feel our own rage at the alleged offender is overwhelming. This is especially true in the more heinous cases when one has also been the examiner for the victim. SAFE nurses have a high level of secondary Post-Traumatic Stress Disorder like symptoms and often need debriefing or counseling of their own. Good programs provide for this.

SAFE nurses have legitimate concerns for our own safety as well. Maintaining a professional attitude when examining an alleged offender may make us less likely to become the target of retaliation. It also should makes it more likely that SAFE nurses will continue to be utilized in this fashion. This will likely enhance the legal proceedings because SAFE nurses do better evidence collection. The alleged offender's body is also a potential crime scene. As with the victim, if possible, he should not be allowed to shower, eat, urinate, etc before the exam. One of my trainers reported an alleged offender who shaved all his body hair before being apprehended. She admits to some delight in digging out the few stray follicles he missed but states she did not to show it. One case I was with involved a livid detective whose officers had allowed the immediately apprehended and known to the victim alleged offender free access to the bathroom. The detective drove home the point that the alleged offender's body is also a crime scene and evidence collection comes first. Those officers won't make that mistake again.

Being objective makes the SAFE nurse’s testimony in court well grounded and helpful if prosecution does occur. It sometimes prevents the need for a court case. In Maryland the rate of perpetrators pleading guilty after their attorneys depose the SAFE nurse or even just the completed rape kit results has been steadily increasing. Some SAFE nurse exams result in the case being dropped because the injuries or evidence are not consistent with the reported crime. SAFE nurse management in the ER has been correlated with increased conviction rates of cases that do go to court in the state of Maryland. Being objective makes us more effective.


SOURCES:
Mercy Medical Center SAFE Training Program Mercy Medical Center 301 St. Paul Place Baltimore, MD 21202

Sexual Assault Needs Assessment Project:
A collaboration of the Maryland DHMH, Center for Health Promotion, Education and Tobacco Use Prevention; The University of Maryland; and the Maryland Coalition Against Sexual Assault - publication pending

Sexual Assault Needs Assessment Project:
Phase 2 Findings
Mark Weist, Linda Kinney, and Eric Bruns from University of Maryland School of Medicine
Joyce Dantzler from the Maryland Department of Health and Mental Hygiene - publication pending

http://www.mbon.org/ (Md Board of Nursing) look under certifications and advanced practice
Sexual Assault Forensic Examiner (SAFE) Certification Maryland regulations regarding SAFE Certification
A memorandum to employers from Barbara Newman, RN, MS, Director of Nursing Practice.
SAFE Initial Application Form & Instructions
SAFE Continuing Education Verification Form (revised 07/2002)
Approved SAFE Programs in Maryland

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