Sexual Assault Nurse Examiners Assist Survivors at the Intersection of Health and Justice Systems

Bob Davis

Patchwork is a podcast from the Office on Violence Against Women at the U.S. Department of Justice in Washington. Patchwork offers a glimpse behind the scenes of a legal movement called the Violence Against Women Act, or VAWA. VAWA provides federal grants to help women at local, state and national levels. Patchwork explains how VAWA awards are made, shows what happens after funds arrive in communities, and share stories of help and hope. Patchwork brings you the voices of people on the front lines combating domestic and sexual violence. Our efforts to serve victims and hold offenders accountable create stories that knit us together and propel us forward.

Welcome to Patchwork.

Kim Day is a sexual assault nurse examiner, which has been come to be known in the field as SANE. In many ways, Kim helped define SANE for the nursing field with more than 40 years of nursing experience. She began focusing on sexual assault, nursing and forensic nursing back in 1998. OVW is recognizing Kim for her contributions to the field as she celebrates her retirement from the International Association of Forensic Nursing, where she has served as grants project director. Kim's impact has been far-reaching. She has helped developed and coordinates aid programs across the nation in big cities and small towns, as well as tribal communities that face challenges from being remote. Directly, and through her course development work, she has helped train countless nurses and forensic examination protocols that are so important following a sexual assault.

Before we get started, I just want to give a short disclaimer. Through Kim's work, countless victims of sexual assault have taken their first steps toward becoming survivors with the help of compassionate nurses. And during our discussion of her work, we may venture into areas that can be difficult to hear, especially for the many sexual assault survivors who are listening. I want to remind everyone that help is available twenty-four hours a day by calling 1-800-656-4673 or going online to www.rainn.org. That's R A I N N dot org. And we'll put those links on our website.

Kim, I'd like to start with the question of how you got into this line of work and what led you to this moment in your life. 

Kim Day

Thank you so much for having me. As you said, I've been a nurse for about 40 years and my main focus had always been working in critical care or the emergency department and in 1990, my husband was transferred to Amarillo, Texas. And in Amarillo, one of the first SANE programs in the United States was functioning well in the emergency department that I started working in. And in fact, the director of that emergency department was Jamie Ferrell, who is one of the founding, kind of, founding mothers of the field of Sexual Assault Nurse Examiners (SANE) care. The program there ran smoothly. It was wonderful. I was an ER nurse and you could see how the patient would come in the door and the SANE nurse would take over their care and care for them through the whole visit to the emergency department. And that was my first experience working with that type of program and it was wonderful, really. Now, if the patient was really injured, very gravely injured, that same SANE nurse would come into the trauma room and participate in the response to that trauma. And if any nurses are listening, they'll understand what that kind of ballet of trauma response is. But that SANE fit perfectly into that and was there to document things and collect forensic evidence when it was necessary, rather than having it be thrown on the floor and lost. And then I was only there for a short period of time as my husband worked for the federal government and we were transferred once again. And I moved to the east coast, started working in a community-based emergency department that did not have the SANE program. And there I was exposed to what is normal in the majority of emergency departments across the United States. When a sexual assault patient would come in the staff would either avoid the room or even draw straws for who had to take care of this patient that was potentially experiencing the worst day of their life. After working in a facility where there was such an orchestrated response, it was glaring and really difficult to be in that situation where I knew the response could be better.

Bob Davis

That takes us right to that critical moment, because here is a patient who really has dramatically unique needs and they’re drawing straws, I can imagine that is because of fear and trepidation that they don't know how to do what they need to do. Talk a little bit about that juncture right there. 

Kim Day

Well, that is the piece that SANE can fill. You could be unfamiliar with what you were doing… and here I was, a nurse with years and years of experience and I could take care of a patient a with an inner-aortic balloon pump in without any issues at all, but here this person comes in after a trauma and like visibly on the outside may look like nothing's happened, but really has experienced trauma just as much as somebody that's been in a really bad car accident and I would have to read the directions in the box to take care of them. And I call it the box, but it’s a sexual assault kit. And that is a terrible experience for the nurse as well as the patient who's looking at somebody reading instructions.

Bob Davis

So you're training nurses to be prepared, to be helpful here. What do you teach nurses is the goal right then in that moment for the patient? 

Kim Day

Well, the goal for the patient is to really mitigate any long-term effects from that trauma, because violence really is a health care issue, because it can impact the long-term health and recovery of an individual. And so your job as a nurse or doctor that comes in to take care of that patient is to first do no harm and then be able to help them move forward from this incident and prevent any potential consequences that that may be a result of that instance. And so training nurses, we can teach certain principles. For instance, don't read the directions in the box. What you do is you talk to the patient and you find out what's happened to them and then you do your care plan from that complaint. I actually have a colleague and a friend who always says that health care providers lose their mind in the presence of the box. And that's what we see. People are uncomfortable with that. 

Bob Davis

Is that because it's a criminal, legal, it's evidence collection? Is it because this is something that may go to court or what what's the shift for nurses who are otherwise very comfortable in their environment? 

Kim Day

I think that you hit it right on the head. It is the potential interaction with the legal system that scares people. And what is really kind of silly, if you think about it, because every single patient that we see in an emergency department has the potential to really have some sort of legal experience, but when we look at this, this is this is one of the factors to consider is that less than 10 percent of the patients that we see after sexual assault, so less than 10 percent ever see the inside of a courtroom. However, one hundred percent of them have a risk of long-term health consequences as a result of the violence. So once again, your focus still needs to be on that health care response to that patient. 

Bob Davis

You know, helping people in the worst moment of their life is really a privilege for emergency medical providers. Talk about some of your experiences being there for people in this moment. There must be some moving times that as a provider make it make it feel worthwhile. 

Kim Day

It always feels worthwhile. It always does. You can have a patient that comes in the door just devastated or angry because the gamut of emotions is what you see in people which we see in everyday life. One of the things that probably is most vivid in my memory is a patient that came in and really was had been into the into our facility multiple times and was really treated poorly. They, in fact, the report I got when I came in to see that patient was there. Their they're really acting out, we think they need to be restrained. They did have a mental health underlying condition. And when I went into the room, the patient was really angry. But the anger was directed towards the people that had really responded negatively and not even taken the time to sit and listen. And this is this is what is really great about being able to be called in or on duty to be able to respond to that patient. Your job at that time is that one patient you have you are able to focus on that one patient and not have to worry about 20 others. Just sitting down and listening is often the thing that will allow them to be able to then be able to tell their story. And really, it is their story that you that you're given the privilege to listen to.

One of the other critical components of this is the partnership with victim advocacy. I would be really neglectful to not mention them as a really critical component to this response. 

Bob Davis

How so, how does that partnership work?

Kim Day

Well, usually in some places there are victim advocates that work or social workers or some other name, they might be called that work actually in the emergency department, others you have to call them in. And when they respond also, those are the people that… I respond and I take care of the immediate clinical needs of that patient. The advocate comes in and has been there before with multiple other people that have actually experienced the same thing. They're able to walk out the door with the patient and continue that walk through the legal system. I don't walk out the door with the patient. I don't know… I know in general what happens after they leave. And I if I if they decline to have an advocate with them, which I discourage, then I can kind of generally tell them what happens. But the advocate knows intimately what the process is, how to get something like an order of protection, how to know what happens next in the legal process if the victim or the patient decides that's what they want. If they don't want that, then they also can offer services generally like counseling services, the ability to even things like safe shelter if the patient is in danger at home. So that I do think that sane are the bridge between the legal system and the patient. The advocate is like the bridge between everything in that whole process. 

Bob Davis

You know, your career has taken you a long way from the emergency department in Amarillo. How do you see the field differently today over the course of your career? What's changed? 

Kim Day

You know, there's some things, some of the messages that we're giving are the same as they were 20 years ago, probably 30 years ago. There's traditionally and continuously a lack of support for SANE services at the facility level, which is really too bad. Some states have managed to overcome that, have centralized programs and some places actually have multi service, they offer services to any victim of unintentional injury. So that would mean even car accidents, gunshot wounds, stabbing, strangulation, sexual assault, child abuse, elder abuse, all of the whole range of impacts that violence or abuse can have upon a patient. A forensic nurse is actually the one to see those patients because we can document what's happened to them and get a really good history, because even if the patient doesn't want to have the box collected in a sexual assault, that history is really important.

Bob Davis

Is this taught much in nursing schools these days? 

Kim Day

It really isn't. It's not taught in nursing school and or and or in medical school. There are there are people that are working to try and get that changed. But at this point, no, it's generally not. something that somebody would request to do outside of the undergraduate nursing programs. And usually what happens is you that you pursue this after you get your registered nursing. 

When a sexual when a nurse takes specialized training to become the SANE, it's done after they're a registered nurse. You have to be a registered nurse with experience. You have to be able to have really pretty strong assessment skills. That means that you can look at the patient's body, understand what's normal, understand what's not normal, and what may be a variation of normal and be able to document that. And generally, a brand new nurse is just getting their feet on the ground and they don't have those years of clinical experience behind them. So they take the classroom training, then they do the clinical training. And that's one change that we've seen over the past probably 10 years or so is it used to be that the nurse would have to get on the job training and take care of patients who were in acute trauma and practice, because nursing is practice, but it was it was really difficult to get that clinical experience and be taking care of a patient.

When I took my training 20 years ago, I was one of those that had to learn by watching another nurse collect the kit, take care of the patient, and then I would have that nurse watch me with another patient. And that's the way we got our clinical skills, not being able to go to an area where it's a classroom, really. It's a hands-on classroom, which is wonderful now. So that that's one new really good change.

We also have now several high-volume forensic sites that see all kinds of patients around the country. There are some programs that see thousands of patients a year through their forensic nurses. And those programs often have offered to have a preceptor program where the nurse can come in and actually work with an experienced examiner to be able to get some hands-on clinical care with patients. And that's new, too, which is wonderful. 

A lot of the nurses, even if they're experienced, are really afraid of testifying in court, working with the Indian Country Training Initiative,  we created a three-day expert testimony class where we bring nurses and prosecutors in from around the country and they work together. They get a full day and a half of training, and the next day and a half is spent in a courtroom with a judge, with a prosecutor, with a defense attorney. What the prosecutor is the student and they're practicing with an expert, which is the nurse, student and the other faculty and we work through scenarios and the nurses will practice testifying and the prosecutors will practice having a nurse to testify. Really fun training.

Bob Davis

How important is it for nurses who are entering the field to have this extra education?  

Kim Day

I think it's important. It's really important. I don't think that every nurse needs to specialize as a sexual assault nurse examiner. I think just like I decide after I graduate from nursing school that I want to specialize in emergency nursing, I would also think that this would be a specialized area of care.

One thing that we also see is that the nurses that are SANE can go on to specialized and see all types of victims of violence. And generally then they're called a forensic nurse examiner. And in some places a SANE is called the forensic nurse examiner. And we are seeing as a trend across the country that in larger institutions like the one I was in, in Amarillo, the nurses are responding to all victims of violence and abuse. 

Bob Davis

What advice do you give to the to the new nurses? What do we need to be focusing on now? What do we need to be trying to do better in coming years? 

Kim Day

The most important thing for any new nurse that's embarking on this journey to be able to provide expert care to these patients that have experienced trauma violence is that you are a nurse and this is a patient. And that is the most important thing that you must always keep in your mind. Your role is to be able to help them through what's happened to them. It's not to solve a case. You're not an investigator. You're not law enforcement. You're a nurse and you have a patient. In the end, if that's what you rely on, your nursing practice, your nursing skills, your compassionate care of the patient, that is the win. So that's what's most important, is the patient in front of you.

Bob Davis

Kim, thank you very much. I really appreciate your time and all the work that you've done in this area. Thank you. 

Kim Day

Thank you very much for having me. 

Bob Davis

And thank you for listening to Patchwork. We want to hear from you. Please let us know how you like this episode and what you'd like to hear on future episodes. You can email us at patchwork@usdoj.gov, tweet us @OVWJustice, or you can just give us a call,  202.307.6026. Thanks to Minh Ha and everyone here at OVW and thank you for listening.