he recent proliferation of Sexual Assault Nurse Examiner (SANE) programs throughout the country represents an important advance in the quality of care provided to victims of sexual assault. These programs have grown dramatically in the past 15 years, from about 20 in 1991 to more than 500 in 2006.^1,2 Sadly, despite the many benefits they offer, SANE programs have not proliferated in rural areas as they have in or near metropolitan areas.

This replication guide highlights one region’s efforts to address the difficulties of starting and sustaining SANE programs in rural areas. Under the leadership of the state sexual assault coalition, the West Virginia Foundation for Rape Information and Services (FRIS), four counties in north-central West Virginia implemented the Regional Mobile SANE Project, using on-call SANEs to serve multiple hospitals.³ This guide was developed to help other rural regions decide whether a mobile SANE project, customized to their local needs, might be a viable option. To that end, it focuses on the process used to plan and implement the West Virginia project and the lessons learned by FRIS and other stakeholders. It also provides a checklist for replicating the project and access to materials developed during its implementation.

This electronic version of Implementing SANE Programs in Rural Communities is easily navigated using the buttons on the left. Additional subpages are indicated by plus signs. Further information about the project and the author is accessed via the top navigation buttons. In addition, OVC offers a printer-friendly option as well as a more traditional print publication (NCJ 221749), which may be ordered through the National Criminal Justice Reference Service’s online ordering system. Greater detail about this project can be found on www.fris.org.

About This E-Publication

Implementing SANE Programs in Rural Communities: The West Virginia Regional Mobile SANE Project describes the project’s development and discusses the essential steps needed to replicate it in other rural communities.

From 2002 to 2005, the Office for Victims of Crime (OVC) provided funding for the West Virginia Foundation for Rape Information and Services (FRIS) to develop and implement a mobile sexual assault nurse examiner (SANE) program in a rural area of West Virginia that could be replicated throughout the Nation. The project demonstrates the flexibility needed when communities are first planning to launch a project. For example, FRIS staff originally planned to use a self-contained mobile unit for forensic examinations. After considering the challenges involved, however, they opted instead to recruit a pool of on-call SANEs who would serve several hospitals in a four-county region. This strategy improved the quality of medical care and forensic examination of sexual assault victims by increasing the number of SANEs available to fill schedules and the opportunities available for them to further build their skills and experience, while decreasing the likelihood of SANE burnout and the cost for the hospitals involved. Although the OVC grant ended in September 2005, the SANE program continues today.

This replication guide has been developed in both a print and online format to provide technical assistance for rural communities interested in developing a similar program. The guide documents the processes involved in planning, developing, implementing, and sustaining the West Virginia project; discusses the “lessons learned”; and provides a replication checklist and information on available resources for those who serve victims of sexual assault.

Much of the information presented here was drawn from FRIS’s “Mobile SANE Project Final Report,” accessed on the FRIS Web site (www.fris.org).

NCJ 221753

Message From the Director

Sexual Assault Nurse Examiner (SANE) programs offer quality medical care and forensic examination to victims of sexual assault, but, unfortunately, many victims living in rural communities find it difficult to access these programs. Rural areas have struggled to establish and sustain SANE programs mainly because of a lack of funding and difficulty in recruiting and maintaining the skill level of SANEs who are specially trained to be sensitive to the needs of sexual assault victims. This replication guide, Implementing SANE Programs in Rural Communities: The West Virginia Regional Mobile SANE Project, highlights an Office for Victims of Crime (OVC) grant-funded project that developed a solution to this problem.

From 2002 to 2005, OVC provided funding for the West Virginia Foundation for Rape Information and Services (FRIS) to develop and implement a strategy for creating a SANE program in a rural area of West Virginia that could be replicated throughout the Nation. As the state sexual assault coalition, FRIS developed a mobile SANE project that involved a pool of on-call SANEs who served multiple hospitals in a four-county region of West Virginia 24 hours a day, 7 days a week. This project has enabled sexual assault victims living in rural areas of West Virginia to access quality medical services, regardless of location or time of day.

FRIS developed the Implementing SANE Programs in Rural Communities: The West Virginia Regional Mobile SANE Project replication guide to provide technical assistance to other rural communities interested in developing a SANE program. The guide describes the strategy that strengthened the design, implementation, and sustainability of a mobile SANE project, and includes materials developed through the project. The publication offers a blueprint for replication so that other communities can be successful in establishing a program similar to the one developed through the West Virginia Regional Mobile SANE Project.

Acknowledgments

OVC thanks Nancy Hoffman, FRIS’s State Coordinator, and Debra Lopez-Bonasso, FRIS’s Education Coordinator, for their significant contribution to this replication guide. Nancy and Debra oversaw the planning and implementation of the West Virginia Regional Mobile SANE Project and continue to provide technical assistance to the project as needed. Thanks also go to the following for their input: Tammy Barberio, Clinical Supervisor, United Hospital Center; Karen Whiteman, SANE and Project Administrator for the West Virginia Regional Mobile SANE Project; Allen Wilson, Administrator, St. Joseph’s Hospital; and Renee Yokum, Advocate, Women’s Aid in Crisis.

About the Author

Kristin Littel has provided extensive technical assistance on issues relating to violence against women, including information gathering, writing, editing, product development, and meeting planning and facilitation. She was a victim advocate for many years, holding positions of executive director of a rape crisis center, co-coordinator of a sexual assault unit in a mental health agency, support group facilitator, and volunteer advocate for sexual assault and domestic violence victims. Since 1996, Littel has consulted with a variety of governmental and nongovernmental agencies. These include the U.S. Department of Justice’s Office for Victims of Crime and Office on Violence Against Women, the U.S. State Department’s Bureau of International Information Programs, the STOP Grants Technical Assistance Project of the Pennsylvania Coalition Against Domestic Violence, the Center for Sex Offender Management, the Sexual Assault Resource Service, the National Sexual Violence Resource Center, the Resource Sharing Project of the Iowa Coalition Against Sexual Assault, Ending Violence Against Women International, the National Network to End Domestic Violence, and the Rappahannock Council Against Sexual Assault.

A SANE Program for Rural West Virginia

FRIS offers information, technical assistance, training, and other resources to support SANE program development in West Virginia, and the concept of a regional mobile SANE project first surfaced at a FRIS-sponsored SANE training in 2002. The coalition embraced the idea immediately, recognizing the potential benefits such a program would offer to victims living in rural areas. These victims had limited access to medical resources: several of the state’s 55 primarily rural counties lacked licensed medical facilities. Few rural communities supported a SANE program and those that did struggled to maintain an adequate number of SANEs. In smaller hospitals that saw few patients who presented as sexual assault victims, it was difficult to justify the costs of a SANE program and hard for SANEs to maintain their clinical proficiency. To help its rural communities overcome some of these problems, FRIS explored the feasibility of pioneering a mobile SANE project that would bring the services of SANEs to victims of sexual assault who lived in rural areas.

• What Distinguishes SANEs From Other Nurses?
• Why SANE Programs Are Important
• Rural SANE Programs—Few and Far Between
• Benefits of a Mobile SANE Project
• FRIS Seeks Funding for the Project

What Distinguises SANEs From Other Nurses?

SANEs are registered nurses who have advanced education and clinical preparation in conducting forensic medical examinations of sexual assault victims.^4,5 Experienced SANEs offer survivors of sexual assault compassion and a commitment to preserving their dignity, expertise in identifying physical trauma and psychological needs, skill in coordinating appropriate care and referrals, knowledge about what evidence to look for and how to document injuries and other forensic evidence, and expertise in how to preserve forensic evidence for later use in court.

Most SANE programs use on-call nurses to provide around-the-clock coverage for a medical facility, commonly a hospital emergency department.⁶ When staff identify a patient as a victim of sexual assault, they first assess and treat any serious injuries she or he may have, and request that an on-call SANE come in to examine the victim.⁷ Thorough evidence collection and testimony by SANEs have helped prosecutors win increased numbers of convictions and guilty pleas from offenders.⁸

Why SANE Programs Are Important

The appeal of SANE programs lies in their capacity to address problems that victims often encounter when seeking care after a sexual assault. These problems can include, but are not limited to, the following:

• Long waits in hospital emergency departments before victims receive care.
  
  
• Medical staff who are unable to provide a full range of services (e.g., to address victim concerns about the risk of pregnancy and acquiring sexually transmitted infections).
  
  
• Medical personnel who are not proficient in collecting forensic evidence.
  
  
• Hospital caregivers who do not understand the trauma of sexual assault.
  
  
• Medical personnel who are reluctant to collect evidence of sexual assault because they fear they will be subpoenaed to testify in court.⁹
  
  
• Hospital staff who bill sexual assault victims and fail to inform them of jurisdictional and hospital policies regarding payment for the forensic medical examination. (If a state receives STOP Violence Against Women Formula Grant funds, it must certify that the state or another governmental entity pays the full out-of-pocket cost of forensic examinations.)

Rural SANE Programs—Few and Far Between

Despite the benefits they offer, SANE programs have not been added in rural areas as broadly as they have in or near metropolitan areas.¹⁰ It can be extremely difficult to recruit enough nurses in these often sparsely populated communities to staff a program 24 hours a day, 7 days a week (24/7). Although one or two nurses in the area may be trained SANEs, they alone cannot cover a 24/7 on-call schedule on a continuous basis. Moreover, hospital administrators find it hard to justify the costs of a 24/7 SANE program if few sexual assault victims are seen at their facilities. In addition, when so few sexual assault cases are encountered in an isolated county, SANEs may be unable to maintain sufficient skill in examining victims.¹¹

Benefits of a Mobile SANE Project

The Regional Mobile SANE Project, piloted in West Virginia, eliminates many of the problems listed above and offers a viable model for developing SANE programs in rural areas where funding is limited and a minimal number of trained nurses are available. Counties that participated in the project benefited in significant ways, including the following:

• More SANEs are available to fill a 24/7 on-call schedule because the project recruits nurses from a region rather than a single county.
  
  
• SANEs are less likely to burn out because they have flexibility in when and how often they sign up for on-call shifts.
  
  
• SANEs have increased opportunities to build their clinical experience and skills because more forensic medical examinations are performed regionally than in a single county.
  
  
• Participating hospitals face significantly lower costs compared with hospitals that support a stand-alone, 24/7 SANE program.
  
  
• The region’s rape crisis centers are better able to provide advocacy to sexual assault victims in hospital emergency departments because of the project’s training and coordinating of volunteers.
  
  
• Most important, sexual assault victims in the region receive more competent and timely health care that includes forensic evidence collection.

FRIS and stakeholders from the participating counties were able to implement this initiative because of their enduring commitment to improving care for sexual assault victims and their skill at overcoming challenges.

FRIS Seeks Funding for the Project

FRIS received two grants for the project from the U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime (OVC). One grant supported a feasibility study and the other helped finance the planning and implementation process. Awards were made with the understanding that FRIS would develop a project that could be sustained after this grant funding ended and replicated in other rural regions. These grants, in effect from October 2002 through September 2005, enabled FRIS to—

• Partially support staff time spent on the project.
• Use a consulting firm on a part-time basis to assist with a feasibility study and project planning.
• Hire a part-time community liaison to help plan and facilitate regional meetings and followup committee work.
• Support regional meetings and committee work, as well as SANE and advocate trainings. (Other funding helped cover training costs.)
• Contract with rape crisis centers to hire two advocate coordinators.
• Hire a part-time project administrator.

Communities should not assume that establishing a regional mobile SANE project is dependent on obtaining additional funding. Although FRIS did use grant funding to support its efforts to develop a model project, replicating the project in other regions may require considerably less of a financial investment. Instead of starting from scratch, regions can use the foundation laid by FRIS and the participating communities—the research done on mobile units, the process used to assess the feasibility of potential service areas, the structure developed for the project, the plan created for implementation, and the plethora of protocols, job descriptions and applications, contracts, and forms crafted during implementation.

Existing resources may prove sufficient to replicate the project. Under the Violence Against Women Act, as a condition of receiving STOP Violence Against Women Formula Grant funds, each state must certify that it or another governmental entity bears the full out-of-pocket cost of forensic examinations. Although many states have a designated forensic examination fund, others use their state crime victim compensation fund, or require local government entities, such as police departments or prosecutors’ offices, to pay for the exams. These funds may also be used to help pay for the costs of replicating this project. The West Virginia project accessed the state forensic examination fund to provide some revenue for the project.

In addition, hospitals may be willing to contribute to a mobile SANE project (e.g., by covering the cost of orientation trainings, quarterly SANE meetings, and project administration). Participating agencies and sexual assault response team (SART) members might offer their resources to help develop and maintain the project (e.g., for a feasibility study, regional planning meetings, writing strategic plans, and coordinating advocacy). Local colleges and student interns might be able to assist with a feasibility study. SARTs could also organize fundraising events to raise money to support trainings and equipment purchases.

Assessing Project Feasibility

From fall 2002 through spring 2003, FRIS studied the feasibility of creating a regional mobile SANE system for its state. It hired a consultant to assist with this phase of the project. FRIS initially thought that a SANE should be hired, but found that an individual with research experience was better suited for the role.

The two main tasks of the study were to define the elements of the project and identify potential service areas. For FRIS, a potential service area consisted of two or more adjacent counties. FRIS also wanted to learn about state-specific issues that could affect the project’s success.

Defining Project Elements

Is a Vehicle Necessary to a Mobile SANE Project?

FRIS originally envisioned that a motor vehicle, similar to a bloodmobile, containing the space, equipment, and supplies needed to perform forensic medical examinations would be the linchpin of the project. But the coalition needed first to assess whether a mobile unit was the best model for West Virginia. Because FRIS knew of no existing mobile units for forensic medical examinations, it researched mobile units used for other medical procedures, such as x-rays and dialysis, and for nonmedical purposes, such as libraries. By examining these units, FRIS pieced together a list of elements necessary for conducting forensic medical examinations. These included bathroom facilities, accessibility features for people with disabilities, security, space for a victim advocate, mechanisms for ensuring confidentiality, medical support, liability issues and insurance, and a way to cover the costs of project startup and ongoing operation. Given this comprehensive list, FRIS questioned whether a self-contained mobile unit was appropriate for this project. Most worrisome were the facts that a mobile unit would not provide adequate security and could isolate victims with acute injuries from the treatment available in emergency departments. In addition, outfitting a mobile unit with all these elements would make it large and unwieldy, and difficult to maneuver and to park inconspicuously—in short, a challenge to maintaining victim confidentiality.

Revise the Plan, If Necessary

Based on these concerns, FRIS revised its original plan. Instead of performing examinations in a self-contained mobile unit, its new plan called for a smaller, less conspicuous vehicle to transport SANEs and equipment to different hospitals, where SANEs would perform the examinations. FRIS found a prototype for such a mobile unit at Memorial Hermann Hospital in Houston, Texas. The project coordinator, Rusty Rooms, shared information about the hospital’s mobile unit, which was in the final stages of development. Memorial Hermann Hospital was part of a seven-hospital system that would be served by this unit. The hospital volunteer association donated the vehicle, a Chevy Blazer, and the hospital system agreed to be the vehicle’s owner and to pay for insurance and gas. When a patient presented as a sexual assault victim at any one of the seven hospitals, the hospitals’ existing dispatch system would contact the on-call SANE. The on-call SANE could take the vehicle home or leave it at one of the hospitals and pick it up if dispatched. SANE training, payroll, and liability insurance would be handled by the hospital system. The project coordinator worked 20 hours a week to monitor and coordinate services and had an assistant for 8 hours a week.

Examining the Houston project allowed FRIS to consider how a mobile SANE project in a rural area might differ from one in an urban area. Based on the information it gathered, FRIS identified questions that it would need to answer during project development:

• What strategies might best promote the participation of hospitals that are not in the same system?
  
  
• Should hospitals contribute to the project equally or in proportion to their size, financial capacity, and the number of SANEs they provide?
  
  
• How could the logistical challenges presented by a mobile unit be addressed? For example—
  • Where should a shared vehicle be parked when it is not in use?
    
    
  • How would the vehicle get to the on-call SANE?
    
    
  • How would the costs of insurance, gas, and maintenance be shared?
    
    
  • What issues would arise when serving hospitals across a sizable, mountainous region?
    
    
  • How is timely response facilitated?
    
    
  • Is one vehicle adequate?
    
    
  • How should the purchase of equipment be arranged?
    
    
• How could logistical challenges in administering the program be overcome? For example—
  • How would SANEs be recruited and trained?
    
    
  • How would the training and clinical preparation be made consistent across hospitals?
    
    
  
  Other Regions/Other Issues
  
  Other regions may have different or additional questions they need to answer during project development. They may find that emergency department physicians are reluctant to embrace a SANE practice, and may need to consider ways to overcome this problem. One solution might be to include in the contract with participating hospitals a stipulation that their physicians are required to work with SANEs to provide patient care and facilitate forensic evidence collection.
  
  • Who would hire SANEs and cover the cost of training?
    
    
  • How would payroll be arranged?
    
    
  • How would medical records be retained?
    
    
  • How would SANEs be dispatched?
    
    
  • How would liability for SANEs and the vehicle be addressed?
    
    
  • How would patient privacy issues be addressed and the Health Insurance Portability Act of 1996 (HIPAA) be implemented?
    
    
  • How would medication be dispensed if the SANE was not a hospital employee?
    
    
  • Would project policies be consistent across different hospitals?
    
    
• How could a financially self-sustaining program be created?

When FRIS discussed these issues with the region’s decisionmakers (see “Inviting Stakeholder Participation”), the impracticality of sharing a vehicle over a large geographic area became obvious. Law enforcement and prosecution also questioned how using a mobile unit might affect jurisdictional issues. In the end, it was decided that the most practical and cost-effective plan was to move only the nurses among hospitals, with the on-call SANE going directly to the hospital where the victim presented.

Identifying Potential Service Areas

FRIS gathered three types of information to help identify which regions of the state could support the project.

First, the service area must have reported a sufficient number of sexual assaults and performed enough forensic medical examinations to attract local interest in the project and create the possibility of sustainability. Multiple sources were needed to get an accurate picture of the sexual assaults reported and the numbers of examinations conducted throughout the state. No one source could provide all the data sought. Hospital reports on the numbers of examinations conducted, for example, usually were different from reimbursement data and criminal justice reporting statistics.

FRIS studied data from the following sources to help identify potential service areas:

• West Virginia Prosecuting Attorneys Institute: This institute is the state’s agent for providing reimbursement to licensed medical facilities for the forensic medical sexual assault examinations they perform (with reimbursements paid from the West Virginia Forensic Medical Examination Fund).
  
  
• West Virginia Crime Lab: The crime lab processes sex crimes kits submitted for testing by law enforcement in the state.
  
  

Tap SARTs for Advocacy

Sexual Assault Response Teams are typically eager to promote SANE programs as a viable way communities can improve their response to victims of sexual assault. The teams in the region where the project was implemented advocated for their local hospitals to participate in the project and helped to recruit SANEs from their counties.

• The state’s licensed medical facilities: Hospital emergency departments were asked to report the number of forensic medical sexual assault examinations they conduct annually, recognizing that not all examinations result in a sex crimes kit being collected.

Second, FRIS gathered information from each county, including the number of licensed medical facilities and SANEs in each and its existing SANE programs, rape crisis centers, and sexual assault response teams (SARTs). Support for a regional mobile SANE project is often greater in areas where SANE programs, rape crisis centers, and active SARTs already exist. To some extent, communities that have these elements are aware that SANE programs lead to improved care for victims and increase the likelihood that the forensic evidence collected will aid in criminal investigations. Rather than being threatened by the idea of a regional project, SANEs in the local hospitals saw its potential to bring more stability, strength, and cost effectiveness to their work.

FRIS also considered how a region’s geographical size, terrain, and weather could affect response time. Travel in most regions of the state involves driving on mountainous roads that can be difficult to navigate during severe weather (e.g., rain, fog, snow, and ice).

Third, FRIS hired a consultant to conduct a telephone survey of hospital emergency departments around the state to help clarify information gleaned from other sources. The consultant also gathered data on existing emergency department practices related to the forensic medical examination and hospital interest in a mobile SANE project. For each emergency department, the consultant attempted to connect with a nurse manager, clinical supervisor or charge nurse, or another responsible person who could accurately answer questions.

The survey revealed several issues that would affect project development. A severe nursing shortage in the state meant that the mobile SANE project would have to compete with other hospital on-call programs for nurses. In addition, many of the hospitals surveyed were part of a larger health care system, but were not networked locally. This would make working together a challenge for hospitals that were not in the same network. Lastly, many West Virginia hospitals lowered their expenses by contracting with out-of-state companies for their emergency department physicians. This fact undercut a common selling point of a SANE program: that it costs hospitals more for a doctor to conduct the examination and testify in court than it does for a SANE to do so.

When FRIS looked at the information compiled, one six-county region in north-central West Virginia clearly stood out as a potential service area for the project. This region was served by three rape crisis centers. Four of the six counties had SARTs. Each county had a licensed medical facility, and most had at least a few SANEs on staff. A sufficient number of examinations were performed and reimbursed in the region to provide a base of revenue for the project (through the state Forensic Medical Examination Fund).

Inviting Stakeholder Participation

With a potential service area identified, FRIS began planning a 1-day meeting of key decisionmakers from the region to discuss the project’s feasibility. Prior to the meeting, these stakeholders received background material about the project and its expected benefits to better prepare them to participate in discussions. At the meeting, all decisionmakers were encouraged to provide input on the project to ensure that everyone understood the issues involved before choosing whether or not to participate.

• Elements of a Successful Meeting
• Meeting Agenda

Elements of a Successful Meeting

To plan for the meeting, FRIS sought input and assistance from the directors of the three rape crisis centers in the region: Women’s Aid in Crisis (WAIC), HOPE, Inc., and the Rape and Domestic Violence Information Center.¹² This alliance was a logical one, given that FRIS had strong ties to these centers in its role as the state sexual assault coalition. The centers also coordinated the SARTs in their service areas, allowing FRIS access to SART members. The centers’ help was invaluable in compiling a list of organizations and persons to invite and in recruiting these stakeholders. FRIS mailed out invitation letters and the centers followed up with calls to all those invited.

Attendees represented disciplines and entities that were involved in the local immediate response to sexual assault: hospital administrators and clinicians (e.g., a clinical nursing supervisor or head nurse of a hospital emergency department), SANEs, rape crisis centers, law enforcement, prosecution, prosecution office-based victim advocacy, social services, emergency medical services, and local colleges. An effort was made to invite agency decisionmakers as well as staff involved in immediate response.

FRIS planned the meeting with participants’ comfort in mind. The coalition found a central location for the meeting and provided lunch. A stipend of $100 was offered for each participant to attend, although only two requested it.

FRIS found a meeting facilitator who was not affiliated with any of the organizations invited. Using this neutral facilitator helped promote open dialogue among stakeholders, particularly among hospital administrators who were more used to working competitively than collaboratively.

Meeting Agenda

The meeting took place in April 2003. After introductions were made, time was allotted to create a common base of knowledge about SANE programs and SARTs and provide background information on the project. A brainstorming session followed to identify issues related to project logistics and possible challenges. During lunch, the meeting’s planners sorted the issues identified into categories for the afternoon dialogue. Participants were grouped with representatives from their communities during lunch so they could talk informally about the implications of the project for their jurisdictions. After reconvening, participants focused on how to address obstacles to project implementation, the potential benefits such a project offered, and strategies for making it work.

Two critical outcomes resulted from this meeting. First, four of the six counties initially identified agreed to participate in the project (Harrison, Lewis, Randolph, and Upshur Counties). Each had a local hospital, a few SANEs working in the hospital, a rape crisis center, and an active SART. Two counties opted out. Lacking sufficient SANEs or the strong SARTs that the other counties possessed, they believed it would be too difficult to gain the support needed to implement and sustain the project.

Second, the participants agreed that although sharing a vehicle over their region’s geographic area would not work, sharing SANEs among hospitals seemed feasible.

Working With Community Stakeholders

After the initial discussion, the large group of stakeholders met on several occasions to develop a plan for implementing the project. The group identified a goal date for project implementation, general issues that needed resolution, and a tentative timeline for task completion. Some stakeholders were also assigned to one of three subcommittees. The larger multidisciplinary group meetings provided a forum for discussing subcommittee recommendations and making decisions related to project implementation. But because key stakeholders, particularly those from the hospitals, were often not present, it was difficult to finalize decisions. Ultimately, numerous decisions related to project implementation had to be put on hold for several months until all the hospitals formally committed to the project.

The subcommittees were asked to work through discipline-specific issues, such as SANE program operation, hospital administration of the project, and coordination of victim advocacy.

• SANE Committee
• Advocacy Committee
• Hospital Committee

The SANE committee, composed of FRIS staff and the SANEs from the four counties, made several critical recommendations:

• Recruitment efforts should go beyond emergency departments to reach a more diverse representation of nurses.
  
  
• A screening process for SANE candidates was needed.
  
  
• Free training should be offered to SANE candidates in return for their signed contracts in which they agree to participate in the project. Participating SANEs should complete both adult and pediatric SANE training courses.
  
  
• The project must be able to offer competitive wages to attract and retain nurses. West Virginia was suffering an acute nursing shortage, and on-call pay varied widely throughout the country, from no payment unless an examination was conducted to $3 per hour. In addition, SANEs were commonly paid $150 for conducting a forensic exam. Based on this information, the committee recommended $3 per hour on-call pay for SANEs and a flat SANE fee of $200 for each examination conducted. The flat fee would cover traveling to and from the service area, conducting the exam, and testifying in court if necessary.
  
  
• A 12-hour on-call shift fit nurses’ typical work schedules. Two shifts a week was considered the maximum frequency for each on-call nurse.
  
  
• At least 12 SANEs were needed to fill the on-call schedule.

The advocacy committee was made up of FRIS staff and the directors of WAIC and HOPE, Inc. Each rape crisis center serves two counties in the four-county area. The centers already used volunteers in other areas of their programs and were eager to establish the advocacy component of the project. The grant allowed for the coalition to contract with each center to hire a part-time advocate coordinator. Through its initial work, the committee created job descriptions and devised a plan for recruiting and training advocates.

The hospital committee was composed of FRIS and representatives from the four interested hospitals: United Hospital Center in Clarksburg, Davis Memorial Hospital in Elkins, St. Joseph’s Hospital in Buckhannon, and Stonewall Jackson Memorial Hospital in Weston. Although they were not networked together, these hospitals were willing to collaborate on this project. The committee was responsible for getting the hospitals to agree on the terms of their participation. Arriving at consensus among the hospitals was complicated, due to several factors:

• Decisions that hospital representatives made related to the project were subject to the approval of their CEOs.
  
  
• It was difficult to gather representatives from all four hospitals together at the same time to discuss the project. FRIS had to work energetically behind the scenes to encourage the hospitals to participate in talks and negotiations on the terms of their collaboration.
  
  
• These hospitals were competitors in a small market for patients and personnel, but they had to join together for this project. Contract negotiations among these unlikely allies required considerable time and effort.
  
  
• Although the hospitals were pleased to be part of an improved response to sexual assault victims, they needed to be confident that the project would be a fiscally sound investment.

Creating a Strategic Plan

Based on its research and recommendations from community stakeholders, FRIS developed the following strategic plan for project implementation (adapted for this replication guide):¹³

• Developing the Program
• Recruiting and Training SANE Nurses
• Recruiting and Training Advocates
• Implementing the Program

Developing the Program

• Develop and execute memorandums of understanding (MOUs) for participating hospitals.
  
  
• Develop and execute MOUs for participating rape crisis centers.
  
  
• Identify the host hospital for the project. Develop and execute a contract between FRIS and this hospital. Resolve any related administration and operation issues.
  
  
• Develop a job description and application form for a project administrator. Hire a project administrator.

Recruiting and Training SANE Nurses

• Develop job descriptions and applications for SANE nurses.
  
  
• Develop SANE commitment agreements.
  
  
• Recruit nurses for SANE training sessions.
  
  
• Conduct training sessions (all SANEs are to receive both adult and pediatric training). Train a minimum of 30 nurses to be SANEs.
  
  
• Secure contractual agreements from a minimum of 12 to 15 newly trained SANEs to participate in the project on an on-call basis.

Recruiting and Training Advocates

• Develop a job description and application form for the advocate coordinator positions in each of the participating rape crisis centers. Hire advocate coordinators.
  
  
• Develop a recruitment brochure for the program.
  
  
• Recruit volunteers for advocate training sessions.
  
  
• Conduct training sessions. Train a minimum of 25 volunteers to serve as advocates for the regional SANE program and a minimum of 8 advocates who can train future volunteers.
  
  
• Secure commitment agreements from at least 10 newly trained advocates to provide extended evening and weekend coverage.

Implementing the Program

• Provide an orientation to SANEs and volunteer advocates who have agreed to participate.
  
  
• Develop SANE exam and treatment protocols that are compatible with the participating hospitals.
  
  
• Develop a completion evaluation form for the State Crime Lab to use to evaluate sexual assault evidence collection kits submitted for evidence processing.
  
  
• Develop advocate protocols that are compatible with the participating rape crisis centers.
  
  
• Develop an on-call system for SANEs, along with a backup system, that will provide 24/7 coverage at all participating hospitals.
  
  
• Develop an on-call system for advocates, along with a backup system, that will provide 24/7 coverage at participating hospitals.
  
  
• Identify an appropriate space for conducting SANE examinations in participating hospitals.
  
  

About the Camera

The project uses the Macro 5 SLR camera as an alternative to a colposcope. Cost was a factor in this decision, as only one of the hospitals had a colposcope and the project lacked the funds to purchase colposcopes for all participating hospitals. The camera cost approximately $800, compared to about $23,000 for a colposcope. It was believed that it would be better to standardize the use of the cameras across all hospitals and train SANEs to use them, rather than each hospital having different equipment and training SANEs in how to operate each piece. (See note 14 for recent information on the availability of the Macro 5 camera.)

• Develop specifications for examination equipment to be purchased (e.g., medical storage carts and Macro 5 cameras).¹⁴
  
  
• Procure and provide equipment, supplies, and forms to participating hospitals.
  
  
• Assemble and distribute SANE resource manuals to participating SANEs. Recommended manuals include hospital protocols, extra forms, contact information for SANEs and other agencies, checklists of what to do, an information sheet for addressing the risk of sexually transmitted infections and pregnancy, and maps of the service areas of each hospital that show the locations of examination rooms and storage carts.

By far the most challenging component of planning this project was determining how to administer it across participating hospitals that were not in the same health care system or accustomed to working together. After searching for and not finding a model to guide its efforts, FRIS realized it had to create one. Fortunately, the region already had basic structures in place for SANE program operation, victim advocacy, and interagency coordinated response. Project planners needed only to adapt these structures to fit the mobile SANE project's parameters.

• The main task for those planning the SANE project was to determine how to effectively deliver services to patients at multiple sites on a 24/7 basis. In some instances, planners had to move away from traditional models of SANE program operation to ensure that the logistical details (e.g., nurse recruitment, wages offered, and on-call scheduling) would support the project and lead to its success.
  
  
• Prior to project planning, rape crisis centers had provided advocacy services in some but not all of the participating hospitals. The centers' primary task for this project was to expand their coordination efforts to ensure consistent access to and provision of these services across all hospitals.
  
  
• Although it was critical that local law enforcement and prosecution agencies supported the project and encouraged hospitals to participate, the project did not require any changes in the agencies' responses in these cases.

Using the strategic plan as a guide, FRIS and the counties involved spent a little more than a year implementing the West Virginia project.

Developing a Contractual Agreement With Hospitals

First of all, project planners will have to identify a host hospital that is willing to take on the responsibility of administering the mobile SANE project. The roles and responsibilities of the host and other participating hospitals need to be delineated and agreed to by all participants, and a contractual agreement signed by all before project service areas can be defined and staff recruited and trained. This chapter specifies the roles of FRIS and the host and participating hospitals, discusses some of the significant issues to be resolved, and summarizes project expenses and income.

• Resolving Issues Among Hospitals
• Roles and Responsibilities of the Hospitals
• Role of FRIS
• Budget

Resolving Issues Among Hospitals

Numerous aspects of project implementation depended on the hospitals signing a contractual agreement. Until the hospitals had formally committed to the project, the service area could not be defined. Before they were willing to sign an agreement, however, the hospitals first had to resolve many issues. Among them were the following:

• How much would each hospital contribute to the project? In a concession by the smaller hospitals, the hospitals agreed to contribute to the project equally, rather than in proportion to their size, number of SANEs, or financial capacity. Although the smaller hospitals historically treated smaller numbers of sexual assault victims, each hospital would be paying for the same services to be available 24/7.
  
  
• How would hiring and payroll for nurses be handled? To standardize the way SANEs were paid, it was decided that the host hospital would hire all SANEs on a temporary part-time basis. The three smaller hospitals agreed to this stipulation, although they were concerned about being able to retain the SANEs who worked for them outside of the project if the larger hospital offered more competitive wages. Fortunately, this arrangement has not led to significant problems in nurse retention for the smaller hospitals.
  
  
• How would patient privacy issues be addressed? About the time the project was taking shape, the medical field was struggling to figure out how to implement the Health Insurance Portability Act of 1996 (HIPAA). Because SANEs would be shared across hospitals, the hospitals grappled with the issue of how HIPAA might affect their service provision and recordkeeping. They concluded that potential privacy problems would be addressed by having the host hospital serve as the employer of all of the SANEs and the keeper of all records for the project.
  
  
• What was the liability risk posed to the hospitals by using SANEs? Although FRIS’s research indicated that no SANE had been the defendant in a civil action as a result of conducting a forensic examination, liability was of paramount concern to the hospitals during the project participants’ initial conversations. FRIS emphasized that the SANEs were collecting evidence, not performing medical examinations. It also asked the hospitals to assess their liability without trained medical personnel collecting the evidence. In the end, hospitals concluded that project implementation would neither increase nor decrease their liability.
  
  
• Who would cover the costs of providing the required SANE orientation? The host hospital required that all SANEs it hired go through its orientation, complete with a physical examination and background check. It sought to have the project cover the costs of this 2-day program, with SANEs to be paid on the same scale as its own nurses. The smaller hospitals initially rejected this stipulation, but ultimately agreed to share these costs. In turn, the host hospital covers the costs of quarterly SANE meetings (which amounts to, primarily, paying SANEs’ salaries while they attend these meetings).

Roles and Responsibilities of the Hospitals

After most of the initial issues among hospitals were ironed out, one of the hospitals needed to assume the role of host for the Regional Mobile SANE Project. The largest hospital, United Hospital Center, agreed to take on this responsibility.

After much negotiation, the four participating hospitals and FRIS signed an “Agreement for the Provision of Regional SANE Service.” Each hospital agreed to—

• Identify three nurses from the county where it was located who would participate in the project. Nurses did not necessarily have to be employed by the hospital. To function effectively, the program needed at least 12 SANEs.¹⁵
  
  
• Pay $1,000 per quarter to the host hospital for services related to the project (with the host hospital also contributing this amount to the project).
  
  
• Bill the state Forensic Medical Examination Fund for examinations conducted at each hospital and submit these reimbursements, for services rendered, to the project. This state fund reimburses hospitals $350 for each approved examination.
  
  
• Designate an appropriate, secure, and private space in the facility where SANEs can conduct forensic medical examinations of sexual assault victims, as well as a separate waiting area for victims and their support persons.
  
  
• Provide common examination supplies as needed to facilitate the examination.
  
  
• Contact the on-call SANE when a patient presents as a sexual assault victim at its facility.
  
  
• Designate a locked and secure area for storing the sex crime kits until they are released or picked up by law enforcement (hospitals typically hold kits for up to a month in cases in which victims are undecided about whether they will report the assault to law enforcement).
  
  
• Collect data on sexual assault patients as requested by FRIS.

In exchange, each hospital would receive 24/7 SANE service and advocate coverage; adult and pediatric SANE training for nurses participating in the project; and a medical storage cart stocked with the necessary supplies for the forensic exam, a Macro 5 Camera, a map, a copy of the protocol, and an identification badge for each location.

In addition, the host hospital agreed to—

• Hire/employ nurses on a temporary part-time basis to be trained as SANEs and provide SANE services on a regional basis.
  
  
• Compensate SANEs at a rate of $3 per hour on call and $200 per examination.
  
  
• Compensate nurses for their participation in required trainings.
  
  
• Bill other hospitals at a rate of $1,000 per quarter and $350 per examination conducted.

The host hospital also provided liability insurance for the project.

Role of FRIS

FRIS’s responsibilities in planning and implementing the West Virginia Regional Mobile SANE Project were outlined as follows. The coalition would—

• Hire/employ a project administrator who would recruit and retain SANEs, develop and maintain an on-call SANE schedule, develop a protocol for standards of care, collect and maintain data on program operation, and provide backup SANE coverage.
  
  
• Recruit and schedule advocates, in conjunction with the advocate coordinators and rape crisis centers.
  
  
• Provide support staff to develop the strategic plan and administer the support grant program, grant writing activities, data collection and analysis, project evaluation, and other related activities.
  
  
• Provide and cover the costs for SANE and advocate trainings.
  
  
• Purchase and provide hospitals with the equipment they need to conduct forensic medical examinations of sexual assault victims.

Budget

Developing a project that was fiscally sound was critical for FRIS and the participating hospitals. The fact that the state Forensic Medical Examination Fund could be accessed to partially cover project costs was appealing to hospitals, as such reimbursements would considerably reduce the amount they needed to contribute to maintain the project.

Several first-year expenses were covered through the OVC grant, including the costs of the project administrator and advocate coordinator positions, medical storage carts and Macro 5 Cameras, SANE and advocate training, and SANE resource manuals. FRIS also used other funding sources to support these trainings. A summary of the remaining project expenses for the first year follows:

Host hospital orientation for 12 SANEs × 16 hours training × $30 per hour	= $  5,760
$3 per hour on-call SANE pay × 24 hours × 365 days	= $26,280
Total Project Expenses	$32,040

As far as income for the first year, the state Forensic Medical Examination Fund reimburses hospitals $350 for each examination. Of this amount, $200 will be deducted to pay the SANE; the remaining $150 will be project revenue. Based on statistics FRIS gathered from the Forensic Medical Examination Fund, the fund was expected to pay participating hospitals for 104 examinations during the project's first year. With expenses at $32,040 and an estimated $15,600 in revenue from the fund, a balance of $16,460 remained. The rounded-off balance was divided among the four hospitals.

$150 reimbursement to the project for each exam × 104 exams	= $15,600
$4,000 per hospital per year	= $16,000
Total Project Income	$31,600

If fewer than the estimated 104 exams were conducted, the host hospital would lose money (e.g., if 90 exams were reimbursed by the state Forensic Medical Examination Fund at $150 each after deducting SANE pay, the project would receive a total of $13,500 rather than the projected $15,600, ending up with $2,100 less than budgeted). But if more than 104 exams were conducted, it could profit.

Hiring Personnel and Developing Procedures

Two months before project startup, FRIS hired a project administrator (see job description) to work with FRIS 10 hours a week to—

• Coordinate with participating hospitals to develop protocols and procedures.
  
  
• Purchase medical storage carts for each facility and stock them with the supplies and equipment necessary for the forensic examination. (The carts are locked while not in use; each SANE has a key that opens all the carts.)
  
  
• Create a resource manual for each SANE. (A manual is also stored in the storage carts.)
  
  
• Develop SANE-related contracts, forms, job descriptions and applications, and procedures.
  
  
• Devise an on-call system for SANEs. The project administrator schedules the SANEs and provides each emergency department director with a copy of the schedule. (The emergency department director contacts the on-call SANE if a patient presenting as a sexual assault victim arrives at a hospital. The project administrator serves as a SANE backup.)
  
  
• Develop procedures for payroll. The project administrator processes SANE timecards and payments through the host hospital.
  
  
• Devise a system for gathering case data needed for quarterly statistical and financial reports. For the hospital to bill the project for an examination, SANEs must fill out a data collection sheet and submit it to the project administrator within 24 hours after an examination.

Paying attention to details allowed the project to get off to a smooth start. The project administrator and FRIS realized, for example, that it could be problematic for SANEs to dispense medications to patients at a facility in which they were not employees. As a remedy, standing orders were developed at each facility listing medications typically needed in these cases. Physicians would sign orders that enabled staff nurses rather than SANEs to dispense these medications as needed in each case.

The rape crisis centers also each hired an advocate coordinator for 20 hours a week to expand their capacity to provide advocacy services to sexual assault victims who present at local hospitals. During project startup, these coordinators communicated with the hospitals to develop on-call advocate protocols, recruited volunteer advocates, worked with FRIS to provide training, and transitioned their agencies into absorbing this service. An MOU was created to outline the details of the collaboration between the rape crisis center and FRIS (view MOU).

Making the SANE and Advocacy Components Operational

FRIS involved local sexual assault response teams in recruitment efforts and publicized regionally the need for SANEs and advocates to secure at least 12 SANEs and 25 volunteer advocates for the project. In addition, the coalition developed applications and contracts for SANE and volunteer advocate candidates, specifications for equipment and supplies, and an on-call system. Before the project began, FRIS coordinated training efforts for both groups.

• Recruitment
• Screening
• Training

Recruitment

To obtain SANE candidates, nurses were sought from hospital emergency departments as well as other medical areas. As a result, emergency department nurses, hospice nurses, medical/surgical nurses, psychiatric nurses, and retired nurses applied to be SANEs.

Screening

FRIS developed applications for SANE and volunteer advocate candidates.

SANE candidates were asked to provide information about their professional background and to answer questions about their qualifications (list was adapted for use in this replication guide):

Each hospital recommended its own nurses for the project. Additional references were required from SANE candidates who were not employed by a participating hospital. All SANE applicants were interviewed by the nurse manager at the host hospital.

Advocate candidates were asked to provide the following information (adapted for use in this replication guide):

In addition to filling out applications, SANE and advocate candidates were asked to sign contracts indicating that they understood the responsibilities of the position. The SANE agreement further noted that if SANEs did not fulfill their 1-year commitment, they would be asked to reimburse the project for training expenses.¹⁷ (View volunteer advocate contract.)

Training

Before project implementation, FRIS coordinated adult and pediatric SANE trainings for newly recruited nurses. Near the end of the project year, both trainings were repeated, allowing those who had already completed the training to attend as a refresher course while also training a new group of SANEs.

The project administrator and FRIS assisted the nurses in arranging opportunities for them to complete the clinical component of the trainings. They also helped the nurses work out the logistics of completing the orientation required by the host hospital and related paperwork. Scheduling and attending the orientation was challenging for the nurses because they all had other jobs.¹⁸

FRIS also coordinated training for the newly recruited volunteer advocates, followed by a train-the-trainer program for advocate coordinators and other rape crisis center staff. The advocate coordinators conducted additional trainings with new volunteers during the grant project period and held regular volunteer supervision and continuing education meetings.

Implementing the Project

Upon its implementation in September 2005, the Mobile SANE Project immediately began functioning as FRIS and its community partners had envisioned.

• Thoughtful Planning Paid Off
• Each Component of the Project Succeeded

Thoughtful Planning Paid Off

• Participating hospitals were consistently able to provide sexual assault victims with SANE and advocacy services. By year’s end, 107 victims had been served through the project.
  
  
• The Forensic Medical Examination Fund reimbursed hospitals for all 107 examinations conducted. This figure exceeded FRIS’s projection of 104 examinations reimbursable during the first year and was enough to ensure that the host hospital earned a positive financial return.
  
  
• Positive media coverage helped increase community awareness of this project. For example, the press covered a celebration held a month after project implementation, during which several advocates and nurses gave uplifting testimonials about their project experiences.
  
  
• Child sexual abuse victims were examined close to home for the first time because of the project. Before its implementation, child victims had to travel outside of the region for pediatric sexual abuse examinations.
  
  
• Standardized protocols were used by the SANEs, advocates, and hospitals across the region. The planning that went into developing these protocols and getting people to follow them resulted in smooth delivery of services. Because the project was formally supported by hospital leadership, for example, emergency department directors, physicians, and nurses were generally responsive to SANEs regardless of whether or not they were on staff. Hospital staff also benefited because they could divert sexual assault cases to on-call SANEs and advocates, which left them free to help other patients.
  
  
• The project promoted local and regional collaboration at many levels. Hospitals worked together to support, implement, and maintain the project. SARTs and rape crisis centers encouraged project development. The SANE program and rape crisis centers made sure the region had SANEs and advocates available 24/7. Hospital personnel contacted SANEs and advocates when victims of sexual assault arrived in their emergency departments, which led to victims receiving optimal service.
  
  
• All participating hospitals made changes to their policies and practices in order to be involved in the project. Prior to project implementation, all protocols, forms, and evidence collection kits were geared for adult patients only. Hospitals now instituted a pediatric protocol and medical history form. Also, the data collection form that accompanies the kit was revised to ask for additional case information.

Each Component of the Project Succeeded

• The SANE program was a success due to several factors. The project had no significant problems recruiting nurses. With 13 nurses trained and participating in the project, a sufficient number of SANEs were available to cover the 24/7 on-call schedule. Although a modest turnover of SANEs occurred, filling these positions was not difficult. SANEs generally felt positive about their roles and believed the project supported their work. Participating SANEs functioned well as a team and were able to work through issues and problems among themselves. Having a project administrator who was a SANE proved to be invaluable. She provided backup numerous occasions, including times when more than one victim presented at a hospital. Quarterly SANE meetings, which the nurses were paid to attend, allowed the nurses to share experiences and best practices, and to obtain additional training.
  
  
• The advocate component was equally successful, with 51 volunteer advocates trained and participating in the project. Because advocacy services were well coordinated with SANE services, more sexual assault victims presenting at local hospitals had access to advocate support than ever before.
  
  
• Traveling across this mountainous region to provide timely on-call services had its challenges, but the SANEs found it to be manageable. They were able to depend on one another to resolve issues as they arose. For example, SANEs could contact each other if they needed to switch shifts due to weather-related problems such as a mountain pass being too icy to cross. The quarterly SANE meeting was also a useful forum for discussing issues such as how to deal with situations that affected their response time. Because advocates responded only to cases at hospitals within the service area of their local rape crisis centers, they encountered no new challenges related to response time.

The only glitch in project startup occurred on the first day of implementation. Not all nurses had completed the clinical preparation they needed for pediatric SANE competency by that time. A child presented as a sexual assault victim at a participating hospital on that day, and the nurse on call was one who needed further pediatric clinical experience. The project administrator was called in to conduct this examination. In hindsight, the project should have been 100-percent ready from day one.

Sustaining the Project

Creating a sustainable project was emphasized throughout the planning and implementation process. FRIS knew that grant funds supporting the project would run out at the end of September 2005. At that time, it would need to abstain from direct involvement. If the project was to survive, it was imperative that regional stakeholders be able to maintain it on their own. Much of the planning process was geared toward producing a programmatically and fiscally sound project. Elements that contributed to project sustainability include the following factors:

• FRIS and the participating counties were committed to making the project work, despite challenges.
  
  
• Preliminary research was instrumental in designing a project that fit the region’s needs.
  
  
• Careful groundwork helped to identify a region in the state that had the capacity to support the project.
  
  
• Rape crisis centers and SARTs worked energetically to garner local support for the project.
  
  
• Community stakeholders were involved in planning and implementing it.
  
  
• The hospitals were willing to collaborate on this project, and FRIS was willing to help them work through any concerns.
  
  
• An advocacy component was included in the project.
  
  
• SANEs were involved in making decisions related to SANE program administration.
  
  
• A detailed 1-year implementation plan was developed.
  
  
• Positions essential for project operation were created.
  
  
• The project developed materials that would require only minor updating in subsequent years (e.g., MOUs with the hospitals and rape crisis centers, agreements with SANEs and advocates, job descriptions and applications, protocols and procedures, forms, and resource manuals).
  
  
• Forensic examination equipment was procured for all participating hospitals.
  
  
• Each hospital signed a formal agreement stating that it would provide nurses from its area to participate as SANEs.
  
  
• A balanced budget was developed.

The West Virginia Mobile SANE Project is now in its third year, thanks to the dedication of its partner hospitals, rape crisis centers, SARTs, project administrators, advocacy coordinators, and of course, SANEs and volunteer advocates. Ongoing technical assistance from FRIS has also been critical in helping Mobile SANE deal with regional problems as they arise.

Several noteworthy changes have occurred since the grant expired. The host hospital, rather than FRIS, now hires and employs the project administrator. To cover this expense, each hospital increased its contribution to $2,000 per quarter, for a total of $8,000 per year. The rape crisis centers have continued their volunteer sexual assault advocacy programs in conjunction with the project. One center absorbed the cost of the advocate coordinator position; the other decided to have its staff share the responsibilities of this position.

The project also has increased the number of counties it serves. In its second year, one county dropped out and two new counties were added. The new counties, located at the farthest ends of the region, have had difficulty arranging for nurses from their areas to participate as SANEs. Consequently, the SANE program must cover a larger region with the same number of nurses, and it takes SANEs longer to travel to and from hospitals in the new counties. As a result, Mobile SANE has had increased turnover among its nurses during the past year and has had to spend more time recruiting and training new SANE candidates than expected. To maintain a sufficient number of SANEs to fill the on-call schedule and reduce SANE response time, the project is considering dividing the SANE team into two teams that would each serve a smaller area.

No doubt other changes will occur in the future that could affect the project’s sustainability. These changes further illustrate that the project must be adaptable enough to weather these changes while remaining true to its goal of providing quality services for victims of sexual assault in this region of the state.

A Rural SANE Solution

Where they exist, SANE programs have raised the standard of care for patients presenting as victims of sexual assault and improved the collection of forensic evidence. These programs have grown tremendously in metropolitan areas in the past decade and a half; it is now time to see parallel growth in rural areas. For such progress to occur, however, rural communities must overcome considerable challenges in starting and sustaining SANE programs.

The Regional Mobile SANE Project of West Virginia offers a viable model for developing SANE programs in rural areas where funding is limited and a minimal number of nurses are available. The work done by FRIS and regional stakeholders to plan and implement the West Virginia project has laid a foundation for other areas to follow. Rural communities are encouraged to use this replication guide to determine whether a mobile SANE project might work for them and to help them start planning their own.

Replication Checklist

The West Virginia Regional Mobile SANE Project has great potential for replication in rural regions. The checklist included here will guide communities seeking to replicate the project in their own states and counties.^* Those involved in planning need to consider how the tasks in the checklist should be customized to fit the unique needs of their region. Planners also should note that some tasks may occur concurrently and do not necessarily need to happen in the order listed.

Carrying out the steps of this checklist requires that one or more entities take the lead in assessing the project’s feasibility in a region and coordinating planning and implementation efforts. Although a state sexual assault coalition might be willing to take on this role, it is important to also explore other possible project leaders at the state and local level.

• Assess the feasibility that a region could support and sustain a mobile SANE project. If a region has been identified from the start, completing the tasks below can help planners assess the feasibility of implementing the project.
  • Determine who will do the feasibility study.
    
    
  • Gather data from jurisdictions on the numbers of reported sexual assaults and examinations performed over a specific time period.
    
    
  • Identify areas that have a sufficient number of reports and examinations to attract local interest in the project.
    
    
  • Identify mechanisms the state or jurisdiction uses to pay for forensic medical examinations (similar to West Virginia’s Forensic Medical Examination Fund).
    
    
  • Consider how reporting and examination figures compare to the number of sexual assault victims seen by the local rape crisis center, if one exists.
    
    
  • Find out what procedures hospital emergency departments follow regarding sexual assault victims and the services provided to them. Also, assess the hospitals’ interest in sponsoring a mobile SANE project.
    
    
  • Determine if the following are present within a county or region:
    • A sufficient number of licensed medical facilities and SANEs.
    • Existing SANE programs.
    • Rape crisis centers.
    • Active sexual assault response teams (SARTs).
      
      
  • Consider how a region’s size, terrain, and seasonal weather conditions could affect the response time of SANEs and advocates.
    
    
  • Analyze the data collected to determine whether a region might be able to support the project, or to identify regions where the project might be successful.
    
    
  • Identify regional issues that could affect the project.
  
  
• Invite input and participation from communities within the region. Gather together key stakeholders to assess their interest in and capacity to participate in the project.
  • Determine who will coordinate this specific effort. The coordinator(s) can collaborate with the local rape crisis centers to identify key stakeholders for the project.
    
    
  • Invite stakeholders to participate in a meeting. Request that rape crisis centers and SARTs assist in recruiting stakeholders.
    
    
  • Arrange a time and location for the meeting. Think about how to entice stakeholders to attend (e.g., by offering lunch or a stipend).
    
    
  • Consider using a facilitator to conduct the meeting who is not affiliated with stakeholders.
    
    
  • At the meeting, provide stakeholders with an overview of the project and an opportunity to comment on whether they think it would be practical and cost effective for their region. Give them a chance to provide input on what issues need to be resolved and what adaptations to the West Virginia model will be necessary. Find out whether communities would like to further explore the possibility of implementing the project and which specific stakeholders would like to be part of the planning process.
  
  
• Work with community stakeholders to develop the project. Use both large, multidisciplinary forums and smaller committee meetings to address issues that need to be resolved and develop the implementation plan.
  • Identify who will coordinate development efforts.
    
    
  • Specify how the project will adapt West Virginia’s model to meet local needs (e.g., an advocacy program for victims presenting at local hospitals may already exist and need only be coordinated with the project).
    
    
  • Outline how the SANE program will operate and coordinate with hospitals and advocates.
    
    
  • Outline how the advocacy program will operate and coordinate with SANEs and hospitals.
    
    
  • Outline how the hospitals will be involved and coordinate with SANEs and advocates.
    
    
  • Seek the support of law enforcement and prosecution offices in promoting the project in local communities, particularly among hospitals.
    
    
  • Incorporate mechanisms in the plan for stakeholders, as well as victims served, to provide feedback on its strengths and challenges and on the quality and effectiveness of the examination process. Improvements to the project should be based on this feedback.
    
    
  • In working with stakeholders, identify factors for each component of the project (SANEs, advocacy, and hospitals) that may facilitate or impede project implementation and sustainability. Consider how best to build on the positives and overcome the challenges.
    
    
  • After a plan is complete, meet as appropriate to carry out the implementation process.
  
  
• Secure funding and resources to support project implementation.
  • Coordinators and participating agencies should consider what is needed to implement the project. For example—
    • Personnel needs.
    • Needs related to meeting coordination, travel, and communication among stakeholders.
    • Recruitment and training needs.
    • Needs for equipment, supplies, and services (e.g., cell phones, pagers, an answering service, printing).
      
      
  • Determine additional funding required for these needs, if any. Also explore what can be done without additional funding and what existing resources the region has that might be useful.
    
    
  • Identify potential funding sources and apply for funding. Consider applying jointly with other entities if it will assist in planning and implementation or increase the likelihood of receiving an award.
    
    
  • If awarded funding, comply with funders’ requirements (e.g., to submit periodic reports).
  
  
• Employ necessary personnel.
  • Determine the need for contractual versus salaried personnel. (What period of time will each be needed and for what specific tasks?)
    
    
  • Clarify how each position will be financed and identify the supervising/contracting agency.
    
    
  • Develop job descriptions and applications for each position.
    
    
  • Advertise positions, screen candidates, and hire qualified personnel.
    
    
  • Provide training and supervision.
  
  
• Develop a written plan for implementation and sustainability and give all stakeholders a copy.
  • Compile the decisions made and tasks identified by community stakeholders and present them in the plan.
    
    
  • Include a tentative timeline for implementation.
  
  
• Develop a basic structure for hospital administration of the project.
  • Identify the administrative party or host hospital for the project. Develop and execute a contract for the host hospital that outlines its responsibilities. Resolve any administrative or operational issues.
    • Work with participating hospital representatives to identify the most appropriate host hospital.
    • Resolve any related issues.
      
      
  • Develop and execute a memorandum of understanding (MOU) for participating medical facilities.
    • Involve hospital administrators who have the authority to make financial decisions in contract discussions.
    • Consider using an outside entity as a mediator in working out compromises and keeping negotiations moving forward.
    • Identify and resolve issues among hospitals.
    • Clarify the hospitals’ roles in—
      • Arranging for nurses to participate in the project.
      • Covering the cost of the project.
      • Seeking reimbursement for examinations performed.
      • Providing space for examinations in their facilities.
      • Providing necessary supplies and storage areas for evidence collected.
      • Contacting SANEs and advocates when patients presenting as sexual assault victims arrive at their facility.
      • Collecting data in these cases.
        
        
  • Outline in the MOU what hospitals will receive for their investment in the project.
    
    
  • Create a budget for the project (this task may go hand in hand with developing MOUs).
    • Identify project expenses.
    • Identify project income.
    • Consider what contributions are needed from involved agencies to develop a balanced budget.
  
  
• Take steps to operationalize the SANE component of the project.
  • Develop SANE protocols that are compatible with all participating medical facilities.
    
    
  • Develop an on-call system for SANEs (and a backup system) that provides 24/7 coverage at participating medical facilities.
    
    
  • Identify examination space in all participating medical facilities where SANEs may conduct examinations.
    
    
  • Develop specifications for examination equipment and supplies to be purchased.
    
    
  • Procure and provide equipment and supplies to the participating medical facilities.
    
    
  • Develop a form to aid in the evaluation of evidence collection submitted for processing.
    
    
  • Assemble and distribute resource manuals to participating SANEs.
    
    
  • Recruit and train SANEs.
    • Develop job descriptions and applications for SANE nurses.
    • Develop SANE commitment agreements. Consider what would entice SANEs to sustain their participation over time.
    • Recruit nurses for SANE training sessions.
    • Identify the minimum number of SANEs needed and train at least that number.
    • Coordinate and conduct adult and pediatric SANE training sessions (consider back-to-back pediatric and adult training sessions).
    • Assist nurses in fulfilling their clinical requirements in a timely manner.
    • Secure written commitments from the newly trained SANE nurses in which they agree to participate in the project on an on-call basis.
    
    
  • Hold regular forums to allow SANEs to work as a team, do peer reviews, resolve problems, share promising practices, receive clinical supervision, and obtain continuing education and information about changes in the project.
  
  
• Take steps to operationalize the advocacy component of the project.
  • Develop and execute an MOU for participating rape crisis centers.
    
    
  • Develop protocols for advocates to follow that are compatible with the participating rape crisis centers.
    
    
  • Develop an on-call system for advocates (and a backup system) that provides 24/7 coverage at participating medical facilities.
    
    
  • Recruit and train volunteer advocates.
    • Develop a recruitment brochure for the sexual assault advocate program. Consider what would entice volunteers to sustain their participation over time.
    • Recruit volunteers for training sessions.
    • Identify the minimum number of volunteers needed to serve as advocates for the regional SANE project and train at least that number.
    • Coordinate and conduct training sessions.
    • Train a number of advocates to provide ongoing training to future volunteers.
    • Secure written commitments from the new advocates in which they agree to participate in the project.
      
      
  • Hold regular forums to allow volunteer advocates to work as a team, resolve problems and share promising practices, receive supervision, and obtain continuing education and information about changes in the project.
  
  
• Implement the project when all components are ready to be fully operational.
  • Seek positive publicity for the project to encourage more victims to seek care.
  
  
• Sustain the project.
  • Complete the checklist tasks (customized as needed) to help ensure that each step of the planning process is geared toward producing a programmatically and fiscally sound project and that issues related to sustainability are considered.
  • Celebrate project successes and milestones.
  • Seek positive publicity to help maintain community support for the project.
  • Continue to evaluate the project’s effectiveness over time and, based on evaluation results, make changes necessary to improve the project.
  • Seek out additional funding and resources as necessary to maintain the project.
  • Encourage stakeholders to continue to meet as needed to discuss how to creatively deal with challenges as they arise. Keep asking, “What can we do now to make the project work?”

---

*The steps in the checklist are similar to the steps that FRIS took to develop the model project, as discussed in this document. However, they are not exactly the same because what communities need to replicate the project is different from what FRIS needed to do to research and develop the model project.

Resources

• For More Information
• Resources Cited

For More Information

Contact OVC’s Training and Technical Assistance Center (OVC TTAC) to obtain more information about Implementing SANE Programs in Rural Communities: The West Virginia Regional Mobile SANE Project.

OVC TTAC
Phone: 1-866-OVC-TTAC (1-866-682-8822)
(TTY 1-866-682-8880)
Fax: 703-279-4673
Web site: www.ovcttac.gov
E-mail: [email protected]

This replication guide includes, in adapted form, much of the material developed in planning and implementing the West Virginia Regional Mobile SANE Project. To access the original material, go to www.fris.org.

For additional project information, please contact one of the following individuals:

Nancy Hoffman, State Coordinator, or Debra Lopez-Bonasso, Education Coordinator
West Virginia Foundation for Rape Information and Services
112 Braddock Street
Fairmont, WV 26554
Phone: 304-366-9500
Web site: www.fris.org

For copies of this replication guide and other OVC publications, or information on additional victim-related resources, contact OVC’s Resource Center:

OVC Resource Center
P.O. Box 6000
Rockville, MD 20849-6000
Phone: 1-800-851-3420 or 301-519-5500
(TTY 1-877-712-9279)
Ask OVC: http://ovc.ncjrs.gov/askovc
Web site: www.ovc.gov/ovcres/welcome.html

OVC publications can also be ordered online through www.ncjrs.gov/App/Publications/AlphaList.aspx.

Resources Cited

Web sites:

Sexual Assault Nurse Examiner/Sexual Assault Response Team
www.sane-sart.com
This site provides information and technical assistance for individuals and institutions interested in developing new SANE-SART programs or improving existing ones.

Sexual Assault Forensic Examiner Technical Assistance
www.safeta.org
This site is geared to disseminating the 2004 National Protocol for Sexual Assault Forensic Medical Examinations: Adults/Adolescents and providing related technical assistance.

International Association of Forensic Nurses
www.forensicnurse.org
IAFN works to provide leadership in the practice of forensic nursing by developing, promoting, and disseminating information about forensic nursing science. For information about the Journal of Forensic Nursing, visit the IAFN Web site and click on the journal’s link.

National Sexual Violence Resource Center
www.nsvrc.org
The National Sexual Violence Resource Center is a comprehensive collection and distribution center for information, research, and emerging policy on sexual violence intervention and prevention. See http://www.nsvrc.org/publications to access numerous online protocols and documents that address the examination process.

National Sexual Assault Coalition Resource Sharing Project
http://www.resourcesharingproject.org
This coalition, also known as RSP, helps state sexual assault coalitions throughout the country access the resources they need to develop and thrive.

End Violence Against Women International
www.evawintl.org
EVAW International offers multidisciplinary training and consultation regarding crimes of sexual assault and domestic violence. See www.evawintl.org/onlinetraining.aspx to access information about its online training institute.

Information on funding opportunities and grant writing:

• Office of Justice Programs, U.S. Department of Justice:
  www.ojp.usdoj.gov/funding/funding.htm
• Office on Violence Against Women, U.S. Department of Justice: www.justice.gov/ovw/currentsolicitations.htm
• All current federal funding opportunities: www.grants.gov
• Foundation Center (for other federal and private funding): http://foundationcenter.org/findfunders
• Guidance on grant writing: http://grants.library.wisc.edu/organizations/proposalwebsites.html.

Publications:

SANE Development & Operation Guide
Linda E. Ledray, Ph.D, R.N., F.A.A.N.
Washington, DC: U.S. Department of Justice, Office for Victims of Crime, 1999, NCJ 170609. www.ovc.gov/publications/infores/sane/saneguide.pdf

A National Protocol for Sexual Assault Forensic Medical Examinations: Adults/Adolescents
Washington, DC: U.S. Department of Justice, Office on Violence Against Women, 2004, NCJ 206554.
www.ncjrs.gov/pdffiles1/ovw/206554.pdf

National Training Standards for Sexual Assault Medical Forensic Examiners
Washington, DC: U.S. Department of Justice, Office on Violence Against Women, 2006, NCJ 213827.
www.ncjrs.gov/pdffiles1/ovw/213827.pdf

The Effectiveness of Sexual Assault Nurse Examiner (SANE) Programs
Rebecca Campbell with contributions from Renae Diegel
Harrisburg, PA: VAWnet Applied Research Forum, National Online Resource Center on Violence Against Women. Retrieved month/day/2004, from: http://www.vawnet.org.
http://new.vawnet.org/category/Main_Doc.php?docid=417

Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims
Kristin Littel
Washington, DC: U.S. Department of Justice, Office of Victim of Crime, 2001, NCJ 186366.

Related Links

Web Sites and Online Services

OVC's Web Forum-Forum for victim advocates, prosecutors, and other professionals to exchange promising practices.

Training and Technical Assistance Center-Web site for OVC center that provides technical assistance and training resources to victim service providers and allied professionals.

Calendar of Events-Web site integrating information on conferences, trainings, and other victim assistance-related events.

Directory of Crime Victim Services-Electronic directory for finding crime victim services.

OVC Resource Center-Information clearinghouse for emerging crime victim issues.

Grants.gov-Site for finding funding resources from OVC.

Publications and Other Products From OVC

Rural Victim Assistance: A Victim/Witness Guide for Rural Prosecutors

Sexual Assault Advocate/Counselor Training online training center

Resources by Topic

OVC also offers several more publications, online resources, and listings for more information on the subject. To learn more, browse through OVC's Topical Resources on-

• Help for Victims of Sexual Assault and Rape
• Sexual Assault/Victimization Publications

Other Related Resources

West Virginia Foundation for Rape Information and Services Web site

SANE-SART Web site

Notes

¹The 1991 number of 20 programs was reported by G.P. Lenehan (1991, February) in “Sexual Assault Nurse Examiners: A SANE Way to Care for Rape Victims,” Journal of Emergency Nursing 17:1.

²The 2006 number of 500 programs was drawn from electronic communication on October 18, 2006, with Carey Goryl, Executive Director of the International Association of Forensic Nurses. This number is indicative of SANE programs in the United States and its territories that are voluntarily registered with the association. There may be additional programs that have not registered with the association. To view the registry, go to www.iafn.org/displaycommon.cfm?an=5.

³Much of the information about the project in this e-publication was drawn from FRIS’s “Mobile SANE Project Final Report” (unpublished). For the sake of brevity, it will not be continuously referenced throughout this document.

⁴Additional terminology exists to denote medical professionals who are specially trained and clinically prepared to perform forensic medical examinations. Examples are forensic nurse examiner (FNE), sexual assault forensic examiner (SAFE), and sexual assault examiner (SAE). For this bulletin, the term SANE is used.

⁵Henceforth in this document, the term “forensic medical sexual assault examination” will be referred to as the “examination” unless further clarification is appropriate. For a discussion of what is involved in this examination, see A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents, 2004, U.S. Department of Justice, Office on Violence Against Women, NCJ 206554.

⁶Although most SANE programs are located in hospital emergency departments, some are in other hospital departments or community settings (e.g., a women’s center, a college health department, or a community health clinic).

⁷When a patient is seriously injured, SANEs must be prepared to work alongside health care personnel (e.g., emergency department physicians) who are stabilizing and treating the patient. SANEs may sometimes need to perform examinations in settings such as an operating room, a recovery room, or an intensive care unit. Drawn from A National Protocol for Sexual Assault Medical Forensic Examinations (Adults/Adolescents): 77.

⁸This paragraph is partially drawn from N. Hoffman and D. Lopez-Bonasso, “West Virginia Goes SANE” (unpublished article).

⁹This list of problems was drawn from R. Campbell, 2004, The Effectiveness of Sexual Assault Nurse Examiner (SANE) Programs, VAWnet Applied Research Forum, National Online Resource Center on Violence Against Women: 1; and K. Littel, 2001, Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims, U.S. Department of Justice, Office for Victims of Crime: 1, 2, NCJ 186366.

¹⁰Go to www.iafn.org/displaycommon.cfm?an=5 to learn about locations of SANE programs registered with the International Association of Forensic Nurses.

¹¹The problems cited in this paragraph were drawn from page 2 of the “Mobile SANE Project Final Report” (unpublished), submitted by FRIS to OVC at the end of its grant period.

¹²WAIC and Hope, Inc., served the counties that decided to implement the project.

¹³Drawn from FRIS’s “Regional Mobile SANE Project Strategic Plan” (unpublished document).

¹⁴Note that Polaroid has discontinued production of the Macro 5 SLR camera, but is still making the film. According to the adult version of the SANE-SART Training Manual, use of a Polaroid, 35mm, or digital camera should be based on what is accepted by the prosecutor/judicial system in a particular area of the country. It is the standard of practice that two sets of prints are made, one for police if the sexual assault is reported and one for the medical record. For further guidance on using photography to document forensic evidence and on the required specifications for camera equipment, please refer to A National Protocol for Sexual Assault Medical Forensic Examinations (2004), chapter 5, “Photography”: 85:

Consult with local criminal justice agencies regarding the types of equipment that should be used (e.g., prosecutors can assess which types of equipment produce results acceptable by the court). In general, any good-quality camera may be used as long as it can be focused for undistorted, closeup photographs and provides an accurate color rendition.* If digital photography is used, the reliability of photographic images must be considered due to technological advances in computer alteration. Also consult with local examiners, because they are often knowledgeable regarding photographic and video equipment used in these cases and their effectiveness in capturing images during the exam.

*The California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001: 56.

¹⁵Initially, the hospital contract stipulated that a participating hospital would be assessed $2,000 if it could not arrange for three nurses to be SANEs. This stipulation was removed from later contracts.

¹⁶After the first year, a requirement was added that nurses must have at least 2 years of R.N. experience before practicing as a SANE.

¹⁷The project has not yet determined a way to enforce this requirement. The few SANEs who left the project before their first year was completed were not asked to reimburse the project for training costs.

¹⁸As a point of clarification, nurses were not required as part of their contract for this project to complete orientation trainings at the other participating hospitals. Nurses working outside of the project for the other hospitals, however, are subject to the policies of those hospitals.

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The Office for Victims of Crime is a component of the Office of Justice Programs, U.S. Department of Justice.