Forensic Nurse Examiner Program 

Project narrative: 

The Tulsa Police Department introduced the Sexual Assault Nurse Examiners Program (SANE) in 1991 to ensure more timely medical treatment and accurate collection of forensic evidence. SANE is a unique, community -based team approach that has become a national model for the dignified and compassionate treatment of sexual assault victims.

As soon as a rape is reported, a police officer is dispatched to the victims location. Simultaneously a SANE nurse and a rape crisis advocate are called to a quiet, comfortable suite of rooms donated by one hospital to serve the entire community as a site in which the examinations are to be performed. When the victim arrives with a law enforcement officer, she/he is examined immediately by a nurse that has received specialized education in the examination of patients that have been raped. The rape crisis advocate provides support to the victim and family throughout the examination. The twelve member corps of nurses examine approximately 350 adult and adolescent individuals per year. 

SANE received the 1994 Innovations in American Government Award.  The program received $100,000 to use in replication activities. Since that time communities throughout the United States as well as other countries have consulted with the program to develop and implement strategies in order to provide similar services. In 2002, SANE was once again recognized by the Innovations program for significant accomplishments since receiving the original award.

Long waits in emergency departments that were previously experienced by the victims and law enforcement have been eliminated therefore getting the officers back out on the street to perform their duties. The forensic lab has reported a dramatic improvement in evidence collection and preservation. There has been a steady increase in the number of cases that result in judicial proceedings. A significant increase has been seen in plea agreements that are reached.

Funding for the program comes from a variety of sources. The Oklahoma Crime Victim Compensation Board pays for the examination and medications. Day to day operation is supported by the City of Tulsa. Private foundation funds and grants have supported the purchase of necessary equipment. 

Tulsa SANE has for many years provided professional treatment to rape victims in our community and has transferred many of the philosophies and procedures to other victims of crime that need a medical forensic evaluation.

In 1997, the Pediatric SANE program was implemented. The focus of this program is on sexually assaulted prepubescent children that have been assaulted within the previous 72 hours. The program is administered in the same way as the adult and adolescent SANE program. In addition to the education required for the adult examiner the nurses that perform the examinations attended an additional course specific to children and adolescents. A clinical component is required and the nurse completes this with an experienced nurse and at the Children's JUSTICE Center. The JUSTICE center is a Child advocacy center that houses the Tulsa Police Department child crisis unit, members of the Department of Human Services, forensic interviewers, pediatric physicians with OU College of Medicine, and the Tulsa District Attorney office. The medical staff provides the appropriate medical follow-up of the children seen by the sexual assault examiners and through the association with the Center the children have all the services necessary for support following an assault.

The combined SANE programs have provided services to approximately 6500 sexual assault patients since operations began in 1991.

The Drug endangered children program (DEC) was developed in late 2001 and early 2002. This program was designed to provide forensic medical examination to children removed from methamphetamine homes. When a child was discovered, usually by the narcotics investigators, in an active meth lab they are placed in protective custody of law enforcement. A coordinated response is then activated involving the child crisis detectives, DHS, and a nurse that has been educated in evaluating children living in these environments. At the time of the examination the child is assessed for general health status, medical needs, development and  signs of abuse and neglect. Urine is collected as evidence and the examination is documented and the child is prepared for and sent to a location determined to be safe.

Many of these children test positive for methamphetamine or the metabolites of the drug.  Their follow-up medical care is provided by the JUSTICE Center. In 2004 Oklahoma became the first state in the country to enact a limit on the amount of pseudoephedrine that could be purchased by one person. Because pseudophedrine is one of the major components necessary in manufacturing of the drug, over the next few months there was a drastic decline in the number of meth labs discovered and consequently the number of children examined fell to just 1-2 a year. In  2009 there was the beginning of  a resurgence in the amount of methamphetamine manufactured. A different manufacturing technique has been incorporated making it easier, cheaper and much faster to obtain the methamphetamine high. The program developed a few years ago is now being resurrected to address the issues facing this community.

The Domestic Violence Nurse Examiner Program was developed in response to the recognition that intimate partner violence (IPV) remains one of the biggest  public health issues today.  Oklahoma continues to struggle with a high rate of IPV. According to the 2007 Domestic Violence Fatality Review Board Annual Report an average of 78 domestic violence homicides occur each year in Oklahoma.  The number of persons presenting to the Family Safety Center continues to increase. The Family Safety Center is a location similar to the JUSTICE Center housing many services that a person experiencing domestic abuse needs. The Family Violence detectives reside there, a nurse is there 4-6  hours per day 5 days per week, domesctic violence advocates,  a court hearing is held each day and individuals can obtain and emergency protective order. A minister is onsite to provide spiritual support to anyone that desires it and civil legal attorney are available onsite to help victims with those needs. The forensic nurse entails a forensic medical exam, a danger assessment and  safety planning as basic services to everyone that is seen.  Over 2000  individuals have been examined by a nurse specifically educated in the care of patients experiencing intimate partner violence.

Victims of interpersonal violence are most open to change immediately after a crisis or episode of violence. Change is a process not an event so our goal is to promote optimal change and provide a plan that will decrease the number and severity of episodes of violence. If this opportunity is missed or delayed, many victims will employ defense mechanisms (minimization of the event, denial, ambivalence) leaving themselves and their children in danger of future harm.

The Domestic Violence Nurse Examiner Program was implemented in February 2006. It consists of a core group of nurses educated in the care of individuals that have experienced interpersonal violence. They provide forensic medical examinations that address gaps in and limitations of current services provided to these patients.  This was the first specialized program of its kind in the State of Oklahoma. The program was modeled after the highly successful and nationally recognized Tulsa Sexual Assault Nurse Examiner (S.A.N.E.) Program.                                                                                     

In November of 2007 the sexual assault non-report program began. This program was developed to address the federal and state mandate that sexual assault patients be afforded a free forensic medical examination without the requirement that they report to law enforcement. The examination is completed just as if the patient was going to report. The exception is that the items and documentation made at the time of the examination is turned over to the police department with only an identifying number.  If and when a person changes their mind about reporting, an authorization form to release the information is signed. The investigation proceeds with the evidence and the history provided to the nurse shortly after the incident secured and available to the investigation even if the report was made weeks later.      

Education is another major component of the Forensic Nursing Service. Formal nursing contact hour courses are offered for SANE, Pediatric SANE, and Domestic Violence. Additionally presentations are made at healthcare, law enforcement, and community meetings and conferences. Feedback and evaluations are commonly positive. We have partnered with Oklahoma State University Health Science Center specifically with the Forensic Science department and are developing an online SANE course. This will offer nurses some flexibility in taking the course. Currently nurses have to be away from their patient care duties 40 hours consecutively. This is very difficult for many healthcare facilities so they do not send nurses for education or make them take vacation and pay for the course themselves.

The Tulsa Institute of Trauma, Abuse and Neglect (TITAN) is a partner in evaluating services. Currently four research projects are underway.  A sexual assault case tracking study began in 2008. Researchers visited the police department to collect data from sexual assault cases through the SANE case files. Additionally the Oklahoma State Courts Network (OSCN) were accessed looking at what transpired in the court system. The data entry is complete and analysis is underway this spring. More than 50 interviews with SANE coordinators around the country have been done, extensive participant observation, and textual analyses are being utilized to explore ways that SANE nurses frame their role in the reponse to rape victims.

Another project that explores the relationship between victimization and psychological health is assessing patients for anxiety prior to the exam, and after the exam. An additional component presents a short video intervention that addresses anxiety and response issues. The patients are randomly selected to participate is this component and if selected will be assessed again after viewing the video. DNA swabs are collected in consenting participants that will be looked at from the perspective that genetics plays in development of post traumatic stress disorder.

Another  evaluation research project is addressing the organizational procedures used by SANE. Recruitment and retention is typically a difficult issue for nursing units. This program is somewhat immune to this problem. In an effort to understand the organizationa processes that contribute to the success, the hiring practices, compensation, training and supervision is to be evaluated. They will also be looking at the personality characteristics of the SANE nurses related to the stabilithy of this program. This program will be weighed against other programs of comparable size. A literature search has been completed and the tools to utilize are being investigated.      

Strong basic philosophies with victim needs positioned in the center of most of what happens developed in the early 1990's has made it relatively easy to replicate the SANE program. Those same philosophies have been transferred to other victim populations with great success.

» Tulsa Forensic Nursing Services

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