Challenges and Collaborations: A Case Study for Successful Sexual Assault Nurse Examiner Education in Rural Communities During the COVID-19 Pandemic.

ABSTRACT: Challenges can often only be overcome with collaboration. In this case report of a Health Resources and Services Administration-funded program for Advancing Nurse Education - Sexual Assault Nurse Examiner, we describe the unique challenges and collaborations that have taken place in rural communities as we continued to train nurses during the COVID-19 pandemic. Geography and lack of availability of sexual assault nurse examiner (SANE) trainees brought many challenges as we prepared them to successfully pass the SANE certification examination and recruit new cohorts to expand SANE education.During the implementation of this program, we found that our process model, community collaboration, and commitment to these rural counties were the keys to our success before and during the COVID-19 pandemic.SANE trainee process and outcome measures were collected through quantitative and qualitative data collection. These data from the first cohort, along with the strategies implemented as all partners navigated the challenges of COVID-19, helped to strengthen our collaboration and expand the program. Details of these strategies and outcomes to date will be discussed.

The Regional Underserved Sexual Assault Nurse Examiner Program or RUSANE program was designed to provide training to qualified registered nurses in rural and underserved communities. It was developed to address specific barriers rural and underserved counties in South Florida faced in treating victims of sexual assault including lack of resources, limited or no Internet access, and physical geography forcing patients and providers to travel multiple hours for services. Through specific didactic and clinical preparation, our trainees are able to provide comprehensive, trauma-informed sexual assault medical forensic examinations to adult and adolescent victims of sexual assault and abuse.

Background and Significance of the Case

Before our program, there were no SANE-trained nurses in Hendry or Glades County. Hendry Regional Medical Center (HRMC), a critical access hospital that serves both counties, is the only hospital and emergency room that treats approximately 16,000 patients a year (HRMC, 2021). Persons who experienced a sexual assault and presented to this emergency department would often have to either wait over 12 hours for a SANE from outside the county to arrive or seek care outside the county. The inability to access SANE services has been estimated to severely impede recovery and prosecutorial success (Johnson & Hiller, 2019).

The feedback from our program model informed us of the needs of the SANE trainees and the challenges of both COVID-19 restrictions and geography. SANE training programs accredited by the International Association of Forensic Nursing (IAFN) that were available in the state before RUSANE were not suitable or appealing to potential SANE trainees. Nurses cited that (a) these programs were not offered within the county/community; (b) the 40-hour didactic training in the state was offered in 5-day segments, meaning nurses would not be able to work for 5 days in a week; (c) SANE trainees living in rural counties/communities did not have reliable Internet access for online courses; and (d) in-person training was key to continued engagement and prevention of SANE attrition.

During the implementation, we found our process model, dedicated SANE trainer, IAFN-accredited clinical and didactic courses, community collaboration, and commitment to these rural counties as keys to our success before and during the COVID-19 pandemic. Our strategies for community collaboration, namely, having a consistent physical presence and in-person classes in the county, and working with multiple community agencies, resulted in requests for program expansion into other rural counties and improvement of services for persons who had been sexually assaulted.

With the COVID-19 pandemic, we faced significant challenges. Specifically, the emergence of COVID-19 led many nurses to face the greatest challenges of their careers, in efforts to deal with COVID restrictions, new protocols, increased patient loads, and personal ramifications, while still training for SANE certification (Chen et al., 2020; Fernandez et al., 2020; Manzano García & Ayala Calvo, 2021; Uchmanowicz et al., 2020).

Description of the Case

As of December 2019, the RUSANE program trained the first cohort (n = 6) of IAFN SANE-trained nurses, providing Hendry County with a small team of reliable nurses to aid patients who had been sexually assaulted. Within 2 months, HRMC saw four persons present to the emergency department requesting a sexual assault examination. The COVID-19 pandemic has exposed many underlying health disparities, including access to care, likelihood of contracting disease, and likelihood of experiencing domestic violence (Bright et al., 2020; Hirko et al., 2020). Many long-standing challenges that the RUSANE program faced were augmented by the trials of COVID-19, but they were met head on with the united efforts of program leaders and trainees alike.

As previously mentioned, geography had always been a pertinent issue for the RUSANE team. Before COVID-19, meetings, trainings, and case reviews were all done face-to-face, with RUSANE team members traveling to our rural partners. However, because of COVID restrictions, both at our institution and at HRMC, in-person meetings and trainings were no longer possible.

Furthermore, the increasing numbers of patients having COVID-19 were burdensome enough to necessitate the cancelation of elective procedures and other routine care. Nurses at HRMC, including our trainees, were scheduled more frequently to help manage the spiking cases of patients with COVID-19. The increased scheduling made it highly difficult for trainees to meet with the SANE trainer, and it was no longer possible for the trainees to meet with the trainer as a group as their additional shifts conflicted with one another.

Acquiring qualified and motivated trainees was another issue already experienced by the RUSANE program that was aggravated by COVID-19. As illustrated in Table 1, there are few IAFN-trained SANEs available in the United States (IAFN, 2020), let alone Florida and its rural counties. Despite creative attempts to mitigate a rapidly dwindling supply of nurses, the COVID-19 pandemic exacerbated preexisting nursing deficits that are rife in rural hospitals (Manzano García & Ayala Calvo, 2021). Burnout caused by the pandemic, as well as staff departing for more lucrative assignments, severely reduced HRMC staff. In response, RUSANE trainees at HRMC experienced increased hours and shifts, reducing their time to study and train for certification. In a supportive effort, HRMC hired traveling nurses to manage the staffing crisis and remained committed to the first cohort of trainees remaining involved in the RUSANE program.

TABLE 1

Number of IAFN SANE-Certified Nurses Based in the United States, Florida, and Rural Florida Counties

Region	No. of SANEs
United States	1339
Florida	39 (0.02%)
30 Rural Florida counties	1

Source: International Association of Forensic Nursing (IAFN, 2020). SANE(s) = sexual assault nurse examiners.

Like much of the rest of the county, the pandemic created difficulties in terms of access to childcare or schooling (Miller, 2021). For our trainees, this strain for childcare further reduced their time and ability to prepare for the certification examination. To confront these issues, we collaborated with our trainees, clinical partners, and community partners to find ways that we could creatively use technology and telehealth; we created online testing games, conducted one-on-one Zoom coaching sessions, distributed practice certification examinations, and debriefed with trainees individually (based on their schedules) and reviewed the topics that required the most assistance.

The collision between a surge in hospitalized patients requiring nursing care and societal conditions that elevate the risk for domestic and sexual violence was another obstacle. Sexual assault survivors in rural areas face unique challenges, as they are frequently forced to travel long distances to access the services of certified SANEs (Thomas et al., 2019). HRMC saw a significant drop in patients presenting to their emergency rooms for sexual assault services. The actual number of patients who sought care for sexual and domestic violence decreased by over 50%, depriving novice SANEs of the opportunity to build and maintain competence (Bright et al., 2020; Muldoon et al., 2021; Centers for Disease Control and Prevention, 2021). To meet this challenge, we ensured our monthly Zoom meetings and one-on-one trainee meetings allowed our SANE trainees to vent their feelings and frustrations in addition to their standard case and content review. We also worked with hospital administration on alternative scheduling for the trainees and spreading our didactic content over 3 weeks instead of compressing the trainings into one 40-hour work week.

Summary of Key Findings

Hendry County has been the principal area of focus for the RUSANE program, with HRMC serving as our principal clinical partner. Before the pandemic, residents of Hendry County experienced considerable negative outcomes regarding poverty and health status compared with the rest of the state (University of Wisconsin Population Health Institute, 2020). In addition, Hendry Country did not have any SANE-certified, or trained, nurses stationed within the county.

We collaborated with our partners to overcome challenges during the COVID-19 pandemic, which disproportionately hit rural areas. Partners included city police, county sheriff's office, state attorney's office, and emergency medical services. The RUSANE organizational model, detailed in Figure 1, shows the connections between our community partners and our trained group.

FIGURE 1

Project organizational chart. FIU GFJC = Florida International University Global Forensic Justice Centre; FIU NWCNHS = Florida International University Nicole Wertheim College of Nursing & Health Sciences; RUSANE = Regional Underserved Sexual Assault Nurse Examiner.

We maintained regular communication with our partners as much as possible regarding their efforts to handle the pandemic within the county, including phone calls with individual agencies and our biannual community advisory board meetings. This information helped us create reasonable expectations for our trainees by understanding their workload as well as helping us to plan future trainings and reviews. By doing so, we were able to continue to track cases conducted by our trainees and receive feedback from our trainees' performance. This included feedback from the state attorney's office in tracking cases conducted by our trainees and the sheriff's office ensuring that kits were properly sealed and that the chain of custody was maintained.

Although the pandemic limited the number of people who had been sexually assaulted willing to present at an emergency department and seek SANE services, each trainee has seen improvements in their abilities to provide sexual assault examinations. This is largely because of the routine virtual meetings with our SANE trainer, which provided structured case reviews. SANE trainee processes and outcome measures were collected using both quantitative and qualitative approaches to track SANE trainees' performance. In addition, to gauge trainee competence, a 44-item evaluation tool (Commission for Forensic Nursing Certification, 2013) that complemented our process and outcome measures was completed by the SANE trainer. Our SANE trainer was present to assist and observe every sexual assault examination conducted by the SANE trainees.

A baseline evaluation was conducted immediately after the trainees' clinical skills course, before any of the trainees conducting a sexual assault examination. Participants can score between 1 (requiring extensive prompting) to 5 (performs behavior independently); items may be scored as N/A if the patient declined a specific aspect of a sexual assault examination, for example, collection of oral specimens. These outcome measures are of particular importance as they gauge the trainees' evidence collection skills. Although all measures are recorded and tracked across trainees, the following are items that are most indicative of readiness for independent practice:

Uses proper techniques, collects appropriate evidence according to local protocol, and documents and maintains chain of custody evidence accurately, including skin surface specimens, oral and anogenital specimens, and blood and urine specimens.

Adheres to evidence-based policies and procedures for SANE providers.

Incorporates professional standards, evidence-based clinical guidelines, ethical decision making, and research into management.

Correctly educates patients about self-care, disease processes, therapies, and drug regimens based on cultural and educational background.

Shows knowledge of relevant legal regulations for SANE provider practice, including reimbursement for services.

Follows assessment guidelines and standardized procedures for age-specific and special populations: adolescents, adults, older adults, pregnant women, and those with special needs.

All RUSANE trainees have improved from their baseline evaluation, and all received an overall mean score ranging from 4.19 to 4.69 on their most recent case examinations. These items, in tandem with trainee attendance at case review meetings and one-on-one sessions with the SANE trainer, have been most reflective of a given trainee-maintained commitment and success for SANE training and certification.

Discussion

Although rural patient caseloads are not comparable with larger, more urban areas, their lack of resources, healthcare facilities, and specialized providers leaves rural residents without the help that they need and deserve (Johnson & Hiller, 2019). Before the RUSANE program, Hendry County had zero certified or trained SANE nurses. Meeting this need has allowed these nurses to have IAFN didactic and clinical training that is not only evidence based but also learner centered and reduces traveling and financial stress (Maier, 2012). Ensuring that our curriculum was IAFN accredited, including our clinical requirements, provided our trainees and clinical partners with confidence that they were receiving proper training and support. In addition, developing and delivering didactic and clinical skills training at our rural clinical partners' site and compensating nurses for their training and for their on-call time has shown to be successful in recruiting and retaining nurses in rural areas. Currently, HRMC has maintained an on-call schedule for the SANE trainees, guaranteeing 24/7 coverage and rapid response time for persons who have been sexually assaulted, presenting to the emergency department. This has changed the environment for those who present at HRMC. They no longer wait multiple hours, or travel outside their county, to receive SANE services. As we expand, we move forward using data from our process and outcome measures, focus group information, and course evaluations to move our program forward to meet the goals of this Health Resources and Services Administration-funded project: to increase the number of qualified SANE-trained nurses in South Florida, increase access and distribution of SANE services, and maintain stakeholder support and involvement.

Conclusions

Rural areas were severely hit by the COVID-19 pandemic, with limited resources to properly combat the resultant closures, patient load, and mandated safety measures. A dedicated preceptor and SANE trainer, along with collaboration and commitment maintained by relevant community partners, fostered SANE trainees to function in a rural community. Not only that our strategies proved to retain trainees, but also the success of our strategies led other rural communities and agencies to seek these services. We hope that, with COVID-19 vaccination distribution and subsequent drops in cases, nurses will be less burdened, and we will see increased interest in SANE training among qualified nurses

Although the pandemic has taken a strong toll on nurses throughout the United States and has stymied the progress of our original RUSANE program plans, we have proudly been able to maintain engagement with most of our trainees. This was made possible through our reliance and inclusion of a dedicated SANE trainer, our ability to maintain relationships with stakeholders, and the development of alternative study tools such as practice tests, simulations, and case reviews. A combination of our relationships with stakeholders, community presence, publications in scientific journals, presentations in other rural communities, and local media has led to counties neighboring Hendry to seek training and structured RUSANE support.

It is difficult to gauge the full effect of our program given our small cohort size and the limitations that were brought by the pandemic, but we are confident that the RUSANE project model can and should be applied to programs seeking to train and certify nurses in rural areas. Programs in rural areas should prioritize community relations and flexibility in their approach based on differences in resources available to rural versus urban residents. Despite our challenges, we have now formed relationships in other rural communities to continue and expand our program. The Florida Council Against Sexual Violence is now providing information to our team so we can meet the needs of all the rural counties in Florida. In the face of the COVID-19 pandemic, our work continues.