Sexual Assault Nurse Examiner Programs Research Articles

Availability of Certified Sexual Assault Nurse Examiners in Appalachian States

IntroductionSexual assault nurse examiners are crucial care providers in cases of sexual assault. However, it is not clear whether sexual assault nurse examiner availability differs throughout the 13 states that comprise the Appalachian region of the United States. Therefore, this cross-sectional analysis identified sexual assault nurse examiner availability in 13 states and determined differences in availability by both county-level Appalachian status and county-level rurality status. MethodsData were downloaded from 2 public sexual assault nurse examiner registries for the included 13 states. Descriptive statistics of sexual assault nurse examiner certification type and availability by state were calculated. In addition, bivariate analyses of sexual assault nurse examiner availability by rurality and by Appalachian status were performed using 2-sample z-tests for equality of proportions. ResultsState-level sexual assault nurse examiner availability ranged from 0.34 to 0.86 sexual assault nurse examiners per 100,000 residents. Sexual assault nurse examiner availability in these 13 states did not differ by Appalachian status. However, rural areas had significantly lower sexual assault nurse examiner availability than urban areas in these 13 states. DiscussionThese data support previous literature on the need for stronger sexual assault nurse examiner programs in rural areas in the United States. Future research should take sexual assault prevalence into account to determine whether local sexual assault nurse examiner access needs, as well as appropriate support for sexual assault nurse examiners, are being met throughout Appalachian states.

Sexual Assault Nurse Examiner (SANE) program: Long-term impact on confidence and attitudes on SANE trainees

Aim/ObjectiveThe current study examined the long-term impact of SANE programming on the confidence of SANE trainees and on their attitudes toward the SANE role after obtaining SANE certification. BackgroundNationally, sexual assault examiners (SANEs) are in short supply. However, the shortage of SANE nurses takes on a special meaning in the medically underserved United States– Mexico border region where human trafficking is seen as a threat in the region and sexual assaults may be less likely to be reported. In recent years, SANE training programs have established across the country to address the shortage of SANEs. Although positive outcomes have been reported among SANE training programs, the long-term outcomes of programming for trainees are not known. DesignA descriptive longitudinal study with repeated measures was conducted. MethodA total of N = 66 registered nurses who had more than 2 years of nursing work experience were recruited to participate in a SANE training program. The current study included only n = 27 participants who completed the questionnaire at 3 points (Time 1) baseline, (Time 2) 6 months after SANE certification, and at (Time 3) 12 months after SANE certification. General linear modeling and repeated measures analysis of variance were used to analyze the data. Type 1 error was set at p = 0.10. An original 43-item questionnaire was developed to measure the SANE trainees’ confidence and their attitudes toward the SANE role. ResultsInitially, an increased sense of self-confidence was found among trainees at least six months after completing SANE certification; however, this slowly diminished after one year. Likewise, attitudes toward the SANE role deteriorated six months after obtaining SANE certification. ConclusionLack of support and infrastructure to integrate SANE into the wider medico-legal community could explain the diminishing confidence and attitudes of SANE toward the role. The findings of this study have implications for the establishment of support infrastructures in the workplace and community to enhance the recruitment of nurses in SANE programs, the retention of SANEs in the workforce, the sustainability of SANE programs in underserved communities, and the establishment of protocols to integrate SANEs into sexual assault response teams (SARTs), especially in medically underserved US–Mexico border regions.

Characteristics of acute sexual assault care in New England emergency departments.

Interventions such as written protocols and sexual assault nurse examiner programs improve outcomes for patients who have experienced acute sexual assault. How widely and in what ways such interventions have been implemented is largely unknown. We sought to characterize the current state of acute sexual assault care in New England. We conducted a cross-sectional survey of individuals acute with knowledge of emergency department (ED) operations in relation tosexual assault care at New England adult EDs. Our primary outcomesincluded the availability and coverage of dedicated and non-dedicated sexual assault forensic examiners in EDs. Secondary outcomes included frequency of and reasons for patient transfer; treatment before transfer; availability of written sexual assault protocols; characteristics and scope of practice of dedicated and non-dedicated sexual assault forensic examiners (SAFEs), provision of care in SAFEs' absence; availability, coverage, and characteristics of victim advocacy and follow-up resources; and barriers to and facilitators of care. We approached all 186 distinct adult EDs in New England to recruit participants; 92 (49.5%) individuals participated, most commonly physician medical directors (n=34, 44.1%). Two thirds of participants reported they at times have access to a dedicated (n=52, 65%, 95% confidence interval [CI], 54.5%-75.5%) or non-dedicated (n=50, 64.1%; 95% CI, 53.5%-74.7%) SAFE, but fewer reported always having this access (n=9, 17.3%; 95% CI, 7%-27.6%; n=13, 26%; 95% CI, 13.8%-38.2%). We describe in detail findings related to our secondary outcomes. Although SAFEs are recognized as a strategy to provide high-quality acute sexual assault care, their availability and coverage is limited.

Sexual Assault Nurse Examiner Education Needs in Texas.

Background: As with many areas of the nation, Texas lacks a robust sexual assault nurse examiner (SANE) workforce. A program in Texas offers courses to educate and expand SANE skills to better provide trauma-informed care to vulnerable populations. Methods: A survey to stakeholders of a SANE educational program, as part of a planned program evaluation, elicited not only barriers to providing care but also specific program needs to better expand access to sexual assault and domestic violence medical forensic examinations in Texas. Results: In January 2022, a total of 40 stakeholders, all registered nurses in the state of Texas, provided vital information on their current program. Analysis of written survey responses provided themes regarding barriers to providing SANE care and suggestions for expanded education. Discussion: The survey provided valuable feedback and comments on the perceptions of the current SANE program. Written responses offered direction for additional learning desires of SANEs associated with the program as well as areas for the program to expand to meet the needs of the learners. This stakeholder guidance has implications beyond this one SANE education program to enhance and expand other programs based on learner needs.

2216. ROAR ED-SANE: A Retrospective Observational Assessment Review of an Emergency Department Sexual Assault Nurse Examiner Program’s Adherence to CDC Guidelines for Sexually Transmitted Infections

Abstract Background Sexual assault survivors are at increased risk for sexually transmitted infections. Due to patient vulnerability, institutions have implemented Sexual Assault Nurse Examiner (SANE) protocols to care for these patients. These protocols guide evidence collection, testing, treatment, and medical follow-up to ensure optimization of sexually transmitted infections (STIs) treatment, monitoring and follow-up. Previous gap analyses have identified decreased prescribing of prophylactic STI medications and scheduling follow-up appointments compared to guideline recommendations. The purpose of this study was to assess adherence of medication prescribing and follow-up scheduling practices to Centers for Disease Control (CDC) guidelines. Methods This study was a single-center, retrospective, observational, descriptive assessment which evaluated adherence rates to CDC guidelines, to scheduling medical follow-up, and patient attendance at scheduled appointments. Pediatric and adult patients who presented to the emergency department at Mayo Clinic Health System in La Crosse, WI from January 2018 through December 2021 were included. Data collected through chart review included demographics and laboratory data necessary for prescribing prophylactic HIV medications, antibiotics for STIs, emergency contraception, and vaccine administration. Descriptive statistics were used to evaluate results. Results One hundred three patients were evaluated. Majority of patients were female and presented within 3 days of assault. Medication adherence to CDC guidelines was ≥ 80% for chlamydia and gonorrhea whereas < 80% was noted for trichomoniasis and HIV prophylaxis. Adherence to post-ED discharge follow-up was 40%. Conclusion Opportunities to improve adherence of ED-SANE protocols for medication prescribing and medical follow-up for trichomoniasis and HIV prophylaxis exist. Disclosures All Authors: No reported disclosures.

Responding to the Challenges and Barriers Unique to Rural Appalachian Sexual Assault Nurse Examiner Programs

ABSTRACTThe purpose of this article is to explore the opportunities and barriers challenging sexual assault nurse examiners (SANEs) operating in rural and underserved areas. These challenges include the absence of established SANE programs, patient isolation and poverty, inadequate community support, and ensuring program sustainability. While not specific to rural communities, these challenges and barriers are further exacerbated by long-held beliefs and misconceptions that exist in small, close-knit communities. To mitigate these challenges, SANE programs in rural communities are asked to respond with creative and unique solutions. Through strong community partnerships and carefully coordinated efforts, SANE programs can thrive in even the most isolated and economically depressed rural communities.

Improving Access to Postassault Healthcare for College Students: Creating a Campus-Based Sexual Assault Nurse Examiner Program.

National prevalence data indicate that college students are at a high risk for sexual assault, but most institutions of higher education do not provide postassault medical forensic examinations as part of student-facing healthcare services. College sexual assault patients might have access to sexual assault nurse examiners (SANEs) in local hospitals, if they are available where they are attending school, but unfortunately, many student victims do not have options for postassault health services. Creating campus-based SANE programs could address this gap in services and increase access to healthcare. In this article, we describe how we created a free-standing, campus-based SANE program at Michigan State University. We worked with a multidisciplinary community advisory board to identify core guiding principles to inform stakeholder engagement, program location decisions, program policies, training protocols, staffing plans, and collaborative partnerships with other disciplines (e.g., advocacy, law enforcement, prosecution, forensic sciences). We discuss how we navigated opening the program in the midst of the global COVID-19 pandemic and share lessons learned for creating campus-based SANE programs.

Using Telehealth Technology to Serve Patients Reporting Sexual Assault: An Evaluation of Key TeleSANE Program Features.

Many communities across the country are developing, implementing, or already operating programs that provide patients with access to sexual assault nurse examiner (SANE) expertise and care through telehealth technology (e.g., teleSANE or teleSAFE). The speed at which teleSANE programs are proliferating is outpacing the available research and evaluation to inform key decisions on program development and implementation. During the height of the COVID-19 pandemic, the Massachusetts Department of Public Health SANE Program and its National TeleNursing Center decided to rapidly and temporarily convert a set of hospitals from providing in-person SANE care to remote teleSANE care. Several specific changes were made to this program's established teleSANE model for the rapid, temporary conversion. This article reports on findings from an evaluation of the temporary TeleSANE model that provide insight into key decisions that must be made in the development and implementation of teleSANE program features. Communities considering developing or already operating a teleSANE program should be intentional in making program goals, purposes, and values explicit as well as develop their program accordingly.

Counter‐Clinical Spaces1

Intermediary spaces between health social movements and biomedicine have proliferated since the 1970s and have typically been analyzed through the lenses of co‐optation or hybridization. In this article, we present data from two separate empirical projects (teaching and learning the pelvic exam in medical schools and feminist anti‐violence counseling programs) in order to theorize what we call “counter‐clinical spaces.” Counter‐clinical spaces are medicalized sites of knowledge production and practice that are produced through social movements’ contestations with biomedicine. Other examples include sexual assault nurse examiner programs, LGBT health centers, and sexual health clinics. Counter‐clinical spaces are “counter” and “clinical” in several ways. First, these spaces are distinctly clinical in that they intervene in the health of the body. Second, these spaces are counter‐clinical in that they are organized in critique of dominant medical practices. Crucially, counter‐clinical spaces engage the clinical encounter as a site of transformation: social movement actors target clinicians’ deployment of medical power, especially in their interactions with marginalized persons. We thus attend to the scale upon which social movements make a change in and against medicine, and we highlight how social movement logics can and do change practices even when they are unable to shift structures.

The Right to Say No: Why Adult Sexual Assault Patients Decline Medical Forensic Exams and Sexual Assault Kit Evidence Collection.

The International Association of Forensic Nurses (2018) affirms the importance of evidence-based, trauma-informed, patient-centered forensic nursing services that engage patients as autonomous decision makers. Past research indicates that forensic nurses consistently respect patients' choices and control as they navigate the decisions of medical forensic examinations (MFEs) and sexual assault kit (SAK) collection. Building on that work, this study examined which options patients decline and what factors are associated with those declination decisions. We collected prospective data from seven state-funded sexual assault nurse examiner programs. Forensic nurses recorded information about all adult sexual assault patients (N = 783) regarding four primary decisions: whether to have a MFE, whether to consent to all parts of the MFE or to decline specific services, whether to have a SAK collected, and whether to release the SAK to law enforcement for forensic DNA testing. Most patients consented to a MFE (95%), to all parts of the MFE (81%), to SAK collection (99%), and to release the SAK for forensic DNA testing (80%). Younger patients and those with disabilities were more likely to decline some options. Patients who had not disclosed the assault to others before seeking sexual assault nurse examiner care were also more likely to decline a MFE. Whether patients sought post assault care for more health-focused reasons or legally focused reasons was associated with declination decisions. Healthcare providers should communicate clearly about each step in post assault care and allow patients to decline services as they choose.

Supporting sexual assault survivors with disabilities: Tracing disclosure and referral pathways to postassault health care services.

National epidemiological data indicate that nearly 4 in 10 victims of recent sexual assaults have physical, cognitive/developmental, or mental health disabilities, which can make navigating postassault help seeking more challenging. To streamline services, many communities have created sexual assault nurse examiner (SANE) programs for comprehensive health care, crisis intervention, medical forensic evidence collection, victim advocacy, and legal referrals. SANE programs are recommended as the national best practice for postassault care, but there is virtually no U.S.-based research on whether survivors with disabilities seek these services. The present study sought to identify the disclosure and referral pathways that successfully connected sexual assault survivors with disabilities to SANE programs for postassault care. Forensic nurses in one midwestern state recorded information about all adult sexual assault patients (N = 755) who sought care during a 9-month window of data collection. Survivors with disabilities were significantly less likely than those who did not have disabilities to disclose to informal support providers (e.g., family, friends) and those individuals were unlikely to suggest to survivors with disabilities that they seek postassault health care. Survivors with disabilities were significantly more likely than survivors who did not have disabilities to disclose to formal help sources and to be referred to SANE programs by other formal community services, typically the police. A strong referral network from law enforcement to SANE programs is important, but survivors who do not wish to pursue criminal investigation need reliable pathways to postassault health care. Strategies for promoting community awareness of SANE services are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

60 The Value of an Integrated Sexual Assault Nurse Examiner Program at Trauma Centers: Comparing the Quality of Documentation

60 The Value of an Integrated Sexual Assault Nurse Examiner Program at Trauma Centers: Comparing the Quality of Documentation

Laying the Foundation for the National TeleNursing Center: Integration of the Quality-Caring Model Into TeleSANE Practice.

In 2012, the Massachusetts Department of Public Health Sexual Assault Nurse Examiner (SANE) Program was awarded a grant from the Department of Justice, Office for Victims of Crime, to pilot the use of telemedicine technology to extend the reach of SANE expertise to six diverse communities across the United States. To meet the goals of this project, the National TeleNursing Center (NTC) developed a three-phase professional practice model integrating the Quality-Caring Model (QCM) to support the delivery of NTC teleSANE services. Using the QCM as a foundation for teleSANE practice ensures that patients experiencing a recent sexual assault who participate in teleSANE encounters receive quality forensic nursing care. In this article, we briefly review elements of the QCM, describe the application of the model to the NTC Professional Practice Model, and detail how teleSANEs integrate the QCM Caring Behaviors into all three phases of its model. The NTC Professional Practice Model provides a quality-based teleSANE model that may be translatable to other areas of telenursing practice.

Pushing the Boundaries: The Impact of the Role of the Clinical Nurse /Midwife Specialist (CN/MS) Sexual Assault Forensic Examination (SAFE) in Ireland

Introduction: Landmark research of Magee et al. (2002) (n=3,120) found that in Ireland , 4 in 10 women (42%) and almost 3 in 10 men (28%) experienced sexual assault or abuse in their lifetime. Subsequently, a National Review of Sexual Assault Treatment Services found sexual assault remains one of the most underreported and under recorded violent crimes in Ireland (O’Shea 2006). Key recommendations included expansion of existing services and introduction of a pilot programme in forensic nursing in Ireland, where nurses would undergo a higher diploma and apply for accreditation as CN/MS (SAFE). Short description of practice change implemented: Expansion of Sexual Assault Treatment Units (SATU) from four to six units in Cork, Dublin, Letterkenny, Waterford, adding Galway, Mullingar (2009). Successful implementation of nurse training following pilot programme CN/MS (SAFE). Aim and theory of change: Patients attending SATU may be physically and /or psychologically traumatised making difficult, life changing decisions. SATUs need to be appropriately staffed and available around the clock to provide prompt medical /supportive care and collect forensic evidence. As a nationally agreed service with defined multiagency guidelines (National SATU Guidelines 2014) and choice of care pathways, the CN/MS (SAFE) can consolidate the initial healthcare response to the under-reported crime of rape/sexual assault by utilising specialistic clinical nursing/midwifery knowledge and critical thinking skills to provide optimum patient care. This change also addresses the issue of recruitment/retention of doctors to carry out forensic examinations (O’Shea 2006). Targeted population and stakeholders: All male /female patients age 14 or older who present to SATU following recent rape/sexual assault. The optimisation of the role of nurses /midwives as Forensic Clinical Examiners realises advantages to Patients, SATU services, Nursing/Midwifery, the wider Inter-disciplinary Team, Inter-disciplinary working ,Criminal Justice System. Timeline: 3 groups of CN/CM (SAFE) graduated 2010-16 developing, assimilating, integrating a broad in-depth knowledge base in this speciality through a structured academic and clinical framework. Highlights: Innovations, Impact, Outcomes CN/MS (SAFE) has transformed the care/services for patients significantly advancing and extending the breadth /depth of SATU services namely: availability of trained staff on a 24 hr basis streamlined response times, accessibility, efficiency of healthcare/forensic service delivery (see Table 1) implementation of patient focused care initiatives including increased patient care pathways influential in driving quality improvement in SATUs nationally participation in patient, staff, community education / risk reduction programmes contribute to development, evaluation and implementation of national strategies Table 1 table of case numbers from 2009 to present day will not load! Sustainability: Some CN/MS (SAFE) have advanced skills in both the academic and practice arena and the enhancement and expansion of this nursing/midwifery role to Registered Advance Nurse Practitioner (RANP (SAFE) would support national policy direction promoting quality patient care. Realisation of the RANP (SAFE) would also ‘assist sustainability, the long range thinking’ (Markowitz 2009) for this unique and extremely challenging area of healthcare practice. Transferability: Transferable skills to other health related services e.g. sexual health, paediatric sexual assault forensic examination etc. Scope for other jurisdictions internationally to adopt and develop the Irish model of CN/MS (SAFE) training and role into their own programmes of care. Discussions & Key findings: CN/CM (SAFE) are attached to a SATU strategically located nationally so that the patient has no more than a three hour drive to the nearest SATU. SATU availability helps to minimise patient distress and ensures timely collection of forensic evidence (O’Shea 2006). The CN/CM (SAFE) initiative is unique to Ireland. It demonstrates international leadership, supported at Government level and by the many different disciplines /agencies involved including An Garda Siochana, the Rape Crisis Centres. Since 2009, Forensic Clinical Examiners in Ireland are either Medical Doctors or CN/MSs (SAFE). Conclusions: To date, CN/MS (SAFE) in the realms of rape / sexual assault in Ireland have forged a path through a previously unknown clinical area. Working as Forensic Clinical Examiners, the CN/MS (SAFE) use a consistent, standardised, patient focused approach with the interdisciplinary team to improve outcomes and reduce the long term sequelae for each patient regardless of the circumstances of the incident or a person’s engagement, or not with the criminal justice system. Expansion of SATU services in Ireland and availability of CN/MS (SAFE) has greatly improved accessibility for patients following rape /sexual assault.

Evaluation and Management of Female Victims of Sexual Assault.

Sexual assault is characterized by any sexual contact or behavior that occurs without explicit consent. Classifications vary based on the status of the perpetrator's relationship to the victim (eg, stranger, acquaintance) and characteristics of the victim herself (eg, child, elder adult, mentally disabled adult). Regardless of the classification, sexual assault is a significant individual as well as public health issue affecting women of all ages. While the majority of sexual assault cases are not initially reported to law enforcement, the best available data suggest the lifetime prevalence of sexual assault in the United States is approximately 20% among adult women. With such a significant proportion of women affected by sexual assault, women's health care providers in both ambulatory and emergency care settings play key roles in the evaluation, management, and advocacy of these victims. Establishing standard protocols based on state laws and on victim-centered practices to avoid revictimization of the patient is critical. The primary goals of care include the assessment and treatment of physical injuries, psychological assessment and support, pregnancy assessment and prevention, and therapy for prevention of sexually transmitted infections. In addition, evidentiary collection is a critical component of the sexual assault evaluation and subsequent legal proceedings. This report focuses specifically on the immediate evaluation and management of adult female victims of sexual assault. Best practices include the utility of the Sexual Assault Nurse Examiner and Sexual Assault Forensic Examiner programs, as well as standardized treatment protocols.

Is there a role for paediatric Sexual Assault Nurse Examiners in the management of child sexual assault in Australia?

In Australia, paediatricians and Child Protection Specialists provide the medical and forensic examinations of child victims of sexual assault. There are workforce challenges in the recruitment and retention of doctors to undertake child sexual assault (CSA) work particularly in remote and rural areas. Pediatric Sexual Assault Nurse Examiner (PSANE) programs have existed in the USA and the UK for many years. Using Rapid Evidence Assessment (REA) methodology, a systematic search of the literature was performed to ascertain what is known about SANE programs, to evaluate the evidence for their effectiveness across a number of domains (accessibility, health and legal outcomes and cost effectiveness) and to inform policy on models of care and elements of best practice which may be appropriate for local implementation in Australia. This review showed that despite the limited evidence available and significant gaps in the evidence, SANEs provide a high standard of medical care and are not detrimental to the legal process. By providing recommendations regarding the potential value, effectiveness and feasibility of establishing a PSANE program in Australia, this article may be of interest to other high income countries facing similar workforce challenges in meeting the needs of children with alleged sexual assault.

The Sexual Assault Nurse Examiner's Interactions Within the Sexual Assault Response Team: A Systematic Review.

Many emergency department nurses care for the sexually assaulted victim, when sexual assault nurse examiner (SANE) programs are not available. Therefore, it is important for emergency department nurses to understand the roles of both the SANE and the sexual assault response team (SART). The purpose of this systematic review was to identify the current research on the integration of the SANE among the SART and evaluate the gaps in research of the SANE's role, attitude, behavior, and satisfaction within the collaborative SART. Studies published between 2004 and 2014 using key words were evaluated. A 3-stage search strategy revealed 582 articles. The articles were assessed and categorized according to Level of Evidence definitions. Twelve qualitative and mixed-methods studies were identified. Studies ranged from SART protocols or responses to situational factors to SANE relationships with other SART members. The review reflected the need for more research within the collaborative atmosphere of this multidisciplinary and interagency team that defines the SART, and the individual member's perceptions. Further studies are needed on the SANE's impact on patient outcome and the emergency department nurses role when a SANE or SART program is not available.

Low-Fidelity Hybrid Sexual Assault Simulation Training's Effect on the Comfort and Competency of Resident Physicians

BackgroundAlternative training methods are needed for resident physicians to ensure that care is not compromised should they practice in settings without well-established Sexual Assault Nurse Examiner (SANE) programs. ObjectiveThe purpose of this study is to determine the effectiveness of a simulation-based sexual assault response course for resident physicians at an institution without an on-site SANE program. MethodsEducational intervention study of 12 emergency medicine residents using a low-fidelity hybrid simulation model. The study was comprised of eight male and four female physicians at a military medical center in San Diego, CA. Assessment occurred using three separate metrics. The first was a written knowledge test. The second was a simulated interview and evidentiary examination. These metrics were given 1 month before and 3 months after an 8-h training course. The final metric was Likert-scale questionnaires surveying pre- and post-course feelings of competency and comfort. ResultsThe emergency medicine residents showed a 13% improvement (95% confidence interval [CI] 7−20%) in written examination scores pre and post intervention. Post-course interview and examinations reflected a 44% improvement (95% CI 24−64%) in critical action completion. Pre-course comfort and competency questionnaires were a median of 2 (interquartile range [IQR] 1−3) on a Likert Scale. Post-course survey responses were a median of 4 (IQR 2−5). ConclusionsLow-fidelity hybrid simulation is a useful tool to train inexperienced physicians to perform evidentiary examinations and interviews without sacrificing the privacy and direct care of sexual assault victims.

Understanding how advocates can affect sexual assault victim engagement in the criminal justice process.

Following a sexual assault, survivors may seek help from multiple community organizations including the criminal justice system (CJS). However, sexual assault survivors often feel apprehensive about participating in the CJS and thus, few report their victimizations to law enforcement. Of those who report, many withdraw their participation from the CJS. Rape crisis center advocates often are one of the first professionals victims encounter while seeking help after a victimization and thus, they may play a key role in reducing barriers to victim participation in the CJS. Qualitative interviews were conducted with forensic nurses and victim advocates at a Midwest Sexual Assault Nurse Examiner (SANE) program to examine how advocacy services may influence victim engagement with the CJS. This study found multiple components of advocacy services that may address common barriers to victim participation. Implications for research and practice are discussed.

Evaluating the Legal Impact of Sexual Assault Nurse Examiner Programs

There has been sustained interest in the academic literature and in policy circles regarding how Sexual Assault Nurse Examiner (SANE) programs may bolster sexual assault prosecution rates in their communities, in addition to the health care they provide to their patients. To build evaluation capacity among forensic nurses so that they can evaluate their own programs, a practitioner-oriented, step-by-step evaluation toolkit (the SANE Practitioner Evaluation Toolkit) that can be used by SANE-A and SANE-P programs, and their community partners, to examine sexual assault prosecution rates in their local jurisdictions was created and validated. This article describes the process of creating and empirically validating the toolkit and presents the toolkit itself and accompanying resources that are available to practitioners. This article also provides recommendations regarding program readiness to engage in evaluation activities, without compromising program sustainability and patient care.