Sexual Assault Nurse Examiners in the Health System: A square peg in a round hole.

This week, we were asked to think about our profession and it’s regulatory bodies, and then where our profession fits into the healthcare system. Nurses (Practical, Registered, and Practitioners) fall under the Nova Scotia College of Nursing. There is also legislation through the Regulated Health Professions Network Act (Nova Scotia, 2012) which enables voluntary collaboration to regulate, standardize, and change scopes of practice, without having to go through other time consuming and restrictive methods. This legislation has allowed more innovative practices such as Pharmacy and RN prescribing to happen quickly and help our burdened health care system.

Sexual Assault Nurse Examiners (SANE) are a bit of a conundrum as they are used by the acute, emergent system, which is inappropriate for most people who have experience a recent sexual assault. Emergency departments are busy, loud, and not always private for relaying details that most people find extremely private. They are not psychologically conducive to someone who has recently been traumatized. In addition, most victims do not suffer major physical injuries requiring acute care (Zilkens, et al., 2017). The injuries that are present in sexual assault victims are often minor to moderate bruising and scratches requiring no treatment, or sore ‘raw’ excoriated genitals – also requiring no treatment. Even bruised or excoriated cervices with bleeding are often minor enough to heal on their own.

Let me be clear that sexual assaults still require timely care. The injuries that can cause harm are often the ones that are not evident: sexually transmitted infections including HIV, and unwanted pregnancy are things that require timely treatment. Prophylaxis for contraception and HIV non-occupational Post-exposure Prophylaxis (HIV nPEP) need to be provided within 72 hours of the assault to be effective. Most victims do not report to the hospital immediately after a sexual assault, so this often leaves only hours to be provided. So, care is urgent, but not emergent.

Adding to the complication, is that the best forensic collection requires specialized equipment, which emergency rooms do not have. Forensic collection also needs to be done as quickly as possible to avoid the loss of evidence. It also requires several hours to complete and if the physician and/or nurse has to attend to another patient, one must stay with the evidence or a police officer is required to guard it to maintain the chain of continuity of the evidence. Emergency department staff have more pressing patients to attend to and can not afford the time it takes to do a full forensic collection. SANEs are a valuable resource to Emergency departments but patients could be served better elsewhere.

Hospitals, even small rural hospitals employ many people, and victims are often concerned that someone they know will see them and tell someone in the community. Victims of sexual assault would be likely be better served in a quiet area, at a site in a community where victims are more comfortable going. However, several regulations and policies, and memorandums of understanding (MoUs) need to be put in place for this to happen. Nurses can not work on their own. They would require orders from a physician or NP. It would not be budget-friendly to employ a physician or NP to be around just to serve the occasional sexual assault victim. This would only work in a very large urban hospital. Halifax, with approximately 1 case per day, would not need a full-time physician. SANEs could all take the RN prescriber course, but that is not feasible. It is a full university credit and all the SANEs have full time jobs in Nova Scotia, doing the on-call SANE job on the side. Standing orders could be created but this puts a higher level of accountability on the nurses. Medication delivery to and storage at the site needs to be put in place for proper accountability. Proper forms and documentation need to be created. Agreements of roles and responsibilities between Nova Scotia Health, the SANE program organizations, and the service sites would need to be clearly determined. This is a lot of work to do before anything can be implemented.

As the provincial lead for the SANE program, I can tell you we are in the early stages of working out what this would look like. We are also starting to consider some virtual “tele-SANE” services for our more rural areas where travel is too far. The current NS government is very receptive to modernizing and redefining our out-of-date health care system. Because of the mass shooting incident in 2020, which originated with gender-based violence (2020 Nova Scotia attacks, 2023), the NS government is also very responsive to creating better services for gender-based violence, which is helping this move forward.

It will be a good day when the sexual assault nurse examiner program can serve most of their population in a more appropriate trauma-informed treatment space rather than an emergency department.

There are more initiatives we are working on to address some gaps. Stay tuned and hopefully I’ll be writing about them soon! Thanks for reading to the end.

2020 Nova Scotia attacks. (2023, September 11). In Wikipedia. https://en.wikipedia.org/wiki/2020_Nova_Scotia_attacks , accessed September 23, 2023

Nova Scotia College of Nursing (2023). https://www.nscn.ca/ accessed Sept 24, 2023

Regulated Health Professions Network Act (Nova Scotia, 2012), c 48. https://nslegislature.ca/sites/default/files/legc/statutes/regulated%20health%20professions%20network.pdf accessed on Sept 24, 2023.

Zilkens, R. R., Smith, D. A., Kelly, M. C., Mukhtar, S. A., Semmens, J. B., & Phillips, M. A. (2017). Sexual assault and general body injuries: A detailed cross-sectional Australian study of 1163 women. Forensic science international, 279, 112–120. https://doi.org/10.1016/j.forsciint.2017.08.001