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SANE program staff: Selection, training, and salaries
n the m o s t r e c e n t list of sexual a s s a u l t n u r s e e x a m iner (SANE) programs, 86 w e r e identified. 1 This u p d a t e d list w a s u s e d as the b a s i s of a survey of SANE programs, t h e results of w h i c h will b e c o m p i l e d a n d i n c l u d e d in a SANE Operation and Development Manual. T h e d e v e l o p m e n t of this m a n u a l , f u n d e d b y t h e Office for V i c t i m s of Crime, D e p a r t m e n t of J u s t i c e , will p r o v i d e s t a t e - o f - t h e - a r t i n f o r m a t i o n a b o u t e x i s t i n g SANE programs, as well as a d d i t i o n a l i n f o r m a t i o n for t h o s e w i s h i n g to develop a SANE prog r a m in their area. This is t h e s e c o n d i n a series of articles a b o u t c u r r e n t SANE p r a c t i c e s a n d o p e r a t i n g procedures, b a s e d o n the results of this survey. This article r e v i e w s c u r r e n t p r a c t i c e s of t h e 60 SANE p r o g r a m s t h a t h a v e n o w r e s p o n d e d to t h e q u e s t i o n n a i r e . W h o directs t h e s e SANE p r o g r a m s ? To w h o m does the director report? W h a t t y p e of n u r s e s do t h e y look for w h e n h i r i n g ? H e w large a staff do SANE p r o g r a m s m a i n t a i n ? W h a t t r a i n i n g is provided? H o w are SANEs paid?
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SANE program directors Fifty-four p r o g r a m s c o n t a c t e d h a v e n u r s e s as t h e SANE p r o g r a m director. Of t h e six r e m a i n i n g programs, one p r o g r a m is r u n b y a p h y s i c i a n ' s a s s i s t a n t (PA); one b y a social worker (MSW); o n e b y a n a d m i n istrator; o n e b y a n o n n u r s e w i t h a m a s t e r ' s d e g r e e in e d u c a t i o n (MSEd); a n d two b y p h y s i c i a n s . Followu p p h o n e calls revealed t h a t four of t h e six n o n n u r s e - d i r e c t e d p r o g r a m s do h a v e a n u r s e i d e n t i f i e d as the p r o g r a m coordinator w h o f u n c t i o n s in m u c h t h e s a m e w a y as a n u r s e p r o g r a m director. T h e t w o e x c e p t i o n s i n c l u d e the p r o g r a m r u n b y a n MSEd a n d o p e r a t e d jointly w i t h a rape crisis center, a n d one p r o g r a m o p e r a t e d b y a PA a n d primarily staffed b y PAs.
Linda E. Ledray is Director, Sexual Assault Resource Service, Minneapolis, Minnesota. J Emerg Nuts 1997;23:491-5. Copyright © 1997 by tlle Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/1/84792
Reporting structure Forty SANE p r o g r a m directors report to s o m e o n e in h o s p i t a l a d m i n i s t r a t i o n . S i x t e e n SANE p r o g r a m directors report to a n u r s e m a n a g e r (nine of t h e s e are RD n u r s e m a n a g e r s ) . A n o t h e r 10 SANE directors report to a m e d i c a l director; e i g h t of t h e s e are t h e director of e m e r g e n c y m e d i c i n e . A n o t h e r 14 report to a n o t h e r hospital a d m i n i s t r a t o r i n c l u d i n g t h e vice p r e s i d e n t of p a t i e n t care (n = 4); a s s i s t a n t a d m i n i s trator (n = 3); hospital chief e x e c u t i v e officer (n = 2); a m b u l a t o r y services (n = 2); ED a d m i n i s t r a t o r (n = 1); h u m a n r e s o u r c e s (n = 1); a n d a specialized w o m e n ' s h e a l t h clinic director (n = 1).
A background in obstetrics and psychiatry, and especially experience working in positions that require i n d e p e n d e n c e , such as public health nursing, school nursing, and ED nursing, is preferred by one program. Twelve report to a g e n c i e s o u t s i d e of a hospital a d m i n i s t r a t i v e structure. T h e s e i n c l u d e two w h o report to a rape crisis c e n t e r director; two to a YWCA administrator; two to a district attorney; one to a police detective; one to a family v i o l e n c e coordinator; a n d four to advisory b e a r d s or c o o r d i n a t i n g boards. Five p r o g r a m s are i n d e p e n d e n t a n d i n d i c a t e d no r e p o r t i n g s t r u c t u r e o u t s i d e their organization. Three p r o g r a m s did n o t r e s p o n d to this question.
Staff selection Today m o s t SANEs are female n u r s e s . Only e n e prog r a m i n d i c a t e d t h e y h a v e o n e male n u r s e w h o takes
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call. A p p r o x i m a t e l y 50% of v i c t i m s , e v e n m a l e victims, prefer to h a v e t h e e x a m i n a t i o n c o m p l e t e d b y a w o m a n a n d s o m e t i m e s i n s i s t on b e i n g s e e n b y a w o m a n . >4 A l t h o u g h we, of course, c a n n o t d i s c r i m i n a t e a g a i n s t m a l e n u r s e s w h o w i s h to a p p l y for a SANE position, our p r i m a r y goal m u s t a l w a y s b e to m e e t t h e n e e d s of t h e v i c t i m p o p u l a t i o n w e serve.
A p p r o x i m a t e l y 50% of victims, even male victims, p r e f e r to h a v e t h e examination completed by a woman.
T h e l i t e r a t u r e i d e n t i f i e d t h a t g o o d clinical skills a n d g o o d w r i t t e n a n d c o m m u n i c a t i o n skills are e q u a l ly i m p o r t a n t c h a r a c t e r i s t i c s to look for w h e n h i r i n g a SANE. s A b a c k g r o u n d in o b s t e t r i c s a n d p s y c h i a t r y , a n d e s p e c i a l l y e x p e r i e n c e w o r k i n g in p o s i t i o n s t h a t require independence, such as public health nursing, school n u r s i n g , a n d ED nursing, is p r e f e r r e d b y one p r o g r a m , s G o o d a s s e s s m e n t skills, t h e ability to w o r k i n d e p e n d e n t l y , b e a b l e to e v a l u a t e a situation, a n d k n o w w h e n to a s k for help, are e s s e n t i a l staff requirements7 O n e p r o g r a m d i r e c t o r i n d i c a t e s s h e t e n d s n o t to hire n u r s e s w h o a r e r a p e v i c t i m s t h e m s e l v e s , u n l e s s t h e r a p e o c c u r r e d m u c h longer t h a n a y e a r p r e v i o u s ly a n d t h e n u r s e ' s o w n i s s u e s h a v e b e e n resolved. Her e x p e r i e n c e h a s s h o w n h e r t h a t a SANE c a n n o t h e l p s o m e o n e else r e s o l v e i s s u e s s h e h a s n o t effectively r e s o l v e d herself. 6 O t h e r d a t a , h o w e v e r , s u g g e s t i n c r e a s e d e m p a t h y a n d e f f e c t i v e n e s s on t h e p a r t of S A N E s w h o h a v e b e e n sexually a s s a u l t e d , s Although many SANEs today have advanced n u r s i n g d e g r e e s, t h e m a j o r i t y do noJ),
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r o t a t e d on call, b u t in one of t h e s e p r o g r a m s m o r e t h a n half t h e staff of 36 w e r e p h y s i c i a n s (n = 20).
SANE training T h e r e is no s t a n d a r d i z e d n a t i o n a l c e r t i f i c a t i o n or t r a i n i n g r e q u i r e m e n t s for S A N E s a t t h i s time. However, e s t a b l i s h i n g s t a n d a r d i z e d r e q u i r e m e n t s is cert a i n l y an o r g a n i z a t i o n a l goal of t h e I n t e r n a t i o n a l A s s o c i a t i o n of F o r e n s i c Nurses. 9 This is also a n option b e i n g c o n s i d e r e d at t h e s t a t e level in a n u m b e r of areas. M a s s a c h u s e t t s h a s r e c e n t l y c r e a t e d a s t a t e w i d e s e x u a l a s s a u l t t r a i n i n g p r o g r a m u n d e r t h e ausp i c e s of t h e Public H e a l t h D e p a r t m e n t for b o t h n u r s e a n d p h y s i c i a n certification. R e c e r t i f i c a t i o n is r e q u i r e d e v e r y 2 y e a r s b a s e d on c o m p e t e n c y . ~° A p p r o x i m a t e l y one third of t h e p r o g r a m s surv e y e d b y t h e S e x u a l A s s a u l t R e s o u r c e S e r v i c e (SARS) p r o v i d e their o w n SANE t r a i n i n g a n d certification, a n d t w o t h i r d s u s e a n e s t a b l i s h e d SANE t r a i n i n g prog r a m for their initial training. T r a i n i n g p r o g r a m s typically c o n s i s t of a p p r o x i m a t e l y 40 h o u r s of c l a s s r o o m i n s t r u c t i o n t h a t i n c l u d e s collection of e v i d e n c e (inc l u d i n g forensic p r o c e d u r e s s u c h a s m a i n t a i n i n g t h e c h a i n of evidence); t e s t i n g a n d t r e a t m e n t of sexually t r a n s m i t t e d d i s e a s e s ; e v a l u a t i o n a n d p r e v e n t i o n of p r e g n a n c y ; crisis intervention; e v a l u a t i o n of injuries; documentation; courtroom testimony; working with other related community agencies; and demonstration of c o m p e t e n c e in c o m p l e t i n g a n e x a m i n a t i o n . 3
When a trainer provides "certification" after completing a SANE training c o u r s e , it is i m p o r t a n t t o a s k w h o or w h a t i n s t i t u t i o n is "certifying" the training, b e c a u s e t h e r e is n o n a t i o n a l certification.
S o m e p r o g r a m s also s p e c i f y a d e s i g n a t e d n u m b e r of clinical h o u r s after c o m p l e t i n g t h e d i d a c t i c training. T h e r a n g e , w h e n r e q u i r e d , is from a n a d d i tional 40 h o u r s n to as m a n y as 96 h o u r s of a d d i t i o n a l clinical e x p e r i e n c e , s A d d i t i o n a l clinical h o u r s i n c l u d e normal vaginal speculum and bimanual examination e x p e r i e n c e ; n o r m a l well-child e x a m i n a t i o n s ; courtr o o m o b s e r v a t i o n ; a n d a s e t n u m b e r of a d u l t or child SANE e x a m i n a t i o n o b s e r v a t i o n s . M o s t p r o g r a m s do
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not have a s e t n u m b e r of required clinical h o u r s b u t rather train u n t i l the n e w SANE i n d i c a t e s s h e feels comfortable w i t h the procedures. Some p r o g r a m s require t h e t r a i n e e to r e t u r n a s i g n e d certificate of c o m p l e t i o n for t h e clinical c o m p o n e n t before receivi n g t h e course c o m p l e t i o n certification. W h e n a trainer provides "certification" after c o m p l e t i n g a SANE t r a i n i n g course, it is i m p o r t a n t to ask w h o or w h a t i n s t i t u t i o n is "certifying" t h e training, b e c a u s e t h e r e is no n a t i o n a l certification. In m o s t c a s e s it is a local hospital or SANE program. C o n t i n u i n g e d u c a t i o n credit hours should always b e p r o v i d e d w i t h t r a i n i n g .
Although no two programs currently have the same expectations, the most common requirements i n c l u d e c o m p l e t i o n of a s p e c i f i c n u m b e r of s e x u a l assault examinations per year, for e x a m p l e , four to s i x e x a m i n a t i o n s ; a t t e n d a n c e at staff meetings; CEUs such as SANE-relevant literature reviews, conference attendance, and externships with physicians and nurse p r a c t i t i o n e r s ; or c o n t i n u i n g to t a k e call a n d b e a c t i v e l y i n v o l v e d in t h e S A N E program.
All b u t e i g h t p r o g r a m s s u r v e y e d i n d i c a t e d t h a t o n c e t r a i n i n g is completed, t h e y require specific criteria b e m e t to m a i n t a i n certification. A l t h o u g h n o two p r o g r a m s currently h a v e t h e s a m e e x p e c t a t i o n s , t h e m o s t c o m m o n r e q u i r e m e n t s i n c l u d e c o m p l e t i o n of a specific n u m b e r of sexual a s s a u l t e x a m i n a t i o n s per year~ for example, four to six e x a m i n a t i o n s ; a t t e n d a n c e at staff m e e t i n g s ; CEUs s u c h as S A N E - r e l e v a n t literature reviews, c o n f e r e n c e a t t e n d a n c e , a n d ext e r n s h i p s w i t h p h y s i c i a n s a n d n u r s e practitioners; or c o n t i n u i n g to take call a n d b e actively involved in t h e SANE program.
Staffing patterns D e t e r m i n i n g t h e n u m b e r of SANEs to hire d e p e n d s on t h e n u m b e r of cases e x p e c t e d monthly, as well as t h e fact t h a t regardless of t h e n u m b e r of c a s e s SANEs m u s t b e available 24 hours a day, 7 days a week. Only o n e p r o g r a m s u r v e y e d i n d i c a t e d t h a t it w a s n o t able to provide c o n t i n u a l c o v e r a g e b e c a u s e of a s h o r t a g e of staff. This is also a f u n c t i o n of d e d i c a t i o n , however. Two p r o g r a m s w i t h c o n t i n u a l c o v e r a g e did so w i t h just o n e SANE ! O n e of t h e s e n u r s e s s a w 80 c a s e s per year a n d worked a n o t h e r job as well. She did occasionally take a vacation, at w h i c h t i m e t h e ED staff c o m p l e t e d the sexual a s s a u l t e x a m i n a t i o n s . T h e cons e n s u s from SANEs is t h a t it is extremely difficult to c o m p l e t e more t h a n two sexual a s s a u l t e x a m i n a t i o n s w i t h o u t t i m e off b e t w e e n cases. Several directors w h o w e r e currently o p e r a t i n g w i t h fewer t h a n five SANEs i n d i c a t e d t h e y w e r e in t h e process of t r y i n g to a d d more staff to avoid b u r n o u t .
It is e x t r e m e l y difficult to complete more than two sexual assault examinations w i t h o u t t i m e off b e t w e e n cases. Several directors who were currently operating with fewer than five SANEs i n d i c a t e d t h e y w e r e in t h e p r o c e s s of t r y i n g to a d d m o r e s t a f f to a v o i d b u r n o u t . Of t h e p r o g r a m s surveyed, 64% h a d 10 or fewer SANEs, 32% h a d 11 to 20 SANEs, a n d only 4%, two programs, h a d more t h a n 20 staff. O n e of t h e s e h a d 30 staff a n d c o m p l e t e d 1600 e x a m i n a t i o n s a year (1:53); t h e other h a d 36 staff a n d c o m p l e t e d 200 e x a m i n a t i o n s per year (1:5.5). Only 22 p r o g r a m s reported b o t h t h e SANE staff n u m b e r a n d the n u m b e r of e x a m i n a t i o n s c o m p l e t e d e a c h year. Of these, the staff/examin a t i o n ratio reported varied from a low of 1:3 to a h i g h of 1:225 e x a m i n a t i o n s per year. Twelve p r o g r a m s h a d a SANE s t a f f / e x a m i n a t i o n ratio of 10 or fewer; 10 h a d a ratio of 11 to 20 c a s e s per year per SANE; 4 prog r a m s h a d a ratio of 21 to 40 e x a m i n a t i o n s per SANE, per year; a n d 5 p r o g r a m s h a d a ratio of 75 to 225 e x a m i n a t i o n s per SANE, per year. T h e p r o g r a m w i t h h i g h e s t s t a f f / e x a m i n a t i o n ratio of 1:225 e m p l o y e d only four SANEs in a p r o g r a m t h a t
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a v e r a g e d 900 e x a m i n a t i o n s per year. The n e x t h i g h est ratio w a s 1:120. In this p r o g r a m 10 SANEs s a w a n a v e r a g e of 1200 c a s e s per year. Unlike a n y other program, SANEs in this p r o g r a m w e r e e m p l o y e d for 8 hours M o n d a y t h r o u g h Friday d a y s w h e n m o s t of their c a s e s ( m a n y c h i l d r e n w h o h a d s c h e d u l e d e x a m inations) w e r e s e e n a n d t h e y worked on-call on t h e off shifts. T h e y are p a i d $30 per hour, a n d their director reports t h e y w a n t more hours rather t h a n fewer (personal c o m m u n i c a t i o n w i t h Pat Speck, J a n u a r y 1997).
P r o g r a m s p a y i n g m o r e for each examination indicate t h a t t h e y d o n o t p a y for costly on-call time.
w h e n the SANE is called i n for a n e x a m i n a t i o n . Pay certainly a p p e a r s to be a n effective m o t i v a t o r in this program. A p p r o x i m a t e l y one third of t h e r e s p o n d i n g prog r a m s p a y the SANE a per case rate for t h e e x a m i n a t i o n s w i t h a r a n g e of $50 to $200 per e x a m i n a t i o n . T h e other two thirds of p r o g r a m s p a y a n hourly rate from $18 to $50 per hour for t h e a c t u a l t i m e s p e n t completing the evidentiary examination. The average rate p a i d is $25 per hour for the e x a m i n a t i o n . Some p r o g r a m s i n d i c a t e t h e y p a y a rate e q u a l to the comm u n i t y staff n u r s e hourly salary; others p a y 1.5 t i m e s t h e c o m m u n i t y staff n u r s e salary. Some h a v e established a m i n i m u m n u m b e r of hours t h e SANE is paid w h e n she goes i n for a case. This m i n i m u m r a n g e d from 2 to 4 hours. T h e t i m e e s t i m a t e d to c o m p l e t e a n e x a m i n a t i o n r a n g e d from 2.5 to 5 hours, w i t h a n avera g e of 3.2 hours. More t h a n half, 30 programs, also p a y t h e s a m e hourly rate for a t t e n d i n g staff m e e t i n g s .
SANE salaries F r o m t h e very b e g i n n i n g SANE p r o g r a m s h a v e worked to keep p r o g r a m costs as low as possible, 6 b u t t h e y h a v e also always e m p l o y e d p a i d staff. There are no a c c o u n t s in t h e literature of the u s e of u n p a i d , volu n t e e r SANEs, e v e n t h o u g h , as F r a n k attests, "no one is g e t t i n g rich d o i n g this. ''~2 Most SANEs work partt i m e as a SANE a n d h a v e other p o s i t i o n s to g u a r a n tee their i n c o m e s 5 s,14 Some p r o g r a m s i n d i c a t e t h e y p a y for on-call time, a fee per e x a m i n a t i o n completed, for staff m e e t i n g s , a n d for courtroom testimony. Most SANE p r o g r a m s report p a y i n g the n u r s e s per case for the e x a m i n a t i o n . The r a n g e d o c u m e n t e d in the literature is from $100 per e x a m i n a t i o n . 5,6,12,14,15 to $150 per e x a m i n a t i o n , is O n e p r o g r a m i n d i c a t e s t h e y p a y t h e SANE a 3-hour m i n i m u m at the local staff n u r s e salary level a n d more if the e x a m i n a t i o n takes longer t h a n 3 hours. 6 Programs p a y i n g more for e a c h e x a m i n a t i o n i n d i c a t e t h a t t h e y d % n o t p a y for costly on-call time. ~<16 O n e prograrkf
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Our s u r v e y i n d i c a t e d t w o t h i r d s of t h e r e s p o n d i n g p r o g r a m s p a i d for o n - c a l l t i m e a n d o n e t h i r d d i d not. O n - c a l l p a y r a n g e d f r o m $1 to $ 7 . 5 0 p e r hour, w i t h a n a v e r a g e of $ 2 . 8 9 p e r hour. In our s u r v e y , p r o g r a m s n o t p a y i n g for o n - c a l l t i m e d i d n o t n e c e s s a r i l y p a y m o r e for examinations.
Summary A l t h o u g h there are no n a t i o n a l s t a n d a r d s for SANE programs, a r e v i e w of 60 p r o g r a m s h a s identified m a n y similarities. By far the majority of p r o g r a m s are d i r e c t e d b y n u r s e s w h o report to a n u r s e m a n a g e r or hospital administrator, m o s t often t h r o u g h t h e emerg e n c y d e p a r t m e n t . All b u t one SANE i d e n t i f i e d is female, a n d only 11% h a v e a d v a n c e d degrees, reinforcing the r e c o m m e n d a t i o n i n t h e literature t h a t a n a d v a n c e d d e g r e e is n o t n e c e s s a r y a n d should not b e a r e q u i r e m e n t . A l t h o u g h m o s t p r o g r a m s e m p l o y 10 or fewer SANEs, staffing p a t t e r n s vary greatly a n d are n o t directly a f u n c t i o n of t h e n u m b e r of e x a m i n a t i o n s c o m p l e t e d per year. Most p r o g r a m s u s e a n established SANE t r a i n i n g program, and, o n c e trained,
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S A N E s h a v e s p e c i f i c c r i t e r i a r e q u i r e d for c o n t i n u e d certification. Salaries also vary greatly and range from a l o w of $ 1 8 p e r h o u r w i t h n o o n - c a l l p a y t o a h i g h of $ 3 0 p e r h o u r for s c h e d u l e d h o u r s , $ 5 p e r h o u r o n - c a l l pay, a n d $ 2 0 0 p e r e x a m i n a t i o n . T w o t h i r d s of t h e p r o g r a m s p a y for o n - c a l l t i m e a t a n a v e r a g e r a t e of $ 2 . 8 9 p e r h o u r , a n d t w o t h i r d s p a y a n h o u r l y r a t e for t h e e x a m i n a t i o n t i m e a v e r a g i n g $ 2 5 p e r hour.
References 1. Ledray LE. Sexual assault n u r s e e x a m i n e r (SANE) programs. J E m e r g Nurs 1996;22:460-5. 2. Wright CM, Duke L, Fraser E, Sviland L. N o r t h u m b r i a w o m e n ' s police doctor s c h e m e : a n e w a p p r o a c h to e x a m i n ing victims of sexual assault. Br M e d J 1989;298:1011-2. 3. Ledray LE. T h e sexual assault r e s o u r c e service: a n e w m o d e l of care. M i n n M e d 1996;79(3):43-5. 4. L e w i n g t o n FR. N e w initiatives in t h e i n v e s t i g a t i o n of rape. M e d Leg J 1988;56(3):111-24. 5. Antognoli-Toland R C o m p r e h e n s i v e p r o g r a m for examin a t i o n of s e x u a l assault v i c t i m s b y nurses: a h o s p i t a l - b a s e d project in Texas. J E m e r g Nurs 1985;11:132-5. 6. Ledray LE. T h e sexual assault n u r s e clinician: a fifteenyear e x p e r i e n c e in M i n n e a p o l i s . J E m e r g N u r s 1992; 18:217-22. 7. Ledray LE. Sexual a s s a u l t n u r s e clinician: a n e m e r g i n g area of n u r s i n g expertise. In: A n d r i s t LC, editor. Clinical i s s u e s in p e r i n a t a l a n d w o m e n ' s h e a l t h nursing, vol 4, no 2. Philadelphia: Lippincott; 1993. p. 180-90. 8. L e n e h a n GR There b u t for t h e g r a c e of G o d . . . : t h e effects on sexual a s s a u l t n u r s e e x a m i n e r s of working w i t h r a p e vict i m s [dissertation]. Boston: Harvard University; 1996.
9. Lynch VA. P r e s i d e n t ' s report: goals of t h e IAFN. Fourth A n n u a l Scientific A s s e m b l y of Forensic Nurses, Kansas City Conference, N o v e m b e r 1996. 10. M a s s a c h u s e t t s N u r s e s Association. M N A collaborates w i t h DPH to t r a i n s e x u a l a s s a u l t n u r s e e x a m i n e r s . M a s s a c h u s e t t s Nurse 1995;65(10):4. 11. Kettleson D. Rape: n u r s e s t r a i n e d to take evidence. Unit N e w s / D i s t r i c t News, District of E a s t Hawaii 1995:1. 12. F r a n k C. T h e n e w w a y to c a t c h rapists. Redbook D e c e m b e r 1996:102-20. 13. L e n e h a n GP. Sexual a s s a u l t n u r s e examiners: a SANE w a y to care for r a p e victims. J E m e r g Nurs 1991;17:1-2. 14. T h o m a s M, Zachritz H. ~ l s a sexual assault n u r s e exa m i n e r s (SANE) program. J Okla State M e d A s s o c 1993; 86(June):284-6. 15. Bell K. Tulsa sexual a s s a u l t n u r s e e x a m i n e r s program. T h e O k l a h o m a Nurse 1995;JuI-Sept:16. 16. O'Brien C. Sexual a s s a u l t n u r s e e x a m i n e r (SANE) prog r a m coordinator. J E m e r g Nuts 1996;22:532-3.
Contributions to this column should be sent to Linda E. Ledray, RN, PhD, FAAN, Sexual Assault Resource Service, 525 Portland Avenue South, Minneapolis, MN 55415; phone (612) 347-5832; E-mail.. [email protected].
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SANE program directors Fifty-four p r o g r a m s c o n t a c t e d h a v e n u r s e s as t h e SANE p r o g r a m director. Of t h e six r e m a i n i n g programs, one p r o g r a m is r u n b y a p h y s i c i a n ' s a s s i s t a n t (PA); one b y a social worker (MSW); o n e b y a n a d m i n istrator; o n e b y a n o n n u r s e w i t h a m a s t e r ' s d e g r e e in e d u c a t i o n (MSEd); a n d two b y p h y s i c i a n s . Followu p p h o n e calls revealed t h a t four of t h e six n o n n u r s e - d i r e c t e d p r o g r a m s do h a v e a n u r s e i d e n t i f i e d as the p r o g r a m coordinator w h o f u n c t i o n s in m u c h t h e s a m e w a y as a n u r s e p r o g r a m director. T h e t w o e x c e p t i o n s i n c l u d e the p r o g r a m r u n b y a n MSEd a n d o p e r a t e d jointly w i t h a rape crisis center, a n d one p r o g r a m o p e r a t e d b y a PA a n d primarily staffed b y PAs.
Linda E. Ledray is Director, Sexual Assault Resource Service, Minneapolis, Minnesota. J Emerg Nuts 1997;23:491-5. Copyright © 1997 by tlle Emergency Nurses Association. 0099-1767/97 $5.00 + 0 18/1/84792
Reporting structure Forty SANE p r o g r a m directors report to s o m e o n e in h o s p i t a l a d m i n i s t r a t i o n . S i x t e e n SANE p r o g r a m directors report to a n u r s e m a n a g e r (nine of t h e s e are RD n u r s e m a n a g e r s ) . A n o t h e r 10 SANE directors report to a m e d i c a l director; e i g h t of t h e s e are t h e director of e m e r g e n c y m e d i c i n e . A n o t h e r 14 report to a n o t h e r hospital a d m i n i s t r a t o r i n c l u d i n g t h e vice p r e s i d e n t of p a t i e n t care (n = 4); a s s i s t a n t a d m i n i s trator (n = 3); hospital chief e x e c u t i v e officer (n = 2); a m b u l a t o r y services (n = 2); ED a d m i n i s t r a t o r (n = 1); h u m a n r e s o u r c e s (n = 1); a n d a specialized w o m e n ' s h e a l t h clinic director (n = 1).
A background in obstetrics and psychiatry, and especially experience working in positions that require i n d e p e n d e n c e , such as public health nursing, school nursing, and ED nursing, is preferred by one program. Twelve report to a g e n c i e s o u t s i d e of a hospital a d m i n i s t r a t i v e structure. T h e s e i n c l u d e two w h o report to a rape crisis c e n t e r director; two to a YWCA administrator; two to a district attorney; one to a police detective; one to a family v i o l e n c e coordinator; a n d four to advisory b e a r d s or c o o r d i n a t i n g boards. Five p r o g r a m s are i n d e p e n d e n t a n d i n d i c a t e d no r e p o r t i n g s t r u c t u r e o u t s i d e their organization. Three p r o g r a m s did n o t r e s p o n d to this question.
Staff selection Today m o s t SANEs are female n u r s e s . Only e n e prog r a m i n d i c a t e d t h e y h a v e o n e male n u r s e w h o takes
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call. A p p r o x i m a t e l y 50% of v i c t i m s , e v e n m a l e victims, prefer to h a v e t h e e x a m i n a t i o n c o m p l e t e d b y a w o m a n a n d s o m e t i m e s i n s i s t on b e i n g s e e n b y a w o m a n . >4 A l t h o u g h we, of course, c a n n o t d i s c r i m i n a t e a g a i n s t m a l e n u r s e s w h o w i s h to a p p l y for a SANE position, our p r i m a r y goal m u s t a l w a y s b e to m e e t t h e n e e d s of t h e v i c t i m p o p u l a t i o n w e serve.
A p p r o x i m a t e l y 50% of victims, even male victims, p r e f e r to h a v e t h e examination completed by a woman.
T h e l i t e r a t u r e i d e n t i f i e d t h a t g o o d clinical skills a n d g o o d w r i t t e n a n d c o m m u n i c a t i o n skills are e q u a l ly i m p o r t a n t c h a r a c t e r i s t i c s to look for w h e n h i r i n g a SANE. s A b a c k g r o u n d in o b s t e t r i c s a n d p s y c h i a t r y , a n d e s p e c i a l l y e x p e r i e n c e w o r k i n g in p o s i t i o n s t h a t require independence, such as public health nursing, school n u r s i n g , a n d ED nursing, is p r e f e r r e d b y one p r o g r a m , s G o o d a s s e s s m e n t skills, t h e ability to w o r k i n d e p e n d e n t l y , b e a b l e to e v a l u a t e a situation, a n d k n o w w h e n to a s k for help, are e s s e n t i a l staff requirements7 O n e p r o g r a m d i r e c t o r i n d i c a t e s s h e t e n d s n o t to hire n u r s e s w h o a r e r a p e v i c t i m s t h e m s e l v e s , u n l e s s t h e r a p e o c c u r r e d m u c h longer t h a n a y e a r p r e v i o u s ly a n d t h e n u r s e ' s o w n i s s u e s h a v e b e e n resolved. Her e x p e r i e n c e h a s s h o w n h e r t h a t a SANE c a n n o t h e l p s o m e o n e else r e s o l v e i s s u e s s h e h a s n o t effectively r e s o l v e d herself. 6 O t h e r d a t a , h o w e v e r , s u g g e s t i n c r e a s e d e m p a t h y a n d e f f e c t i v e n e s s on t h e p a r t of S A N E s w h o h a v e b e e n sexually a s s a u l t e d , s Although many SANEs today have advanced n u r s i n g d e g r e e s, t h e m a j o r i t y do noJ),
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r o t a t e d on call, b u t in one of t h e s e p r o g r a m s m o r e t h a n half t h e staff of 36 w e r e p h y s i c i a n s (n = 20).
SANE training T h e r e is no s t a n d a r d i z e d n a t i o n a l c e r t i f i c a t i o n or t r a i n i n g r e q u i r e m e n t s for S A N E s a t t h i s time. However, e s t a b l i s h i n g s t a n d a r d i z e d r e q u i r e m e n t s is cert a i n l y an o r g a n i z a t i o n a l goal of t h e I n t e r n a t i o n a l A s s o c i a t i o n of F o r e n s i c Nurses. 9 This is also a n option b e i n g c o n s i d e r e d at t h e s t a t e level in a n u m b e r of areas. M a s s a c h u s e t t s h a s r e c e n t l y c r e a t e d a s t a t e w i d e s e x u a l a s s a u l t t r a i n i n g p r o g r a m u n d e r t h e ausp i c e s of t h e Public H e a l t h D e p a r t m e n t for b o t h n u r s e a n d p h y s i c i a n certification. R e c e r t i f i c a t i o n is r e q u i r e d e v e r y 2 y e a r s b a s e d on c o m p e t e n c y . ~° A p p r o x i m a t e l y one third of t h e p r o g r a m s surv e y e d b y t h e S e x u a l A s s a u l t R e s o u r c e S e r v i c e (SARS) p r o v i d e their o w n SANE t r a i n i n g a n d certification, a n d t w o t h i r d s u s e a n e s t a b l i s h e d SANE t r a i n i n g prog r a m for their initial training. T r a i n i n g p r o g r a m s typically c o n s i s t of a p p r o x i m a t e l y 40 h o u r s of c l a s s r o o m i n s t r u c t i o n t h a t i n c l u d e s collection of e v i d e n c e (inc l u d i n g forensic p r o c e d u r e s s u c h a s m a i n t a i n i n g t h e c h a i n of evidence); t e s t i n g a n d t r e a t m e n t of sexually t r a n s m i t t e d d i s e a s e s ; e v a l u a t i o n a n d p r e v e n t i o n of p r e g n a n c y ; crisis intervention; e v a l u a t i o n of injuries; documentation; courtroom testimony; working with other related community agencies; and demonstration of c o m p e t e n c e in c o m p l e t i n g a n e x a m i n a t i o n . 3
When a trainer provides "certification" after completing a SANE training c o u r s e , it is i m p o r t a n t t o a s k w h o or w h a t i n s t i t u t i o n is "certifying" the training, b e c a u s e t h e r e is n o n a t i o n a l certification.
S o m e p r o g r a m s also s p e c i f y a d e s i g n a t e d n u m b e r of clinical h o u r s after c o m p l e t i n g t h e d i d a c t i c training. T h e r a n g e , w h e n r e q u i r e d , is from a n a d d i tional 40 h o u r s n to as m a n y as 96 h o u r s of a d d i t i o n a l clinical e x p e r i e n c e , s A d d i t i o n a l clinical h o u r s i n c l u d e normal vaginal speculum and bimanual examination e x p e r i e n c e ; n o r m a l well-child e x a m i n a t i o n s ; courtr o o m o b s e r v a t i o n ; a n d a s e t n u m b e r of a d u l t or child SANE e x a m i n a t i o n o b s e r v a t i o n s . M o s t p r o g r a m s do
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not have a s e t n u m b e r of required clinical h o u r s b u t rather train u n t i l the n e w SANE i n d i c a t e s s h e feels comfortable w i t h the procedures. Some p r o g r a m s require t h e t r a i n e e to r e t u r n a s i g n e d certificate of c o m p l e t i o n for t h e clinical c o m p o n e n t before receivi n g t h e course c o m p l e t i o n certification. W h e n a trainer provides "certification" after c o m p l e t i n g a SANE t r a i n i n g course, it is i m p o r t a n t to ask w h o or w h a t i n s t i t u t i o n is "certifying" t h e training, b e c a u s e t h e r e is no n a t i o n a l certification. In m o s t c a s e s it is a local hospital or SANE program. C o n t i n u i n g e d u c a t i o n credit hours should always b e p r o v i d e d w i t h t r a i n i n g .
Although no two programs currently have the same expectations, the most common requirements i n c l u d e c o m p l e t i o n of a s p e c i f i c n u m b e r of s e x u a l assault examinations per year, for e x a m p l e , four to s i x e x a m i n a t i o n s ; a t t e n d a n c e at staff meetings; CEUs such as SANE-relevant literature reviews, conference attendance, and externships with physicians and nurse p r a c t i t i o n e r s ; or c o n t i n u i n g to t a k e call a n d b e a c t i v e l y i n v o l v e d in t h e S A N E program.
All b u t e i g h t p r o g r a m s s u r v e y e d i n d i c a t e d t h a t o n c e t r a i n i n g is completed, t h e y require specific criteria b e m e t to m a i n t a i n certification. A l t h o u g h n o two p r o g r a m s currently h a v e t h e s a m e e x p e c t a t i o n s , t h e m o s t c o m m o n r e q u i r e m e n t s i n c l u d e c o m p l e t i o n of a specific n u m b e r of sexual a s s a u l t e x a m i n a t i o n s per year~ for example, four to six e x a m i n a t i o n s ; a t t e n d a n c e at staff m e e t i n g s ; CEUs s u c h as S A N E - r e l e v a n t literature reviews, c o n f e r e n c e a t t e n d a n c e , a n d ext e r n s h i p s w i t h p h y s i c i a n s a n d n u r s e practitioners; or c o n t i n u i n g to take call a n d b e actively involved in t h e SANE program.
Staffing patterns D e t e r m i n i n g t h e n u m b e r of SANEs to hire d e p e n d s on t h e n u m b e r of cases e x p e c t e d monthly, as well as t h e fact t h a t regardless of t h e n u m b e r of c a s e s SANEs m u s t b e available 24 hours a day, 7 days a week. Only o n e p r o g r a m s u r v e y e d i n d i c a t e d t h a t it w a s n o t able to provide c o n t i n u a l c o v e r a g e b e c a u s e of a s h o r t a g e of staff. This is also a f u n c t i o n of d e d i c a t i o n , however. Two p r o g r a m s w i t h c o n t i n u a l c o v e r a g e did so w i t h just o n e SANE ! O n e of t h e s e n u r s e s s a w 80 c a s e s per year a n d worked a n o t h e r job as well. She did occasionally take a vacation, at w h i c h t i m e t h e ED staff c o m p l e t e d the sexual a s s a u l t e x a m i n a t i o n s . T h e cons e n s u s from SANEs is t h a t it is extremely difficult to c o m p l e t e more t h a n two sexual a s s a u l t e x a m i n a t i o n s w i t h o u t t i m e off b e t w e e n cases. Several directors w h o w e r e currently o p e r a t i n g w i t h fewer t h a n five SANEs i n d i c a t e d t h e y w e r e in t h e process of t r y i n g to a d d more staff to avoid b u r n o u t .
It is e x t r e m e l y difficult to complete more than two sexual assault examinations w i t h o u t t i m e off b e t w e e n cases. Several directors who were currently operating with fewer than five SANEs i n d i c a t e d t h e y w e r e in t h e p r o c e s s of t r y i n g to a d d m o r e s t a f f to a v o i d b u r n o u t . Of t h e p r o g r a m s surveyed, 64% h a d 10 or fewer SANEs, 32% h a d 11 to 20 SANEs, a n d only 4%, two programs, h a d more t h a n 20 staff. O n e of t h e s e h a d 30 staff a n d c o m p l e t e d 1600 e x a m i n a t i o n s a year (1:53); t h e other h a d 36 staff a n d c o m p l e t e d 200 e x a m i n a t i o n s per year (1:5.5). Only 22 p r o g r a m s reported b o t h t h e SANE staff n u m b e r a n d the n u m b e r of e x a m i n a t i o n s c o m p l e t e d e a c h year. Of these, the staff/examin a t i o n ratio reported varied from a low of 1:3 to a h i g h of 1:225 e x a m i n a t i o n s per year. Twelve p r o g r a m s h a d a SANE s t a f f / e x a m i n a t i o n ratio of 10 or fewer; 10 h a d a ratio of 11 to 20 c a s e s per year per SANE; 4 prog r a m s h a d a ratio of 21 to 40 e x a m i n a t i o n s per SANE, per year; a n d 5 p r o g r a m s h a d a ratio of 75 to 225 e x a m i n a t i o n s per SANE, per year. T h e p r o g r a m w i t h h i g h e s t s t a f f / e x a m i n a t i o n ratio of 1:225 e m p l o y e d only four SANEs in a p r o g r a m t h a t
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a v e r a g e d 900 e x a m i n a t i o n s per year. The n e x t h i g h est ratio w a s 1:120. In this p r o g r a m 10 SANEs s a w a n a v e r a g e of 1200 c a s e s per year. Unlike a n y other program, SANEs in this p r o g r a m w e r e e m p l o y e d for 8 hours M o n d a y t h r o u g h Friday d a y s w h e n m o s t of their c a s e s ( m a n y c h i l d r e n w h o h a d s c h e d u l e d e x a m inations) w e r e s e e n a n d t h e y worked on-call on t h e off shifts. T h e y are p a i d $30 per hour, a n d their director reports t h e y w a n t more hours rather t h a n fewer (personal c o m m u n i c a t i o n w i t h Pat Speck, J a n u a r y 1997).
P r o g r a m s p a y i n g m o r e for each examination indicate t h a t t h e y d o n o t p a y for costly on-call time.
w h e n the SANE is called i n for a n e x a m i n a t i o n . Pay certainly a p p e a r s to be a n effective m o t i v a t o r in this program. A p p r o x i m a t e l y one third of t h e r e s p o n d i n g prog r a m s p a y the SANE a per case rate for t h e e x a m i n a t i o n s w i t h a r a n g e of $50 to $200 per e x a m i n a t i o n . T h e other two thirds of p r o g r a m s p a y a n hourly rate from $18 to $50 per hour for t h e a c t u a l t i m e s p e n t completing the evidentiary examination. The average rate p a i d is $25 per hour for the e x a m i n a t i o n . Some p r o g r a m s i n d i c a t e t h e y p a y a rate e q u a l to the comm u n i t y staff n u r s e hourly salary; others p a y 1.5 t i m e s t h e c o m m u n i t y staff n u r s e salary. Some h a v e established a m i n i m u m n u m b e r of hours t h e SANE is paid w h e n she goes i n for a case. This m i n i m u m r a n g e d from 2 to 4 hours. T h e t i m e e s t i m a t e d to c o m p l e t e a n e x a m i n a t i o n r a n g e d from 2.5 to 5 hours, w i t h a n avera g e of 3.2 hours. More t h a n half, 30 programs, also p a y t h e s a m e hourly rate for a t t e n d i n g staff m e e t i n g s .
SANE salaries F r o m t h e very b e g i n n i n g SANE p r o g r a m s h a v e worked to keep p r o g r a m costs as low as possible, 6 b u t t h e y h a v e also always e m p l o y e d p a i d staff. There are no a c c o u n t s in t h e literature of the u s e of u n p a i d , volu n t e e r SANEs, e v e n t h o u g h , as F r a n k attests, "no one is g e t t i n g rich d o i n g this. ''~2 Most SANEs work partt i m e as a SANE a n d h a v e other p o s i t i o n s to g u a r a n tee their i n c o m e s 5 s,14 Some p r o g r a m s i n d i c a t e t h e y p a y for on-call time, a fee per e x a m i n a t i o n completed, for staff m e e t i n g s , a n d for courtroom testimony. Most SANE p r o g r a m s report p a y i n g the n u r s e s per case for the e x a m i n a t i o n . The r a n g e d o c u m e n t e d in the literature is from $100 per e x a m i n a t i o n . 5,6,12,14,15 to $150 per e x a m i n a t i o n , is O n e p r o g r a m i n d i c a t e s t h e y p a y t h e SANE a 3-hour m i n i m u m at the local staff n u r s e salary level a n d more if the e x a m i n a t i o n takes longer t h a n 3 hours. 6 Programs p a y i n g more for e a c h e x a m i n a t i o n i n d i c a t e t h a t t h e y d % n o t p a y for costly on-call time. ~<16 O n e prograrkf
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Our s u r v e y i n d i c a t e d t w o t h i r d s of t h e r e s p o n d i n g p r o g r a m s p a i d for o n - c a l l t i m e a n d o n e t h i r d d i d not. O n - c a l l p a y r a n g e d f r o m $1 to $ 7 . 5 0 p e r hour, w i t h a n a v e r a g e of $ 2 . 8 9 p e r hour. In our s u r v e y , p r o g r a m s n o t p a y i n g for o n - c a l l t i m e d i d n o t n e c e s s a r i l y p a y m o r e for examinations.
Summary A l t h o u g h there are no n a t i o n a l s t a n d a r d s for SANE programs, a r e v i e w of 60 p r o g r a m s h a s identified m a n y similarities. By far the majority of p r o g r a m s are d i r e c t e d b y n u r s e s w h o report to a n u r s e m a n a g e r or hospital administrator, m o s t often t h r o u g h t h e emerg e n c y d e p a r t m e n t . All b u t one SANE i d e n t i f i e d is female, a n d only 11% h a v e a d v a n c e d degrees, reinforcing the r e c o m m e n d a t i o n i n t h e literature t h a t a n a d v a n c e d d e g r e e is n o t n e c e s s a r y a n d should not b e a r e q u i r e m e n t . A l t h o u g h m o s t p r o g r a m s e m p l o y 10 or fewer SANEs, staffing p a t t e r n s vary greatly a n d are n o t directly a f u n c t i o n of t h e n u m b e r of e x a m i n a t i o n s c o m p l e t e d per year. Most p r o g r a m s u s e a n established SANE t r a i n i n g program, and, o n c e trained,
Ledray/JOURNAL OF EMERGENCY NURSING
S A N E s h a v e s p e c i f i c c r i t e r i a r e q u i r e d for c o n t i n u e d certification. Salaries also vary greatly and range from a l o w of $ 1 8 p e r h o u r w i t h n o o n - c a l l p a y t o a h i g h of $ 3 0 p e r h o u r for s c h e d u l e d h o u r s , $ 5 p e r h o u r o n - c a l l pay, a n d $ 2 0 0 p e r e x a m i n a t i o n . T w o t h i r d s of t h e p r o g r a m s p a y for o n - c a l l t i m e a t a n a v e r a g e r a t e of $ 2 . 8 9 p e r h o u r , a n d t w o t h i r d s p a y a n h o u r l y r a t e for t h e e x a m i n a t i o n t i m e a v e r a g i n g $ 2 5 p e r hour.
References 1. Ledray LE. Sexual assault n u r s e e x a m i n e r (SANE) programs. J E m e r g Nurs 1996;22:460-5. 2. Wright CM, Duke L, Fraser E, Sviland L. N o r t h u m b r i a w o m e n ' s police doctor s c h e m e : a n e w a p p r o a c h to e x a m i n ing victims of sexual assault. Br M e d J 1989;298:1011-2. 3. Ledray LE. T h e sexual assault r e s o u r c e service: a n e w m o d e l of care. M i n n M e d 1996;79(3):43-5. 4. L e w i n g t o n FR. N e w initiatives in t h e i n v e s t i g a t i o n of rape. M e d Leg J 1988;56(3):111-24. 5. Antognoli-Toland R C o m p r e h e n s i v e p r o g r a m for examin a t i o n of s e x u a l assault v i c t i m s b y nurses: a h o s p i t a l - b a s e d project in Texas. J E m e r g Nurs 1985;11:132-5. 6. Ledray LE. T h e sexual assault n u r s e clinician: a fifteenyear e x p e r i e n c e in M i n n e a p o l i s . J E m e r g N u r s 1992; 18:217-22. 7. Ledray LE. Sexual a s s a u l t n u r s e clinician: a n e m e r g i n g area of n u r s i n g expertise. In: A n d r i s t LC, editor. Clinical i s s u e s in p e r i n a t a l a n d w o m e n ' s h e a l t h nursing, vol 4, no 2. Philadelphia: Lippincott; 1993. p. 180-90. 8. L e n e h a n GR There b u t for t h e g r a c e of G o d . . . : t h e effects on sexual a s s a u l t n u r s e e x a m i n e r s of working w i t h r a p e vict i m s [dissertation]. Boston: Harvard University; 1996.
9. Lynch VA. P r e s i d e n t ' s report: goals of t h e IAFN. Fourth A n n u a l Scientific A s s e m b l y of Forensic Nurses, Kansas City Conference, N o v e m b e r 1996. 10. M a s s a c h u s e t t s N u r s e s Association. M N A collaborates w i t h DPH to t r a i n s e x u a l a s s a u l t n u r s e e x a m i n e r s . M a s s a c h u s e t t s Nurse 1995;65(10):4. 11. Kettleson D. Rape: n u r s e s t r a i n e d to take evidence. Unit N e w s / D i s t r i c t News, District of E a s t Hawaii 1995:1. 12. F r a n k C. T h e n e w w a y to c a t c h rapists. Redbook D e c e m b e r 1996:102-20. 13. L e n e h a n GP. Sexual a s s a u l t n u r s e examiners: a SANE w a y to care for r a p e victims. J E m e r g Nurs 1991;17:1-2. 14. T h o m a s M, Zachritz H. ~ l s a sexual assault n u r s e exa m i n e r s (SANE) program. J Okla State M e d A s s o c 1993; 86(June):284-6. 15. Bell K. Tulsa sexual a s s a u l t n u r s e e x a m i n e r s program. T h e O k l a h o m a Nurse 1995;JuI-Sept:16. 16. O'Brien C. Sexual a s s a u l t n u r s e e x a m i n e r (SANE) prog r a m coordinator. J E m e r g Nuts 1996;22:532-3.
Contributions to this column should be sent to Linda E. Ledray, RN, PhD, FAAN, Sexual Assault Resource Service, 525 Portland Avenue South, Minneapolis, MN 55415; phone (612) 347-5832; E-mail.. [email protected].
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