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00:08 Jackie Strohm: Welcome to PA Centered, a podcast designed to help listeners be a part of the solution to end sexual harassment, abuse, and assault. Each episode, we will take on a topic or current event to help spark conversation and break down barriers to building communities free from sexual violence.

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00:32 JS: Hi, I'm Jackie Strohm, the Prevention and Resource Coordinator at the Pennsylvania Coalition Against Rape. I'll be your host today as we're joined by a group of folks involved with the Penn State Sexual Assault Forensic Examination Telehealth Center, better known as the SAFE-T Center, to learn more about how this program enhances care for sexual assault victims in underserved communities. Forensic Nurses Week this year is from November 9th through the 13th, and we thought this would be a great opportunity to thank all the forensic nurses for the work they do, and learn more about the partnership happening in Pennsylvania between hospitals and sexual violence agencies. Today we're joined by three guests. First we're gonna hear from Sheridan Miyamoto, who is an assistant professor in the College of Nursing at Penn State, and director of the SAFE-T Center. Sheridan, can you first tell us about the safety center program? 

01:32 Sheridan Miyamoto: Sure. The SAFE-T Center began really with grant funding from the Department of Justice, and what they were looking for was this recognition that it's really important to have sexual assault nurse examiners respond when someone has experienced sexual violence. And they know and have identified, and lots of studies have shown, that there are not nearly enough people who are trained to do the work. It's not something that nurses get as part of their base training when they become a registered nurse. And so it's really challenging, and there are great disparities in the quality of care that might exist because there aren't SANEs in all of the places where people are experiencing violence. They were really interested in a program that could enhance equity and quality of care in all settings, and especially in rural and underserved communities.

02:34 SM: So, we responded to that grant opportunity with the idea and based on some prior work that I'd done at UC Davis around delivering this care through telehealth, that we could really create a hub of expertise with nurses who have seen lots and lots of cases, have really honed their skills, and are really exceptional at meeting patients where they are, and pairing them with local nurses who get some training and are trained in sexual assault nurse care delivery, but don't get to see nearly enough patients. And if we pair them together, that that really provides an extra layer of quality and two people to think about this very complex work that can sometimes take between three and five hours and really deliver exceptional care to someone when they've experienced a significant trauma and need that emergent care.

03:34 JS: That sounds like such a cool program. Could you tell us a little bit more about it? 

03:43 SM: Sure. That initial funding allowed us to reach out to four rural hospitals in Pennsylvania, and we worked really closely with the Pennsylvania Coalition Against Rape and our local nurses that we knew that were doing the work to really identify where there was a great need. And we had a number of hospitals come forward to participate, and we selected where we really thought this would thrive for the first four sites. Those launched, we had some really early success, and we were fortunate enough to have additional funding come through from the Pennsylvania Commission on Crime and Delinquency, who said, "This is really promising, we know there's great need," and gave us funding to expand the program to an additional four sites. We are just about two years in, and we are currently in eight hospitals in rural Pennsylvania, and one... Actually, one of those sites is more of a suburban area. The SAFE-T Center has hired a team of expert sexual assault nurse examiners, so they have years and years of experience, and are really passionate about being paired with other nurses and helping them develop their expertise.

05:00 SM: On our side, we have this expert team. They're available 24 hours a day, seven days a week, and we respond any time a sexual assault comes in to one of our partner hospitals. We have trained nurses in these rural hospitals. They've received training from us, they've developed their own teams, and we have really looked at this as a community-engaged response within those communities. We meet with advocates and law enforcement and district attorneys, and the hospitals and the nurses themselves, and we really try and build on the community strengths that currently exist, and we are just there as a hub of resources, both in our clinical expertise, but also in how can we best facilitate, say, the relationship between the nurse and the advocate.

05:52 SM: And so one of the things that we've done that I think was a real shift and a huge benefit to both the nurse and the advocate and the patients is to make sure that the advocate is called at the outset for every single exam, and then the patient has the opportunity to decide if they want that support. And what we found is that, in every single one of our examinations where the advocate was called, that the patient was really eager to have them be part of that. Those are some of the changes that we do at the community level. And as we work with people, we are doing... Our TeleSANE is present for the entire examination. So, whether it's three hours or five hours, we're really there as a support and an extra brain in the room to think about all the intricate things that need to happen, and hopefully to be a really good support both for the patient and for the nurse who's conducting that exam.

06:52 JS: For some folks who aren't as familiar with some of this terminology, can you tell us a little bit more about SANEs, or sexual assault nurse examiners, and what their role is in this project? 

07:05 SM: Sure. Sexual assault nurse examiners are registered nurses who have then gone and gotten specialty training. Often it's an emergency department nurse who recognizes that there is no one in their facility who really is ready to respond to someone with special needs related to being a victim of violence, and they go back and get 40-plus hours of training in this area. And then the nurses that we're working with also have additional hands-on training that is done at Penn State, as well as ongoing mentoring through telehealth, so they are building their expertise over time. And what is really unique about sexual assault nurse examiners is the training they receive is highly focused on delivering a trauma-informed response, so that we provide compassionate care, we ensure that people feel believed, and that they have choice, which is especially important when people have just experienced something where a lot of the choice has been taken away from them and a lot of their power has been taken away. We really understand that dynamic and can work to restore that by making sure they understand what their rights are, that we can help navigate that with the other community partners they might engage with, whether they would like to have law enforcement present and what might that look like.

08:35 SM: And SANEs are often the ones in the community, along with advocates, to bring the community together and thoughtfully help a victim navigate all of those services. And their primary function really is about the patient's health and well-being. As a secondary piece, they're really trained to collect and preserve evidence that can be helpful as a case might travel through the criminal justice process, if that's what the patient would like to see happen.

09:11 JS: Thanks so much for explaining that. So we can get a better picture of your overall vision and goals for the project, could you talk a little bit about that for us? 

09:22 SM: Yes. Knowing that this problem of a shortage of individuals who are trained to do this work, so not having nearly enough SANE nurses in the country, that's not unique to Pennsylvania. I really think that the answer is to develop hubs of expertise, like we're doing at the SAFE-T Center, where you can really bring the people who have the very most experience to bear on the problem and to help inspire and support local nurses to grow in that practice. We do that in a number of ways. It's not only that we are there during the consultation, which is really critically important so that nothing gets missed in that critical piece that is timely, but we also provide ongoing training, making sure that nurses continually stay at the top of their game. Even if they maybe only see three patients a year, they're still getting the support from this hub of the changes that come along, ways that they can really stay engaged in the work. We also can provide support for administrative functions within the hospital. There are lots of things that an expert hub can bring, that help keep nurses where they can function, even if they have low numbers in their community.

10:52 SM: That's part of it. I also think, as we build up hubs, we have the opportunity to support lots of places so that we really are systematically decreasing the inequities that exist if you don't have that response in your hospital. Everybody can have this. That's my ultimate goal, is that any hospital who is not seeing large numbers can't maintain a really expert team on their own, has access to that and can get to that level of quality. Part of the way that we see this service is that it's really a comprehensive turnkey service across the country. We have only limited statistics for this, but the turnover in SANEs, because it's an emotionally difficult area, is really high. At two years, 91% of nurses stop doing the work. It's really shocking. And one of the things that we've seen with our program is that the local nurses feel proud of the work that they're doing, and they feel supported by us and can see the value, and it's not so scary to do it when you have a partner that you do it with.

12:06 SM: And so our retention rate has been really high. In the first year, we kept all, 100% of the nurses that we trained locally. And in the second year, that went to 67%, which is still so much better than what we've seen generally as an average. So, I think a lot of that... And of those 67, those are people that... The group that left, left for other jobs completely and left their health system, so we're really saying nurses that feel passionate about their role. And that's exactly what we wanna see without every single hospital having to build their own expert comprehensive program, which is honestly nearly impossible in rural communities because you just can't see the numbers that would allow you to get to that.

12:56 JS: That's so amazing to hear about. I know turnover is very common in this line of work, and I can only imagine what that looks like for SANE, so kudos to all of you for really making sure that folks feel supported. That's such a great outcome. Are there other outcomes of the program that you can share with us? 

13:17 SM: Yes. What I think was a little bit surprising to us but really important is that sexual assault is really a public health crisis, and the numbers are much higher than what people know and understand, and much higher than what's reported. One of the great outcomes is that, after we launched the SAFE-T Center... And we do this again in a really community-engaged way, so we bring the community together to understand what our program might be, we build on those community strengths, we understand how we can be supportive and helpful, but we also do it as a group and that we come together to celebrate the kick-off of the program, we come back each year and talk about the successes of the program, and in those moments, we invite the community in to hear and understand what's happening? And because of really good local media promotion, etcetera, I think we've reached the community and they understand there is this great resource and that their local hospital and advocacy center are really committed to providing high quality care.

14:32 SM: So, what we saw in our first three sites is that two of them doubled the number of patients they've seen in the year prior to SAFE-T coming on board, and one of them tripled the number of patients that they saw. And so I think some of that speaks to the community understanding that, "Wow, there will be somebody who understands what I've gone through, and they are prepared and ready to take care of me."

14:56 JS: Yeah, I can absolutely see how that community outreach would be so beneficial to making survivors feel like they can get the help that they need, especially when paired with an advocate on top of all of the great work that the SANEs are doing.

15:13 SM: Yeah. Another one of our outcomes, and I think this is a really important piece of when I was talking about the advocate being present, and the nurse and the advocate really working together to share with that patient, "Here's what we're gonna do for you as far as a the healthcare response right now," and a warm hand-off to the advocate who's there, as well as being a support for them to say, "Here's what exists for you after, so that we'll support your healing. And here are all the things that we can do." And what we've found, because we are doing research to understand how our program and that partnership impacts the patients, is that over 85% of our patients have said that the telehealth consultation improved the care that they received, and over 85% rate their local care that their nurse that is physically present with them, that the care they got was excellent or very good, which is really remarkable for somebody, probably on their most difficult day ever. Going through an exam, that's three to five hours long. So, just a really challenging time, but they're talking about that the exam itself and the care that was provided helped them to feel better. I attribute a lot of that to that partnership, the nurse and advocate, together with a TeleSANE, and the three people there are thinking about how do we provide this really compassionate, responsive, quality care together.

16:44 JS: That's so amazing to hear. And it sounds like, based on some of the numbers that you shared, that there really is a demand for this type of program.

16:54 SM: Yeah. We've done some real analysis on the need in Pennsylvania, and it's high. There are very few places that have comprehensive care by SANEs, so that means any hour that you're gonna come in that you will encounter a SANE, there are very few hospitals that are able to maintain that. The need is absolutely there, and this is really the beginning of our ability to demonstrate that it's effective and that it works. And just with these eight sites, we've been able to train and put in place, in eight communities, 44 new nurses that have this type of training that otherwise might not have been there. And so this is our beginning way to show that this could be the answer not only in Pennsylvania but across the country, because even in urban setting, sometimes it's tough to solve.

17:57 JS: Sheridan, thank you so much for telling us all about the SAFE-T Center I know that I learned a lot, and I'm sure other folks are gonna be really interested in hearing more about the great work that you've been doing.

18:10 SM: Thank you. It's such an honor, and I really appreciate you shining a light on this work.

18:15 JS: Next, I'm excited to introduce our other guests today, Jessica Birbeck, nurse educator at UPMC Wellsboro, and Marlene Austin, Executive Director of Passages Inc., a sexual violence agency serving Clarion, Clearfield, and Jefferson counties. Jessica, what are some of the impacts the SAFE-T Center has had on patients and nurses in your community? 

18:40 Jessica Birbeck: I honestly don't even know where to begin with what this program has done for our community. It has really increased awareness about sexual assault, and the treatment and exam capabilities that we have in a small rural hospital. For me, I didn't know actually that sexual assault nursing or forensic nursing was really even a field that I would be interested in until attending the first meeting from the SAFE-T Center at our hospital, so they really introduced me to what forensic nursing was to begin with and really just invoked a passion in me for it. I've been part of the team for about two years now and have been the lead coordinator for the past year, and so I've done a lot of recruiting new SANEs and training new SANEs.

19:37 JB: When I started the program, the SAFE-T Center did most of the training for us. They came, they did most of the training, and little by little, they've been giving us the pieces to be able to do the training ourselves. A lot of the orientation and education I do with the new SANEs, I'm actually able to do a lot of it myself with a lot of support from the program, so I think they've brought a lot of expertise to us. It's also encouraged a lot of community outreach that goes beyond just a sexual assault of a patient coming into the emergency room. They've encouraged us to build relationships with the advocacy groups, with law enforcement, with college universities, with community programs. The people that I interact with now is very different than what I did beforehand. There's a lot of community engagement around our program and educating the public on what we have to offer, in addition to working to prevent sexual assault in our area as well.

20:50 JB: The other thing that's great about the SAFE-T Center is the networking opportunities that we have to get to know really expert SANEs in their field of study. The TeleSANEs we work with are just phenomenal. And they really support us, they encourage us, they provide a backup for us that we would never have otherwise. They really have our backs, they're there to make sure we're doing everything right. The TeleSANEs really support us in ways that go beyond what my expectations were to begin with. We really have been building relationships with them, we do joint team trainings, peer reviews, and I've really gotten to know them.

21:40 JB: One of the greatest benefits, I think, it brings to our patients is the quality of care. I feel very confident that the quality of care that I can provide in a rural place like Wellsboro is equal to that of a place in a larger city, and I would not have said that three years ago. When we started, there were a lot of gaps in care and policy and procedures, and we really, in the last two years of being part of this program, have increased the quality of care for our patients drastically.

22:20 JS: Yeah. Earlier when we spoke with Sheridan, she really talked about the outcomes that they've seen from this program and talked about exactly what you're referring to, that folks feel more confident and they feel like they can provide that excellent level of care, so that's great to hear. Thanks, Jessica, for telling us all about how it's impacted your community. Marlene, I would love to hear how working with the SAFE-T Center has enhanced your work as advocates.

22:50 Marlene Austin: Oh, absolutely. I'd like to start with saying that I can't tell you how much that we appreciate the SAFE-T Center program coming to our rural communities that we serve. Without this joint relationship that we have with our hospitals, a survivor would most likely not know that our agency is here, and how much that we're able to help them from this point on. For example, not only through the medical process itself but also that through the legal process and supportive counseling services that we can provide to them and also their family members. Now, a sexual survivor is able to have the very best medical treatment, like Jessica had said, right here in a rural community, the best treatment possible, the very best medical treatment and evidence collection from our SANEs while allowing our advocates to focus on the survivors emotional needs that they would have.

23:55 JS: That's great. It sounds like it's really provided all-around care, better care for survivors.

24:03 MA: Another thing that we're seeing with this new relationship with the SAFE-T Center is the increased engagement with our survivors. Now, the survivor... Like I had mentioned just a little bit ago, the survivor can now come to us immediately after. We've seen a huge increase in survivors following up with us after they have received care at the hospital. This has been a tremendous, tremendous, great experience for not only us, but enabling us to provide that great care, then follow up with our survivors.

24:44 JS: Yeah. How has the SAFE-T Center also increased your relationship with the local hospitals? 

24:51 MA: Oh, a great deal. There are two hospitals that we work with that are part of the SAFE-T Center program. Both of these hospitals have nurses go through the SANE training at the time the SAFE-T program was being implemented, and one of these hospitals went from having zero SANE nurses to six. And this was a hospital that rarely contacted our center to have us send an advocate down there to provide support for a survivor. And now, because of this program, like I said, we've established a wonderful relationship with the emergency room nurses and the staff. An advocate from Passages, whether it be a staff member or a volunteer, is contacted now every single time a survivor comes in to the hospital. And I truly feel like it's just been an exceptional collaborative team approach. Now, the SANEs are able to focus on taking care of a survivor's medical needs and the need to collect very important evidence, while our advocates are there to focus on their survivors' emotional needs.

26:01 JS: It sounds like having both a SANE and a TeleSANE and an advocate has been a really great experience, especially for the survivor.

26:10 MA: It's been a remarkable, remarkable experience for the survivor. And it's just like Jessica was saying, too, it's almost like having now two sets of eyes on the patient. If one misses one thing, the other person is able to jump in there. It's just been remarkable. I can't say enough about the experience that we're having with them.

26:36 JS: That's so great. And I'd love for both of you to share a little bit about how you think that advocates and nurses can work best together. Jessica, I'll start with you, if you have any ideas.

26:50 JB: I think Marlene was exactly right when she just talked about how when nurses are doing some of the task-oriented parts of the exam, the advocate is able to be there and to talk with the patient, to offer their emotional support, to talk about their program, what's happening. A lot of... Part of the exam, it becomes very task-oriented when we start collecting evidence, so there's a lot of assembly that happens of the kit. Every box gets assembled individually, and then after evidence is collected, every box is then sealed and taped and signed. So, there's a lot of tasked parts of what I have to do, and having an advocate there to talk to the patient during that time has been so valuable for me to help me focus on what I have to do, but also for the patient to have somebody to be there right next to them. And also, I think, helps a lot in the healing process for our patients or for the survivors who really start to build a bridge that starts in the emergency room, and then continues straight through in the weeks and months and years that follow their visit with us.

28:15 JS: That's great. Marlene, do you have any other ideas about how advocates and nurses can work best together? 

28:23 MA: Everything that Jessica said is spot on, and I just wanna say that the appreciation goes both ways. I know that when we're finished, the SANE nurses tell us that, "We are so glad you care," because just like you said, Jessica, there are so many tasks that go into that. But I feel, and our advocates feel, the exact same way because we just are so appreciative of the wonderful, compassionate care that they are giving to each patient.

29:00 JS: Like we said at the start of the episode, Forensic Nurses Week this year is next week, from November 9th to the 13th, and I'm wondering, Marlene, if there are any special things that you might have planned or that you might encourage other centers like yourselves to do for the nurses in your community? 

29:22 MA: Absolutely. We have some things planned... I don't want to give too much away during this, but we just want to make sure that we are going to show our appreciation to all of the SANE nurses that we work with. We definitely could not do this now without them. It's just been a great experience, but we wanna make sure that we're showing in any way that we can. And like I said, I don't wanna give too much away, but we have some plans on showing our appreciation to the nurses coming up.

29:58 JS: That's so great. It sounds like, other folks, if you haven't thought about that yet, now might be a great time to do so, to show appreciation to all the nurses and forensic examiners who do this kind of work every single day. Marlene and Jessica, thank you so much for taking the time to share your experiences about working with the SAFE-T Center. It was so great to speak with you, and I hope that folks have learned a lot about the in and outs of the work that you do.

30:29 JB: Thank you so much, Jackie, for having us.

30:32 MA: Yes, thank you, Jackie. And I just wanna say to all forensic nurses out there and all nurses in general, we wanna thank you, you are heroes to so many during this difficult time.

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30:55 JS: If you or a loved one needs help, a local sexual assault center is available 24/7. Call 1888-772-7227 for more information, or find your local center online at pcar.org. Together, we can end sexual violence. Any views or opinions expressed on PA Centered by staff or their guests are solely their own and do not necessarily reflect the opinions of PCAR or PCAR's funders.