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The Role of the Sexual Assault Nurse Examiner in providing care to victims of recent sexual assault

The Role of the Sexual Assault Nurse Examiner in providing care to victims of recent sexual assault

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An essay for the 2011 Undergraduate Awards Competition by Jemima Nilan. Originally submitted for Focused Literature Review at National University of Ireland Galway, with lecturer Ms. Mary E. O'Hara in the category of Nursing & Midwifery
An essay for the 2011 Undergraduate Awards Competition by Jemima Nilan. Originally submitted for Focused Literature Review at National University of Ireland Galway, with lecturer Ms. Mary E. O'Hara in the category of Nursing & Midwifery

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Published by: Undergraduate Awards on Aug 29, 2012
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Abstract This literature review identifies the role of the Sexual Assault Nurse Examiner (SANE).

The SANE is an expanded role in the area of forensic nursing. In light of the new creation of a similar role here in Ireland (Clinical Nurse Specialist/Sexual Assault Forensic Examiner) literature from North America is reviewed to examine the role/ contribution of the SANE in providing care to victims of recent sexual assault. Aspects of SANE practice are explored: the services provided, attention to patient centred care, the practices of the job/role, the challenges it presents, the difference between the care provided by a specialised practitioner and the traditional method of care, and the overlapping legal role of the Sexual Assault Nurse Examiner. The literature has been critically examined to outline the specific services and care provided by the SANE, to gain insight for Irish practice. Key words: Sexual Assault Nurse Examiner; Service provision; Patient Centred Care; Evidence Collection


Introduction and Background

The World Health Organisation (WHO) identified sexual violence as a pervasive global problem with one in five women suffering an attempted or completed rape by an intimate partner at some point in her lifetime (WHO, 2003). Sexual violence has been comprehensively defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic women‟s sexuality, using coercion, threats of harm or physical force, by any person regardless of relationship to the victim, in any setting, including but not limited to home and work” (WHO, 2002, p.6). Victims need comprehensive, gender-sensitive health services to recover from the physical and mental health consequences of sexual assault (WHO, 2003).

Women who experience sexual assault seek medical care for a host of physical and mental health issues including injuries, self-esteem, social functioning, depression, disruption in sleeping and eating patterns, and gynaecological and menstrual disorders (Burgess and Holmstrom 1974; Burgess, 2002; Svavarsdottir, 2010). Additionally there may be concern regarding pregnancy, contracting a Sexually Transmitted Infection (STI) or Human Immunodeficiency Virus (HIV) (Magid et al., 2004), and a need for legally viable evidence in the case of desired prosecution.

Traditionally, victims of sexual violence were seen in hospital Emergency Departments (EDs) but the care was not optimal; often even basic services were not provided, as ED personnel generally had little specialist training regarding standard of care in these cases (Straight and Heaton 2007). Additional problems with traditional ED treatment included long waits, as life-threatening conditions receive priority (Taylor, 2002); invasive, perfunctory, treatment lacking procedural explanation and comfort (Lenehan, 1991); and insufficient and invalid evidence collection, as many ED physicians lack relevant training and experience in performing medical forensic examinations (Littel, 2001).

The Sexual Assault Nurse Examiner (SANE) role began in the United States in 1976 under the pioneering efforts of Linda E. Ledray. A Sexual Assault Nurse Examiner is a nurse


specially trained to provide care to the victim of a sexual assault. SANE programs in the United States consist of specially trained forensic nurses who provide 24 hour first response medical care and crisis intervention to rape survivors in either hospital or clinic settings (Campbell, Patterson and Lichty, 2005a). When a specially trained Sexual Assault Nurse Examiner cares for the survivor there are universally better treatment outcomes (Lenehan, 1991; Littel, 2001; Campbell, Patterson and Lichty, 2005a; Girardin, 2005). The report into „Sexual Abuse and Violence in Ireland‟ (known as the SAVI report) was a groundbreaking national study of Irish experiences, beliefs and attitudes concerning sexual violence (McGee et al., 2002). 3,120 randomly selected Irish adults revealed that 42% of women and 28% of men interviewed had experienced sexual violence at some point in their lives. 6% had disclosed abuse to medical professionals. It is not surprising that with so few people reporting assault, Ireland has the lowest conviction rate (1-2% during 1993 – 2000) for rape and sexual assault in Europe (Regan and Kelly, 2003, p.10). Hanley et al. (2009, p. xxvii) found that reported incidents of rape were overrepresented in counties with easy access to a Sexual Assault Treatment Unit (SATU), suggesting that the presence of units improves the rate of reporting. Additionally, Hanley et al. recommends that a SATU should be established within 80kilometres of any given location, with an accompanying media campaign to increase public awareness (Hanley et al., 2009, p. xxxii). There are now SATUs in Letterkenny, Cork, Waterford, Galway and Mullingar providing appropriate geographical availability of specialised services (O‟Shea, 2006, Eogan, 2010). Aside from the SATU clinical reports which detail the demographics of survivors presenting for treatment, characteristics of the assault and what services were provided, there have been no empirical studies on the consistency and accessibility of such services or how well the dedicated Units are meeting the needs of survivors.

The Sexual Assault Review Committee recommended the training of nurses in forensic medical examination (O‟Shea, 2006) to provide services to victims of sexual assault. A pilot programme was set up in the Royal College of Surgeons Ireland; there are currently 8 Clinical Nurse Specialists (Sexual Assault Forensic Examiners) working in the 6 SATUs around the country (Eogan, 2010). The main aim of the creation of this specialised role as is utilised in the United States and Canada, is to increase the consistency, efficacy and quality of care by using a single well-trained professional (Lenehan, 1991).


As the clinical nurse specialist in forensic examination is a recent addition to Ireland, a body of evidence regarding the efficacy of the service does not yet exist. Due to the paucity of literature on these services in Ireland, literature from North America (United States of America and Canada) will be reviewed in order to build a picture of these services.

The aim of this literature review is to focus on the contribution/role of specialist nurses working with victims of sexual assault and to consider the following: the protocols and practices of these programs, how a SANE delivers patient-centred care and the practical effect of the overlapping legal role of the SANE.


In searching for literature, a number of keywords were selected: „sexual assault‟, „sexual violence‟, „rape‟ and „sexual assault nurse examiner‟. Use of Boolean operators narrowed the search results to articles that were only relevant to nurses working in the area of sexual assault, for example, „sexual assault and nursing‟. These keywords were entered into databases with content pertinent to nursing: Scopus, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Health Source: Nursing. Limiters such as „peer-reviewed‟, „research‟ and articles dating from year 2000 to the present were applied to narrow the search results. The result list became limited quite quickly so it was necessary to review the reference lists of articles already sourced to build a body of literature. The details of these articles were entered into Google Scholar and those found were examined for evidence of peer-review. Interviews were conducted with a Clinical Nurse Specialist/Sexual Assault Forensic Examiner and a member of the Rape Crisis Network of Ireland to find out if other articles were available. After reviewing all of the articles found, several common themes emerged. Literature was then organized using a grid, specifically noting the type of research, methodology used, quality of methodology, findings of the study and central themes.


The reality of service provision by Sexual Assault Nurse Examiner programs
The Sexual Assault Nurse Examiner (SANE) Development and Operation Guide was published to guide service provision for independently functioning programs (Ledray, 1999). It outlines the SANE program goals:

To protect the victim from further harm; to provide crisis intervention; to provide timely; thorough and professional forensic evidence collection; documentation and preservation of evidence; to evaluate and treat prophylactically for sexually transmitted diseases (STDs); to evaluate pregnancy risk and offer prevention; to assess, document and seek care for injuries; to appropriately refer victims for immediate and follow up medical care and follow up counselling and to enhance the ability of law enforcement agencies to obtain evidence and successfully prosecute sexual assault cases. (Ledray, 1999, p.8&9)

The extent to which the SANE provides these services has been the focus of a number of studies. While the SANE program is an improvement over traditional Emergency Department treatment of victims of sexual violence, even in Emergency Departments with 24-hour SANE cover variance in service provision still exists (Stermac and Stirpe, 2002; Stermac et al., 2005; Plichta et al., 2007; Sampsel et al., 2009).

Stermac et al. (2005) conducted a chart analysis of a hospital-based SANE program. Services provided were in line with recommended practice but only 46.8% of survivors consented to the collection of forensic evidence due to victim perception of feasibility of prosecution. Similarly in Ireland, some SATUs are only accessible through Garda referral, meaning victims who do not prosecute will not be offered a forensic examination (Eogan, 2010).

Plichta et al. (2007) surveyed the hospital Emergency Departments of one U.S State. With a good response rate of 75% it was found that where full 24-hour Sexual Assault Nurse Examiner cover was provided, 100% of victims received a forensic examination compared with those with no SANE services (68.8%). Full SANE cover also ensured that emergency


contraception was offered 100% of the time and increased the cases where follow-up counselling was offered.

These studies are purely descriptive and without comparison to the care prior to introduction of the SANE, it is difficult to quantify the improvement made.

Only two studies have been found that used quasi-experimental designs to compare the practice of traditional models of care for sexual assault victims with that of a specialised nurse-led service.

Sampsel et al. (2009) utilised retrospective chart analysis in one Emergency Department (ED) pre- and post- the implementation of a Sexual Assault Domestic Violence Program (SADVP). Post-implementation they found that more victims received STD prophylaxis and post-coital contraception. Wait time to be seen by a healthcare professional was reduced and increased counselling opportunities were available. This program was not specified as a SANE program so the improvements cannot claim to be solely the work of the nurse. However Stermac and Stirpe (2002) compared the care provided by SANEs (n=210) and physicians (n=256) prior to the implementation of the SANE program. SANEs had shorter assessment times and experienced less interruptions. Victims seen by physicians and SANEs were demographically similar but the physicians saw more physically injured victims. SANEs were more likely to complete a partial evidence kit in cases where the victim was distressed.

The strength of these studies lies in their use of comparative analysis; however there are problems with retrospective analysis. A retrospective design involves researchers studying a current phenomenon by seeking information from the past (McKenna et al., 2010, p.218). Unfortunately it relies on existing data most likely collected for non-research purposes and thus lacking the required rigor (McKenna et al., 2010, p.218). The chart is the only source of documentation on the case and there may have been inaccuracies in charting, for example, care that was charted but perhaps not given; there is no way of validating what has been written at the time of secondary analysis. Also, as these studies were conducted in single geographical areas, the results may not be generalisable to a wider audience.


Three national studies of SANE programs further illustrate the variance in service provision. Ciancone et al. (2000) surveyed a random sample of SANE programs (n=61) in operation at that time. Pregnancy testing and post-coital contraception were universally offered services, Sexually Transmitted Diseases (STD) prophylaxis was almost always offered, while STD cultures, HIV testing and toxicology testing were selectively offered. 93% of programs provided a victim advocate. This survey cannot be considered comprehensive, as the response rate was only 66%. Postal surveys have a poor response rate, as they are often forgotten (Polit and Beck, 2012).

Campbell et al. (2006) aimed to build on the earlier work of Ciancone et al. (2000). From a larger sampling frame, semi-structured telephone interviews were conducted with 110 randomly selected SANE program directors, giving a response rate of 89%. Interviews produce higher response rates as people are more likely to cooperate with a researcher (Polit and Beck, 2012, p.305). Of 17 identified services, (as recommended by the SANE Operation Guide (Ledray, 1999)) 70% of programs offered these consistently. Consistency of services offered was related to nurses‟ experience with the criminal justice system, hospital ethos and the financial status of the program. Interestingly a toxicology test was not one of the universally offered services.

Cole and Logan (2008) surveyed three Sexual Assault Response Teams (SART) regarding procedures for responding to alcohol using victims. 89% of possible participants responded. Of these 27.8% were categorized as medical professional, but not specifically nurses. The interview consisted of a vignette (a brief description of an event to which respondents are asked to react (Polit and Beck, 2012, p.325)) followed by questions regarding the participants‟ expectancy of the handling of the case by the various professionals, including the Sexual Assault Nurse Examiner (SANE). 52% were unaware of any formal policies or protocols for such instances.

Logan et al. (2007) took the work of Campbell et al. (2006) further by randomly selecting 243 programs out of the largest sample frame yet (n=549). Despite being a 99 item postal survey, 91% responded (n=231) due to persistent follow up. The surveys were completed by the program co-ordinators. The majority of recommended services were being offered to victims, for example, 99% of programs indicated they offered Sexually Transmitted Disease (STD) prophylaxis, but it was also found STD and Human Immunodeficiency -8-

Virus testing were not always carried out. Reasons cited for this were that it was nonprotocol for the Department of Justice and concern that a positive result would be detrimental to the victim‟s legal outcome. As the interviews were conducted with just the program co-ordinator, there may have been a self-report bias, as they highlighted the best parts of their program.


Sexual Assault Nurse Examiner programs provision of patient-centred care
The Sexual Assault Nurse Examiner (SANE) aims to provide crisis intervention and protect the victim from further harm (Ledray, 1999). SANEs (n=110) described how they provide emotional care to minimise what may be upsetting about the examination process and the strategies used to address victims‟ emotional needs (Campbell et al., 2006). They explained all steps in the examination process, used a soothing tone of voice, did not use medical jargon, reflected a calm demeanour, performed the examination at a comfortable pace and reminded the patient of her safety. Such awareness highlights the SANE programs‟ provision of client-centred care. SANEs also consistently gave referrals to other mental health services such as counselling.

Interviews with 81 victims who had received medical care in Emergency Departments expressed that being asked by doctors about their prior sexual practices contributed to feelings of distress (Campbell, 2005b). Doctors were unaware of this distress, while nurses were significantly more aware of how their behaviour could impact the victim. Interviews were conducted immediately after care was provided to the victims, so reported distress may not be distinguishable from that of the assault.

In-depth interviews with specialist nurses described how they used a person-centred approach, meeting the survivor where they were at (Ross et al., 2010). Using the analogy of „the bridge‟ they described an initial sense of disconnection, the need to proceed cautiously – tentatively stepping onto the bridge – followed by the experience of forming a meaningful connection to serve as the context of care. This study leaves the question of the survivors‟ value of this approach.

Measuring patient-centred care requires considering feelings and attitudes of victims. Women reported that SANEs provided empowering care and made them feel dignified (Campbell et al., 2008) by respecting patients‟ wishes and not pressuring them to pursue prosecution. As a self-audited study, the questionnaire used was designed for internal use only and was not subject to full reliability or validity testing. Similar studies have found that clients‟ experiences with specialised sexual assault services were positive (Ericksen et al., 2002). Victims felt safe in an all-female environment, describing it as a „haven‟. Interestingly, patients appreciated therapeutic touch, explaining they felt „cared for‟ and - 10 -

that it countered the negative feelings associated with the internal exam. It must be noted that this was a very small sample (n=8) and the use of touch may not be appreciated generally as this is a very vulnerable cohort.

Many women attending specialised services found the SANEs very supportive, comforting, understanding and compassionate. In contrast they reported feeling scared, upset, stressed and very vulnerable undergoing a medical-forensic examination (MFE) (DuMont et al., 2008). The women misunderstood the purpose of the MFE, thinking it was for their physical health; they felt the SANEs expected them to consent to it and that they had no choice but to participate.

When the primary goal of a SANE program is to secure the prosecution of a case, the focus is not on patient-centred care and fewer services are provided to victims (Patterson et al., 2006). Programs that placed less importance on prosecution rates focused more on attending to patient‟s emotional needs, and empowering patients with information. These findings are significant as this study sampled programs nationally and there was a response rate of 89%, meaning the findings are generalisable.

In Ireland healthcare professionals working with women who have experienced sexual violence (n=18) cited poor geographical location and the operation of a „true‟ 24 hour service as barriers to patient-centred care (Kelleher and McGilloway, 2009).

SANE program directors have expressed the need for greater collaboration between all parties who provide care to victims of sexual assault (Logan et al, 2007). When SANEs conduct the forensic examination, victim advocates from rape crisis centres are often present to provide support. Cole and Logan (2008) explored the issue of conflict between SANEs and victim advocates. 76.6% of SANE programs surveyed (n=231) have good working relationships with rape crisis centres. Given the sample size, this is an encouraging percentage. Although some coordinators felt the advocate was unnecessary due to the SANE‟s specialised training, the importance of the nurse‟s impartiality and collection of evidence were recognised. Negotiating roles was stressed as important so that nurses do not relinquish all the caring dimensions of their nursing role.

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The Sexual Assault Nurse Examiner and the legal system
The purpose of the forensic examination is simple and single: to collect evidence. It is not necessary to physical health, although this is not always clear to the victim (DuMont et al., 2009), and can cause role conflict for the Sexual Assault Nurse Examiner (SANE).

SANEs (n=70) are more likely to experience role conflict than non-specialist nurses (n=48) working in the area of Sexual Assault Forensic Examination (DuMont and Parnis, 2003). SANEs are also more likely to find the evidence collection kit valuable and to exercise judgement in regards to completion of the exam due to an increased understanding of the complexities of the legal system. As a traditional mail survey (Polit and Beck, 2012), this study had a very low response rate (37.2%) and lacked the statistical power to detect the differences of some of the variables.

Two studies examined the quality of evidence collection by SANEs (Ledray and Simmelink 1997). Both employed retrospective descriptive data analysis, collected data from a single geographical area (Minnesota and Colorado respectively) and were selfreferred audits. Evidence, known as the „rape kit‟ or the „kit‟, submitted to the local Crime laboratory from the SANE programs was examined for completeness and compared to that collected by non-SANEs. Ledray and Simmelink (1997) found that SANE kits (n=24) compared with non-SANE kits (n=73) had better maintained the chain of evidence. However as the non-SANE kits included a larger sample, there was a greater margin for error, and it could be hypothesized that there was a lower volume of SANE cases, therefore allowing more time to take due care with evidence collection. Sievers et al. (2003) examined a total of 515 kits prepared by both SANE and non-SANE. Overall SANE kits were more accurate, more complete and had a completed chain of custody. The larger sample size of this study makes the findings more significant. Although these studies were self-referred audits of single SANE programs, having the Crime laboratory analyse the evidence ruled out bias in favour of the programs, but as there is no national independent auditing body, it is unknown whether appropriate standards were adhered to. Additionally, though the findings are significant for that geographical area, the results may not be generalisable.

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Two comparative studies demonstrate the higher quality of evidence collected by SANEs compared to non-SANEs (Lewis O‟Connor, 2009; Pennington et al., 2010). Following the implementation of a Sexual Assault Examiner (SAE) program which included specialized training and a standardized kit, it was found that the SAEs collected a higher quality of evidence than their non-trained colleagues in other Emergency Departments (Pennington et al., 2010). It is not clear whether the kit or the training contributed more to the increased quality of evidence collection. Using a quasi-experimental design, Lewis O‟Connor (2009) explored the differences by the SANE program/Sexual Assault Response Team (SART) models (n=210) and nonspecialist services (n=210), especially in regard to the efficacy of the SANE/SART models as a tool in the criminal justice system. Having a SANE/SART involved in a case meant significantly more biological evidence was collected and a suspect was three times more likely to be arrested. This suggests a correlation between the superior quality and quantity of biological evidence collected with a SANE/SART intervention and the filing of charges.

In Logan et al. (2007) SANEs surveyed felt that all professions working with victims could benefit from collaborative case reviews to understand from the Criminal Justice System what was and was not helpful when prosecuting a case, to the end of increased successful convictions.

Using mixed-methodology, Campbell et al. (2009) examined how one SANE program affected the extra-legal factors involved in rape cases. Of 137 cases examined, it was found younger victims were more likely to have their cases progress to high-level prosecution outcomes when a SANE was involved. Race had no bearing on the outcome of the case; however, due to the racial homogeneity of this sample, this is not conclusive. Exploration of factors predicting case progression could only be examined among post-SANE cases, as pre-SANE the data was unavailable. Additionally, prior to the SANE program, forensic medical evidence did not appear on police files as it simply was not available.

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Discussion and Conclusions

In reviewing the body of research available, there seems to be a scarcity of research conducted on the Sexual Assault Nurse Examiner (SANE) program. As a new avenue for nursing, a small evidence base is emerging, but is fragmented, making it difficult to provide a cohesive picture of the role of the SANE.

It is clear that SANE is a better way to care for victims than traditional Emergency Department (ED) models (Stermac and Stirpe, 2002; Sampsel et al., 2009) and there is better adherence to guidelines regarding the provision of services to victims (Campbell et al., 2006; Logan et al., 2007; Plichta et al, 2007). On the whole, the medical services offered are similar, but there are some exceptions. Due to financial constraints and ethos some services are restricted and SANEs often exercise professional judgement in relation to services offered, believing services are unnecessary or could harm the victims‟ legal case, (Ciancone et al., 2000; Campbell et al., 2006; Logan et al., 2007) or in the case of toxicology testing, no clear protocol exists (Cole and Logan, 2008). SANE services would benefit from an auditing body similar to the Health Information and Quality Authority here in Ireland, which aims to improve standards of care.

It is unknown if an ED with SANE cover is as effective as a stand alone program. Future research could compare the services offered by hospital SANE programs with community based SANE programs, examining the influence of ethos and finances, and the autonomy of individual SANEs. A comparative study on this subject would be relevant to Ireland, as both models are used, with Sexual Assault Treatment Units based in the community as well as in hospital.

The challenge of providing care to victims of sexual assault is implicit (Ross et al., 2010) and the forensic nursing role was created to improve patient care (Littel, 2001). Providing compassionate care and attending to the bio-psychosocial needs of patients are integral aspects of SANE work (Campbell et al., 2006; Patterson et al., 2006; Cole and Logan, 2008; DuMont et al., 2008), as with any nursing position (Gastmans, 1998).

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Nursing is concerned with the human response to health and illness (American Nurses‟ Association, 1995) so it is inevitable that SANEs express feelings of role conflict (DuMont and Parnis, 2003). This may be an internalisation of the contradictions inherent in forensic nursing – merging the subjective healthcare activities with what are expected to be purely objective practices of evidence collection (DuMont and Parnis 2003). In light of their responsibility to collect evidence, some argue that nurses should perhaps relinquish their caring role in order to remain objective (Campbell et al., 2007). For the SANE to maintain credibility, a degree of objectivity and neutrality as a medical and scientific professional is necessary (Canaff, 2009). Yet where SANE programs were more concerned with legal outcomes, there were less elements of patient-centred care present (Patterson et al., 2006).

While qualitative (phenomenological) research is concerned with the lived experience of people (Jasper, 1994), two studies may not be robust enough to state whether the emotional care described by the nurses was perceived as such by victims. Other findings have shown that victims valued the emotional care provided to them by SANEs who demonstrated compassion, support and made victims feel safe and dignified (Ericksen et al, 2002; DuMont et al., 2008; Campbell, 2008). The most commonly studied model, the nurse led service is viewed as the best. However, as Logan et al (2007) discovered, some SANE programs commented that a more multidisciplinary approach would be beneficial for all involved – victims, nurses, victim advocates, law enforcement and legal professions. An atmosphere of cooperation including would result in a more integrated service to victims and improve legal outcomes for victims (Logan et al., 2007). Nurses‟ scope of practice includes providing patient-centred care; conflict between victim advocates and nurses can be kept to a minimum when roles are clearly defined (Cole and Logan, 2008).

Prior to the implementation of the SANE program, forensic medical evidence was not available to law enforcement (Campbell et al., 2009). This correlates with the Irish situation; lack of evidence has been cited as the main reason the Director of Public Prosecutions does not prosecute (Hanley et al., 2009). SANEs both improved evidence collection and maintained the chain of custody better than non-SANEs (Ledray and Simmelink, 1997; Sievers et al., 2003; Pennington et al., 2010; Lewis O‟Connor, 2009.) Early findings suggest a strong correlation between the quality of biological evidence collected and the filing of charges (Lewis O‟Connor, 2009). It appears that the quality of - 15 -

biological evidence is beginning outweigh the influence of extra-legal factors (Campbell et al., 2009). Larger studies are needed to examine if this is generally true. As the role expands in Ireland, it will be interesting to see if the evidence collected by forensic nurses will contribute to an increase in the number of convictions here.

The research in this area is primarily conducted by non-nursing professions, for example, psychologists (Campbell). While this gives us an objective view of the work that the SANE does, it may highlight the lack of engagement of nursing in this area. Ledray (2007) encourages forensic nurses to seek evidence that will inform their own practice.

After a comprehensive search of the literature and consultation with both a Clinical Nurse Specialist/Sexual Assault Forensic Examiner (CNS/SAFE) and the Rape Crisis Network Ireland (RCNI), it can be stated that there is a serious lack of Irish research in this area. With the exception of the Sexual Assault Treatment Unit (SATU) clinical report and the qualitative work of Kelleher and McGilloway (2009), there has been no other evaluation of the specialist services.

Looking to the future, the greatest factor in improving the SANE program, according to professionals in the field, is research to guide clinical practice, in particular, a qualitative evaluation by victims of the nurse-led service.

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