Sexual Assault Exams

[Peach4Peace]

At work recently I was asked to do a sexual assault exam because the SANE nurse could not come in. I was raped a few years ago, so I became extremely anxious and I worried that I might start to have flashbacks while I was doing the exam. Since once the exam is started it can’t be stopped, I thought it wouldn’t be in the best interest of the patient for me to be the person completing the exam, so at that point I told my charge nurse that I couldn’t do it. My charge nurse told me that there was another nurse that could do it, but basically told me that it’s part of my job and that will be something I’ll need to “come to terms with” or that I need to talk to my manager who will need to give me permission to not do the exams which he said “doesn’t happen.” I feel really awful tonight and I feel like a bad nurse for not doing what was asked of me. I understand that it’s something that’s expected of me, but even after therapy I still suffer from flashbacks and I just don’t think it’s right for the patient for me to put myself in that situation if I can’t keep it together. I feel really alone right now and I guess I’m just wondering if anyone else has been in a similar situation where something was asked of them and they couldn’t do it and how they handled that? Did I do the right thing by telling my charge nurse I couldn’t do the exam, or if should I have just tried to suck it up and go through with it?

[JKL33]

You should speak with your manager about this.

Generally-speaking (under the circumstances) you do not need to feel awful about your reaction. You also aren't a bad nurse with regard to this. Just don't even torture yourself more with self-flagellation. The patient received the necessary care.

You do have a responsibility to get together with your manager and talk through caring for these patients and/or alternative arrangements, etc.

Out of curiosity, has everyone received at least a modicum of training to perform forensic exams? Is this a situation where any one ED nurse's occasion to perform this ends up being very rare (which isn't ideal for either nurse or patient)?

Take care ~

[Mandy2016, BSN]

I believe you absolutely did the right thing. It would have been horrible if you were in the middle of an exam, panicked, and then ended up contaminating evidence or causing harm to yourself or your patient. Everyone has a weak spot, it's nothing to be ashamed of. With your past trauma, I believe that was a perfectly acceptable reason to ask for an assignment change. I also can't imagine this type of patient being an every other day patient, so you hopefully won't even need to ask many more times.

Stop punishing yourself! You deserve a little compassion from your team!

[Duranie]

On 3/16/2019 at 9:58 PM, Peach4Peace said:

My charge nurse told me ... that I need to talk to my manager who will need to give me permission to not do the exams which he said “doesn’t happen.”

Well, unless he knows of another nurse in the dept. who is a rape survivor who ended up being required by management to perform SARS exams after they voiced concerns similar to yours — then I’d say he’s talking out of his sphincter...

‘Go speak to the Nurse manager or whoever you need to in management and explain the situation. Are you still in therapy? If so, ask your therapist for a short letter that states simply that it is not advisable that you conduct or participate in sexual assault forensic exams because due to your own experiences there is potential for you to cause inadvertent harm (psychological, if you freak out mid-exam) to the patient or to cause a break in the chain of custody of forensic evidence if you became unable to complete the exam you had started.

You could also make use of your “Employee Assistance Program” to speak a counselor that the hospital provides. (Usually for free.) You should do this because of the psychological stress that came from being in the situation of having to decline performing the exam and then being bullied about it by your charge nurse. This will create a “paper trail” with regard to this specific incident that you can turn to if needed in the future to show that you had concerns and tried to do what was best for yourself and your patients, at this time.

For the record, as an SA survivor myself— I think you did the right thing.

A patient will pick up on your feelings of anxiety and fear, but because they don’t know why you have that anxiety, they will likely misconstrue that it has something to do with them... which in this case, might make them think that should be ashamed or that they’ve done something wrong, or that you somehow think they shouldn’t be there— any of which could cause them not to go forward with the exam or the report of their assault. Which is, no doubt, the last thing you want to happen. I’m sure what you really want to convey to any SA patient is that they are right where they belong and that they have done nothing wrong and they have nothing to be ashamed of. And that the exam is a necessary part of the SA report they are rightfully pursuing.

Be sure to point out to your manager the above risks and that you (and they) surely wouldn’t want to inadvertently cause any further trauma or stress to an already fragile and vulnerable SA patient.

I’d be willing to bet that your charge nurse’s threat of “it just doesn’t happen” is empty. It probably hasn’t ever happened, but only because it probably hasn’t ever come up before. This is exactly the kind of thing that has to be handled on a case-by-case basis, because there is no one-size-fits-all policy that could ever cover it.

Good luck. Be strong and confident in your knowledge that you did what was best for the patient. You advocated to get that patient the care they needed, even though it wasn’t care you could personally provide. And isn’t that ultimately your job?

[DextersDisciple, BSN, RN]

I was waiting for someone to mention that this is the SANE’S job only, not the ED RN. I worked as a SANE in the past. It would be highly inappropriate for someone who is not trained in chain of custody and certified in sexual assault to be doing a forensic exam.

Perhaps different states vary in this regard though. In my state you would have never been asked to do a forensic exam and if the SANE was tied up in another exam someone else would come out. Even our supervisor would come out if needed. So sorry you were put through that

[canoehead, BSN, RN]

Every nurse in ERs I've worked at were trained on SANE exams, but we would call for a SANE certified nurse first, if they were available.

I would expect coworkers to be supportive if someone feels bad enough that they admit they cant tolerate doing the exam. Then that nurse would end up taking over someone else's assignment while they did the job, so no one is getting away with not working hard. Everyone is entitled to one thing they cant tolerate, so long as they trade work.

I'd also talk to your manager about your issues, so your charge doesn't blow this out of proportion. You could go through EAP first, and that might be easier for you.

[Lunah, MSN, RN]

On 4/3/2019 at 5:27 PM, DextersDisciple said:

I was waiting for someone to mention that this is the SANE’S job only, not the ED RN. I worked as a SANE in the past. It would be highly inappropriate for someone who is not trained in chain of custody and certified in sexual assault to be doing a forensic exam.

Perhaps different states vary in this regard though. In my state you would have never been asked to do a forensic exam and if the SANE was tied up in another exam someone else would come out. Even our supervisor would come out if needed. So sorry you were put through that

I also spent four years working as a SANE in the Army (as a side duty to ED/trauma nursing). Yes, while it is preferable to have a trained and qualified SANE doing the exam and collecting the evidence, SANEs are not available everywhere, in all facilities. In EDs across the US, non-SANE nurses and also physicians perform these exams with regularity, and have done so for years. There is nothing inappropriate about an ED RN performing an exam as long as he/she understands chain of custody, documentation, and the basic principles of evidence collection. We made a checklist for our ED RNs in the event that a SANE was not available. This came in handy the time that I was called in to do a suspect exam, and then was asked to perform the victim exam as well. Can you say cross contamination, Batman?! I flat-out refused to do the second one because it would jeopardize the entire case.

To the OP - definitely speak to your manager. *hugs*

[DextersDisciple, BSN, RN]

On 4/10/2019 at 7:55 AM, Pixie.RN said:

I also spent four years working as a SANE in the Army (as a side duty to ED/trauma nursing). Yes, while it is preferable to have a trained and qualified SANE doing the exam and collecting the evidence, SANEs are not available everywhere, in all facilities. In EDs across the US, non-SANE nurses and also physicians perform these exams with regularity, and have done so for years. There is nothing inappropriate about an ED RN performing an exam as long as he/she understands chain of custody, documentation, and the basic principles of evidence collection. We made a checklist for our ED RNs in the event that a SANE was not available. This came in handy the time that I was called in to do a suspect exam, and then was asked to perform the victim exam as well. Can you say cross contamination, Batman?! I flat-out refused to do the second one because it would jeopardize the entire case.

To the OP - definitely speak to your manager. *hugs*

Hence why I said it was inappropriate for people “not trained in chain of custody” to collect evidence. I also said “different states vary” and this is what would have happened in *my* state.

[laceym]

I am a SANE and that is completely unacceptable for your manager or even your department to think that your job duties as an ER RN include SAFE. You did the right thing. Your experience in the past is no one's business at work. I wish you well and hope that you can be an advocate for those in need of SAFE, but not necessarily be the examiner.