Specialized training: More Spokane ER nurses complete instruction on sexual assault exam kits and victim care

About 100 sexual assault victims a year go to one of MultiCare’s three Spokane emergency facilities. Other victims receive care at Providence’s ERs or outlying hospitals if an attack is reported.

The patients – male and female – are more likely in recent years to see a nurse trained as a Sexual Assault Nurse Examiner, with advanced courses in trauma-informed care and a multistep forensic exam kit for evidence collection and documentation.

It’s work that can stand up in court for a prosecution.

“It goes through specialized training in evidence collection,” said Jen Cantrell, MultiCare nursing professional development specialist and SANE-trained nurse.

“We go through the entire judicial process – pretty much from hospital to court – all the steps in submitting the evidence, working with law enforcement, prosecutors, some trial and testimony prep and then any other things you might find in your exam – specialized assessment, assessment for strangulations, injuries for domestic violence, other potentially emergent medical issues.”

Cantrell said SANE includes training about a patient’s rights, such as having an advocate, and the steps in a sealed “Sexual Assault Evidence Collection Kit.” Completing the exam and entire kit process typically takes three to four hours, she said.

A large part of the training pivots on providing care after such a trauma, in knowing how to talk with victims but still be able to assess what happened.

“It’s understanding what can happen when somebody has experienced a trauma, then how to work with them so you’re not re-traumatizing them, and also to be able to help them through the entire process,” she said.

MultiCare now has 16 SANE-trained members for adolescent and adult care on an on-call team under a collaborative training focus since 2020. They have a minimum 40 hours in SANE education and can go to Deaconess, Valley Hospital or its North Emergency Center.

Providence has 25 SANE-trained providers between emergency departments at Holy Family Hospital and Sacred Heart Medical Center, plus 13 SANE members in its Children’s Hospital Pediatric Emergency Department.

Children who are sexually abused or assaulted typically see a nurse with SANE training and a child life services specialist, said Kacie Dicus, SANE-trained Providence pediatric emergency department nurse manager.

“Our pediatric emergency department child life services has caregivers who have specific training in developmental stages but also in trauma,” Dicus said. “They can help our patient by just being there along with the advocate.

“We use child life services to help us gauge where the patient is developmentally, then they use different sorts of materials to help distract them through their procedure.

“Depending on age, they may play a game on the iPad together or use Model Magic or something to help that patient get through the exam with some sort of distraction or helpful things. If we have a patient who can understand, then we have step-by-step explaining.”

They coordinate with others on a child’s behalf, she said, “so we partner with law enforcement, child protective services and then of course patient advocates and physicians to come up with the best plan.”

While any Washington state registered nurse is qualified to collect an evidence kit, Cantrell said the SANE training goes in-depth from “chain-of-custody” for evidence to what’s required for the legal system.

“The kit itself contains about 15 different envelopes or steps, so we learn how not to cross-contaminate evidence, we learn how many swabs are required and whether they need to be moistened with distilled water or kept dry,” Cantrell said.

“Once the kit is opened, you’ve now opened your chain of custody, so the nurse completing the exam can’t walk away,” for up to four hours. “That doesn’t include any of the time for any additional medical care, if somebody has sustained injuries and needs stitches or to go to an X-Ray.

“We learn how to document those pieces. Where we’re documenting on our chart is really important for where we are finding the evidence. Also, there’s follow-up care, so we learn what medications these patients potentially need to prevent STDs or prevent pregnancies and then who they can follow up with.”

Services include YWCA Spokane for domestic violence victims or Lutheran Community Services, which provides sexual assault advocates. “We also learn the importance of having that advocate as early as possible.”

The training delves into the legalities of record handling, rules if there is a subpoena and possibly testifying in court, Cantrell said. The nurses learn about doing the initial patient interview to know what to do for a physical assessment, clues for evidence and injuries to document.

The patients have a say. “Nurses are mandated reporters,” Cantrell said. “However, if an adult is alert and competent and able to make a decision and decides they don’t want to report to law enforcement, we’re not required to report to law enforcement.”

Often, though, the nurses are navigating through pieces with many agencies. “It becomes an interdisciplinary collaboration between law enforcement, the legal system, advocacy, community groups, the hospital.”

Along with being informed of their rights, the patients can decide what happens during exams, she said.

“I just tell them, ‘This is when you get to take control back. You get to make all the choices, and nothing is going to happen to you that you don’t approve of while you’re in the hospital. We’re going to keep you informed, and you’re going to make the choices.’ ”

The earlier that victims get to the hospital to report sexual assault – without showering, eating or going to the bathroom – the better an outcome to collect evidence toward prosecution, Cantrell added.

But they can step forward at any time, she said. “It’s never too late to come in, talk to somebody or seek help, even if there is no physical evidence we can collect.

“Talking to somebody, getting counseling, acknowledging that something happened to you is a really important piece.”

Providence’s Dicus said she also sees the need to provide the training to more ER nurses. “Over the past few years, I think the need has just been really at the forefront.”

Providence offers its own SANE course and mentored exam work along with an almost 200-page handbook.

Recently, Washington State University College of Nursing received funding to develop Eastern Washington SANE training. In the past, many nurses traveled out of state or to Seattle’s Harborview Medical Center for such courses.

The crime often goes unreported, and fear can stop victims from seeking help, Cantrell said. “It could be fear because they knew the person who assaulted them and not wanting to get somebody in trouble. It can be just wanting to deny that the whole thing happened.

“The only thing the victim has to do is just speak up and say something happened to me and I didn’t consent, and then the SANE nurse and advocate can help walk them through step by step.”