Downing, Nancy R. PhD RN SANE‐A1; Mackin, Melissa Lehan PhD RN2
Role conflict may occur when a person has to play different roles in a single capacity (Van Sell, Brief, & Schuler, 1981). Forensic nursing combines two disciplines—nursing and forensic science. Each discipline has distinct core values, roles, activities and desired outcomes which may compete against one another and create the potential for role conflict (see Table 1). Forensic nursing is a relatively new discipline, “an evolving entity in search of an identity” (Hufft, 2006, p. 43). As forensic nurses continue to define and refine their roles, it is important to be aware of the potential for role conflict and its impact on nurses and on care delivery.
Sexual assault nurse examiners (SANEs) have a high potential for role conflict because they provide personal care to patients yet they must also “collect evidence in an objective and scientific manner” (National Institute of Justice, 2004, p. 89). SANE programs were developed due to the need to improve care of sexual assault patients as well as the quality of evidence collection and witness testimony (Ledray, 2006).
The sexual assault exam serves dual purposes: to “address the needs of the individual” as well as “address justice system needs” (National Institute of Justice, 2004, p. 23). Ledray, Faugno, and Speck (2001) recognized the potential for role conflict and cautioned SANEs against using the term “advocate” to avoid confusion with rape victim advocates. Role confusion has legal implications because being an “advocate” may lead defense attorneys to question the objectivity of SANE testimony.
Role conflict also has implications for SANEs and the patients they treat. Role conflict has been associated with job dissatisfaction and burnout (Corley & Selig, 1992; Stordeur, D'hoore, & Vandernberghe, 2001). Retention is an important issue in sexual assault nursing (Sievers & Stinson, 2002). In one study, 41% of SANEs had experienced burnout in the month previous to data collection (Townsend & Campbell, 2009). Over half of SANEs in another study reported they had experienced a dilemma in their dual roles as caregivers and evidence collectors (DuMont & Parnis, 2003). SANEs were more likely than nurses not trained as SANEs to discourage patients from completing an evidence collection kit or omit parts of the exam because the evidence could be used against the patients in court. This suggests that nurses who self‐identify as forensic examiners make decisions during care provision that is different from those who are not trained as SANEs. SANE programs that were more prosecution‐focused were found to be less likely to provide comprehensive care, including providing information and treatment for sexually transmitted infections and pregnancy prevention (Patterson, Campbell, & Townsend, 2006). This suggests how conflicting values may impact care delivery. The purpose of this qualitative study was to explore the perception of role conflict in sexual assault nursing and its impact on SANEs and on care delivery.
Purposeful criterion sampling (Sandelowski, 1995) was used to identify SANEs who met inclusion and exclusion criteria. Participants were recruited from a listserv developed by the University of Iowa College of Nursing to provide information to SANEs. Members of the listserv were persons who had been trained as SANEs by this institution or were members of the local Sexual Assault Response Team. The listserv was used in order to recruit some SANEs who were not members of IAFN, in case IAFN membership influenced their perception of their role. The listserv included approximately 125 members who were invited to participate if they met criteria (>21 years old; had conducted at least 5 exams and at least 1 exam in the previous 12 months). Fourteen SANEs participated. All but one were from Iowa and all participants were female. Participants were offered $10 gift cards as compensation for their participation.
A semi‐structured interview guide was developed based on literature regarding the role of the SANE. Two experts in sexual assault nursing reviewed the interview guide for relevance and completeness. Sample questions appear in Table 2.
This study was approved by the University of Iowa Institutional Review Board, who did not require participants to provide written informed consents due to minimal risk to participants; explanation of the study and participation in the interview constituted informed consent. An email was posted to the listserv inviting SANEs to participate in a telephone interview about the role of SANEs. The email did not use the term “role conflict” in order to prevent bias in recruitment and responses. Interested SANEs contacted the researcher by email and ultimately 16 SANEs originally agreed to be interviewed. Two respondents were lost to follow‐up. Recruiting stopped after 14 interviews when data saturation was reached, i.e. no new themes emerged (Burns & Grove, 2005). Interviews lasted an average of 28 minutes (range = 13–55 minutes) and were audio recorded with permission. Audio recordings were downloaded to a secure computer and interviews were transcribed to Word documents. All identifying information was removed and documents were identified by numbers only.
Data were analyzed using descriptive interpretive methodology (Thorne, Kirkham, & MacDonald‐Emes, 1997). Descriptive and interpretive coding was assisted using NVivo8 software (QSR International, 2007). Two researchers coded independently then met to discuss the descriptive and interpretive themes until 100% agreement was reached. Discussions included whether the descriptive themes were apparent and interpretative themes flowed logically from the data (Sandelowski, 2000). Content analysis (Morse & Niehaus, 2009) was used to explore patterns and differences and similarities between participant responses based on sample characteristics. The researchers had no expectations of statistical significance due to the small sample size.
Table 3 presents sample characteristics and descriptive data. In general, participants who had been practicing longer had conducted more exams, although this pattern was not uniformly consistent. Most SANEs who had participated in legal proceedings had only had one or two experiences.
Four of the 14 participants explicitly stated they had personally experienced role conflict. Of these 4, all had been practicing for 5 or more years and had conducted at least 60 exams. Beyond the 4 explicit reports of role conflict, 9 of the 14 participants provided implicit examples of conflict between their roles as caregivers and their roles as forensic technicians. There were no patterns identified based on IAFN membership. Although not specifically asked, 4 SANEs stated they considered themselves advocates and 7 stated they are not advocates.
Participants were asked whether they were surprised that SANEs in a past study (Dumont & Parnis, 2003) felt a dilemma regarding their dual roles when conducting a sexual assault exam while non‐SANEs did not. The majority of participants stated they did not personally feel role conflict: “That does surprise me, because I … don't personally see it as a conflict at all;”“I guess I never felt that way;”“I just don't personally feel any role conflict …. I am very comfortable in doing what we do;”
I feel both components are extremely important, and … they don't operate to the exclusion of each other …. I guess I don't get involved in those types of mental arguments …. I just do my job and … provide support and step back after that was done and let them sort it out;
I think [the SANE role] is to be a compassionate fact finder, to … assess the patient for injury, to gather any forensic evidence … and make sure … they understand the process and their rights and that they have control over the exam.
A few SANEs did express role conflict: “I guess I do have a little bit of conflict with the role of the comforter;”“I didn't realize … that we're not so much supposed to be the nurse advocate that we always are. That … it can create biases. And it kind of worried me because I always feel like I am a nurse first.”
Role conflict examples
While 10 participants denied personally feeling role conflict, 9 participants provided examples, including 5 who stated they did not feel role conflict. In some cases, SANEs who felt conflicted expressed a preference for caring over justice‐focused decisions:
I have also seen through my experience that not many patient cases truly go through the whole system and end up in court. And so in my mind, which may be biased, I've decided … if they want feedback, and I think they need it (the nursing care, the caring role) I am going to provide it because I don't think they are going to end up in court anyway;
I can keep it separate for myself …. [W]ell, no I guess I do [feel role conflict]. You know, I am always supportive of them. You know we are not supposed to be. You're supposed to be completely neutral. But of course, when somebody is coming in and saying …, ‘I was just raped,’ of course I feel sorry for them;
You know, and if our role was strictly evidence collection, then you know, we would get nowhere prosecuting some of these people …. Because the jury, you know, would look at us more as an extension of law enforcement than they would the medical community.
Several SANEs gave examples of how justice issues informed the way they provided care: “I just try to tell the patient … my role is to be completely neutral; I am to collect evidence, and that's what I'm here for …. And I do empathize with them, although I am not supposed to;”
[Y]ou have to be very black and white. You have to collect the evidence. I mean, I am always very victim sensitive, don't get me wrong, but I think portraying that you have this emotional attachment to this patient, to any attorney, they will say that … you might excuse the evidence, or you might not have gotten what you needed;
I mean, when you get on the stand, they don't want you to be emotionally attached to the patient …. They want you to say, ‘I medically treated this patient. I got the evidence and I didn't make any judgments.’ … If you get too emotionally attached, that will ruin the case later.
One SANE described how she tried to encourage patients to have evidence collected even when they initially declined: “So I tell [the patient]‘You know, this person is probably going to do this again. They are going to do it to somebody else, and somebody else.’ And that seems to help motivate them [to have evidence collected].” In another case, a SANE described feeling “let down” when a patient didn't want an evidence kit completed. One SANE expressed role strain: “[S]ometimes I think it would be nice to just go in there and collect the evidence and be done … and not have to worry about the teaching and the calming down.”
SANEs as advocates
Although not asked whether they view themselves as advocates, most participants volunteered an opinion on this topic. The definition of “advocate” appeared to vary. Seven stated they did not consider themselves advocates and 4 stated they did consider themselves advocates. For those who did not consider themselves advocates, they cited the potential for bias or the infringement on the victim advocacy role as reasons they were not advocates; some did not provide a reason but merely stated it was not their role: “The SANE … should not be an advocate for the patient, in the sense that you don't want to come across as being biased …. You have to take into consideration the legal aspect;”“I guess before I went through the [SANE] training, I considered myself more of an advocate. And then after the training I realized you were biased if you were the patient's advocate;”“I am not an advocate at all, nor do I want to be …. I think that nurses provide emotional support and referral on those types of issues, but we're definitely not advocates;”“You know I see nurses as advocates …. [but] that is not my role at the moment;”“I learned that we do need to be compassionate and caring … but our role is more evidence collection;”“[W]hen I first became a SANE, I was … afraid that I was going to … step over the bounds … of the SANE nurse, into the advocate's role.” One SANE said being a SANE is different from other nursing roles because “now I am not the advocate to the patient.”
Those who stated the SANE is an advocate discussed advocating for patients’ healthcare needs and providing education and compassionate care: “To be an advocate for them as far as treatment options, whether it is hepatitis B shots, HIV counseling … STI … prophylaxis … and pregnancy. Things like that;”
“I think that a lot of the role of the nurse is about education and, … besides caring, education and leadership and advocacy …. Advocacy I think is making sure that people have the resources that they need to be successful;”
I do think … there is some kind of advocacy on some parts, just in the way that they are compassionate, and they reassure them that it wasn't their fault, and … that they hadn't made that choice …. So I think, anyway, that they are an advocate, too. They stand for the evidence that they collect, and when they go to court;
[B]eing an advocate for our patients, saying, you know, we still need to do this for them and sticking up for what they want to do. If they don't want part of the exam, or they don't want to take a pill, or if they don't want to report it to the cops. You know, we should support them in that.
Others expressed confusion regarding whether they were advocates or not:
I think that as a nurse I should talk to them about those issues …. [I]f they want me to call them because they are still having … flashbacks … I may say to them ‘Well, that is the role of the advocate.’ And they say, ‘Well, I don't know that person. I'm here with you. I'd rather call you. I feel comfortable with you;’
[T]here seems to be two schools of thought on the role of the SANE, and one … is presented as much more of an advocate and the other is that you are a clinician—you're a nurse first, and not there to advocate for the victim in any way, shape, or form …. I think it's very confusing and detrimental to the process of forensic nursing that there's that confusion out there ….
The issue of differentiating patient advocacy from the role of victim advocacy was raised: “I think that nurses provide emotional support and referral on those types of issues, but we're definitely not advocates;”“You know, I see nurses as advocates. As far as I'm concerned, we are the ultimate advocate. But … to get into the advocate role—care of specific items like transportation or housing— … that is not my role at the moment;”“We advocate more by doing our job correctly than … actual verbal advocating; but I do that, too, you know …. I try to comfort with words to the patient;”“I think it depends a lot on what your definition of advocate is …. I mean, I think it means context.”
We identified two interpretive themes from the data: The first was “breaking the rules” which prioritized caring based on contextual factors. The second was using victim advocates as proxy for the caring role that SANEs believed they should not exhibit.
Breaking the rules
Breaking the rules, which included suspending objectivity in some situations, was more likely to occur when the victim was really upset or was a child: “I tell them I believe them … if it's appropriate—especially if they are really crying, and they are really concerned that nobody will believe them;”“[O]bviously if they are crying, you feel sorry for them, and you do; you empathize with them, and you comfort them …;”
I think people are a little jaded towards adult women, or males as far as that's concerned …. ‘Oh, they were drinking, they kind of brought it on themselves.’ But kids, I mean, they never ask for it. They never put themselves in bad situations …. And I have this strong will to advocate for these kiddos. But I know I'm not supposed to be too biased.
Victim advocate as proxy for the caring role
Several participants stated the role of victim advocates was to provide unconditional emotional support to patients while the SANEs focused on the forensic role. In other words, the victim advocate was a proxy for the caring role SANEs would take in other nursing contexts: “The advocate is the one who provides the … I would say ‘tender touch.’ She is for the patient … she is the … emotional giver, too;”“I think … knowing that the advocate is there in one of the roles … that you may have done in the past nursing jobs that you have had …. Just know that someone is filling that role, but it is just not you;”
Basically, … the role of a sexual assault nurse examiner is to collect the evidence … [and]to do the medical portion … and the advocate is there to help with the emotional part of it …. They are doing everything that I had to do before I had the [SANE] education;
[W]hen I would get these young girls, and they were just broken‐hearted, and they were just crying and they … didn't have anybody around … and they needed somebody to put their arms around them and say it was okay. And I had to be really careful because I really wanted to do that, but I shouldn't do that. So … good thing I had good advocates there that stepped in and did that
[W]e are very fortunate to have a great advocate service that says … ‘It's not that she doesn't believe you. We believe you, it's just she can't say it.’ And I let them put words in my mouth all the time. I mean, I don't mind that, because most of the time they are conveying what I really feel. But … it's beyond our scope … beyond what we can say.
Relying on the advocate to provide the caring role may be problematic if the victim advocate is too quiet:
So, I've had advocates that just sit there—they are absolutely quiet, they say nothing—and that puts a strain on everybody in the room, because I am expecting her to do her part as an advocate to provide compassion and empathy …
I do feel uncomfortable [when the victim advocate is too quiet], and I feel really bad for the patient …. And then I will say to the advocate, for instance … ’[D]on't you think this had to be a horrible thing?’ and then try to engage her in carrying on a conversation with the patient.
Our findings suggest that participants recognized the dual role of the SANE nurse. However, most SANEs in our sample did not explicitly endorse role conflict and a few stated they had worked through it. On the surface, this appears to indicate SANEs don't experience role conflict. It is possible other factors may contribute to SANE burnout, including the stress of being on call, working with victims of assault (Seng & Sanubol, 2004) and conflict with victim advocacy programs (Cole & Logan, 2008) and other agencies (Logan, Cole, & Capillo, 2007)
On the other hand, while participants did not endorse conflict between their roles as nurses and forensic technicians, they did express conflict regarding their role as advocates. Many expressed they are “not supposed” to care about their patients, that caring would create legal bias. Others stated they care anyway; in their minds, breaking the rules. It was especially difficult for some to remain objective when the patient was very upset or a child. This creates broader ethical issues, however. If nurses make decisions about who deserves to be cared about based on contextual factors, they run the risk of deciding that some people, especially those they consider culpable for their own suffering, are not worthy of being cared about (Olsen, 1993). Particularly troubling is the fact that SANEs may express more caring toward patients who openly display their distress when several studies have indicated that people who display symptoms of dissociation following a traumatic event are at greater risk of developing PTSD (Bryant, Harvey, Guthrie, & Moulds, 2000; Grieger et al., 2000). Thus, patients who show little emotion after a sexual assault may actually be in great distress.
The data also indicated there was confusion regarding the definition of advocate. Some appeared to be drawing a distinction between their role and the role of the rape victim advocate. Several spoke of advocating for patient's rights to decide what parts of the exam they wanted, whether or not to take medications, taking time to explain the exam carefully and making sure patients understood their options, all patient advocacy roles. This finding suggests the issue raised by Ledray et al. (2001) that confusion over whether SANEs are advocates remains unresolved.
The ANA Code of Ethics states nurses are patient advocates and the Code of Ethics is “not negotiable in any setting” (ANA, 2005, preface). Furthermore, the Forensic Nursing Scope and Standards of Forensic Nursing Practice states the forensic nurse “serves as a patient advocate assisting patients in developing self‐advocacy and empowerment” (International Association of Forensic Nurses, 2009, p. 41). From a legal standpoint, it may be critical for the focus of a sexual assault exam to be medical and not forensic. Hearsay exceptions for admissibility of statements made during sexual assault exams depend on demonstrating that the primary purpose of a sexual assault exam is medical, not forensic (Markowitz & Wess, 2010). In contrast to Dumont and Parnis’ (2003) findings, participants in this study were more likely to encourage patients to have evidence collected rather than to discourage them.
Part of the problem may arise during SANE training. The forensic aspects of the exam are new to most nurses and therefore occupy much of the time during SANE training. This may create the impression that the legal aspects are more important than the nursing care aspects. Over time, SANEs may return to a nursing focus, as was demonstrated by some of the participants in this study. However, many SANEs conduct only a few exams a year, and may never develop proficiency with the forensic aspects of the exam. Thus their relief in allowing the victim advocates to take on the caring role while they focus on the forensic components is understandable. In addition, sexual assault programs run by other professions may define the SANE role (Logan et al., 2007). The effects of role conflict on job burnout and attrition in SANE nursing are not clear in this study since most participants did not explicitly endorse role conflict. However, interviews with former SANEs might be more revealing. This study provides preliminary support that the tension between the nursing and forensic roles in SANE nursing is real.
Some SANEs may also be confused by the difference between “advocacy” and “caring.” Advocacy according to the American Nurses’ Association (ANA) Code of Ethics pertains to actions taken by the nurse to “protect the health, safety and rights of the patient” (ANA, 2005). However, in lay terms advocacy can mean pleading the cause of another, especially in a legal sense (Advocate, Merriam‐Webster Online, 2010). Thus, it is reasonable that forensic nurses might want to reject the term in order to avoid appearing biased. The word “caring” also can have various meanings, even within nursing. For example, caring can be either an action (to care for), or a feeling (to care about) (Gaut, 1983). Jean Watson, the nurse theorist who developed the Theory of Nursing Care, defined caring as “not just an emotion, a concern, or benevolent desire. Caring is the moral ideal of nursing whereby the end is protection, enhancement, and preservation of human dignity (Watson, 1999, p. 29). This definition of caring is very close to the ANA's definition of advocacy.
A limitation of this study is that most participants were trained by the same program, albeit at different times, and most practicing in a single state. SANEs trained under different programs and in other geographical areas may have different perceptions of role conflict and advocacy. For this reason, further research with SANEs trained at a variety of programs and varied geographical areas would further illuminate these issues. Dumont and Parnis (2003) suggested that SANEs internalize the role conflict inherent in forensic nursing, making it more difficult to self‐recognize. A different study design might reveal more examples of role conflict. For example, using vignettes or debriefing with SANEs shortly after exams may make role conflict more salient since in this study it is unknown when participants last conducted exams.
Implications for clinical forensic nursing practice
The concept of the victim advocate as proxy for the caring role appears to be a novel finding and has not previously been discussed. The presence of a victim advocate was shown in this study to be invaluable to SANEs by ensuring patients receive unconditional support. Therefore, a victim advocate should be present at exams, ideally as part of a Sexual Assault Response Team. After a victim advocate introduces herself to the patient and explains her role, the patient then can make an informed decision whether or not they would like the victim advocate to stay.
On the other hand, the presence of victim advocates does not negate the importance of SANEs providing compassionate care. Patients expect healthcare providers to show compassion and believe it is integral to the healing process (Swedish Covenant Hospital, 2004). Persons who train new SANEs should emphasize the preeminence of nursing in this role: “Forensic nursing is a specialty in nursing, not a nursing specialty in forensics” (Kent‐Wilkinson, 2009). The purpose of a sexual assault exam is to provide for patients’ mental and physical healthcare needs. As SANEs continue to define and refine their roles they should be aware of the potential for role conflict and its implications for SANEs and their patients.
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Key Words: Forensic nursing; role conflict; sexual assault nurse examiner
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