Approximately 75,014,000 women and 26,711,000 men will be sexually assaulted in the United States during their lifetime (Black et al., 2011). Although not all victims will seek law enforcement involvement, many may present to an emergency department or a sexual assault center for medical care after the assault. The International Association of Forensic Nurses maintains a database of sexual assault nurse examiner (SANE) programs. Currently, there are 728 programs listed, which care for either the adult/adolescent or pediatric populations.
Examination by a trained SANE nurse is recommended to ensure the medical needs of this patient group are met as well as to ensure quality evidence collection in the event the patient wishes to proceed with prosecution in the future (Darnell, 2011; Ferrell & Caruso, 2011). The National Protocol for Sexual Assault Medical Forensic Examinations states that the “effective collection of evidence is of paramount importance to successfully prosecuting sex offenders” (U.S. Department of Justice Office on Violence Against Women, 2004, p. iii). Types of evidence collected include swab or smear specimens, photographs, clothing, foreign material, hairs, tampons/menstrual pads, and a narrative description of the event.
The medical forensic examination performed by a SANE nurse serves more than one purpose. The primary purpose is to provide comprehensive, compassionate nursing care to patients who have experienced sexual assault (Chasson & Day, 2013). A secondary purpose of the examination is to collect and preserve deoxyribonucleic acid (DNA) evidence (Chasson & Day, 2013; U.S. Department of Justice Office of Violence Against Women, 2004), which is accomplished through the assessment phase of the nursing process (American Nurses Association/International Association of Forensic Nurses, 2009). Also accomplished during the assessment is the collection and documentation of the history of events as described by the patient.
The collection of quality DNA samples can be crucial to a sexual assault investigation and prosecution (Burgess, Lewis-O’Connor, Nugent-Borakove, & Fanflik, 2006; National Institute of Justice, 1999). Because DNA profiles are unique to all individuals except identical twins (National Institute of Justice, 1999), properly collected evidence from a sexual assault examination can assist in the prosecution of the suspected perpetrator or in the exoneration of the wrongfully accused (Canaff, 2009; Lewis-O’Connor, 2009). Through the use of the Federal Bureau of Investigation laboratory’s Combined DNA Index System (CODIS), a database of DNA profiles from laboratories across the United States, forensic analysts can input the DNA profile of an unknown perpetrator and search for a match to existing DNA profiles already in the system (Federal Bureau of Investigation, 2012).
Previous studies have documented the high quality of evidence collected by SANE nurses (Burgess et al., 2006; Ledray, 2001; Ledray & Simmelink, 1997; Lewis-O’Connor, 2009; Littel, 2001; Sievers, Murphy, & Miller, 2003). Others have examined the effectiveness of SANE programs (Campbell, Patterson, & Lichty, 2005; Canaff, 2009; Littel, 2001; Nugent-Borakove et al., 2006). Research has also shown a correlation between SANE collected evidence and documentation with the increased potential of arrest, prosecution, and conviction of the perpetrator (Campbell, Patterson, Bybee, & Dworkin, 2009; Canaff, 2009; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Ledray, 2001; Lewis-O’Connor, 2009; Littel, 2001; Nugent-Borakove et al., 2006).
Details of the sexual assault events provided in a narrative form may help guide the forensic analyst when testing samples (Burg, Kahn, & Welch, 2011) and can provide an understanding as to why a particular sample was collected and what type of biological evidence they should look for. For example, if the victim states the suspect kissed her neck, that swab would be tested for saliva. The narrative can also provide important information showing lack of consent (Littel, 2001) and historical data such as last previous consensual sexual activity. Knowing that a victim had a prior consensual partner prevents DNA profiles from innocent partners from being entered into CODIS.
SANE narrative documentation offers information helpful to members of the investigation and prosecution teams. Burgess et al. (2006) describe how documenting patient actions between the sexual assault and the examination, such as brushing his or her teeth, eating or drinking, and showering, may help prosecutors explain a lack of DNA evidence to jury members. In addition, entering DNA profiles into CODIS helps increase the likelihood of arrest, capture, and prosecution by preventing perpetrator recidivism.
Given the potential impact SANE nurse evidence collection and documentation has on the course of justice, feedback from forensic analysts who process sexual assault kits could be helpful, including suggestions for ongoing education and recommendations for improvement. This study describes forensic analysts’ perspectives on the quality of evidence collection and documentation provided by SANE nurses.
An electronic online survey methodology was used to examine a national sample of forensic analysts, which included criminalists, forensic chemists, forensic scientists, and forensic biologists. A literature search was performed using the terms sexual assault, forensic analysis, evidence collection, evidence analysis, and sexual assault nurse examiner. No established instruments were found in the literature related to quality of evidence collection. On the basis of a critique of the relevant literature and the assistance of a local criminologist, the authors developed a 20-question survey utilizing Survey Monkey software. Additional SANE and emergency medical service colleagues reviewed the survey for clarity, ease of use, and language. On the basis of their feedback, a few changes were made to the survey. Major content areas included the quality of SANE evidence collection and narrative documentation, potential areas for improvement, opinions regarding development of a national sexual assault kit, and feedback mechanisms used by analysts to communicate with SANE nurses.
An Internet search was performed to locate crime laboratories in each of the 50 states and the District of Columbia. The 206 laboratories identified were each contacted by telephone to verify that the laboratory analyzed sexual assault kits. Crime laboratories were excluded if they did not have experience with sexual assault kits or if they preferred not to participate. A brief description of our research was provided, and laboratory staff and/or administrators obtained analysts’ permission for participation and provided their contact information.
A letter was sent, which outlined the current research study, gave instruction for survey completion, and thanked the analyst in advance for his or her input. Analysts were assured anonymity for their responses on the survey as no identifiers would link their responses to their state nor would any be utilized in the description of research findings. Analysts were informed that, by responding to the survey, they were implying their consent to participate in the study. The results were analyzed utilizing the Survey Monkey software. Descriptive statistics (frequency and percentages) were calculated.
There were six questions that provided opportunity for open-ended responses. The responses were coded, and patterns were examined. The data were sorted and categorized by common themes to bring meaning to the responses.
The data collection period was from May through August 2012. This study was approved by the Committee for the Protection of Human Subjects, the institutional review board at Dartmouth. It was deemed “exempt from further review.”
Overview of Survey Data Provided by Analysts
Survey responses were obtained from 86 forensic analysts from crime laboratories representing 39 states in the U.S. Position titles varied by state. The initial questions of the survey were used to gather data regarding the number of sexual assault kits received by the laboratories each year and the number processed (see Table 1). The highest percentage of laboratories received (41%) and analyzed (48%) between 1 and 250 kits annually. The discrepancy between the annual number of kits received and the number of kits analyzed reflects laboratory practice patterns where all kits received may not be analyzed. For example, a laboratory may receive 260 kits but may only analyze 240 in a given year.
Descriptive data related to analysts’ perceptions of evidence collection are displayed in Table 2. According to responding analysts, a written narrative was included in 94% of the kits they examined. All of those who received narratives reported that they found them useful. Of the remaining 6% of analysts who stated that they do not have this documentation available to them during analysis, all indicated that they would find it useful. On the basis of the information contained in the narrative, 91% of analysts stated that most kits their laboratory received contained samples that were collected appropriately, such as known DNA buccal swabs obtained from all patients regardless of oral assault if required per local protocol. Approximately 91% of analysts also responded that most of their kits were collected within local protocol time frame guidelines.
Most analysts (n = 75, 91.5%) agreed that SANE nurses collect a higher quality of evidence than non-SANE trained examiners. It was also reported that, for 91.8% of laboratories responding (n = 78), most kits completed by SANE nurses contained samples that met their laboratory’s standard for “good analytical quality.”
A free-text box was provided for analysts to detail frequently seen oversights, defined by the authors as errors or omissions in collection and/or documentation, found most frequently in kits completed by SANE nurses (see Section II below).
Fifty-three percent (n = 45) of analysts indicated that there was a feedback mechanism in place to communicate with the SANE nurses who completed the kits. Of those without a formal way to communicate with their SANE nurses, 41% (n = 32) would be open to one if it was confidential, held no source identifiers, and did not interfere with the legal process (see Section III below for additional descriptions of this process).
When asked if they found the quality of documentation and evidence collection declined when a SANE nurse completed a kit that they were not as familiar with, such as those nurses who work in areas bordering other states, most analysts (n = 45, 53%) stated that this was not applicable to their laboratory, meaning they always use the same kits. Of those analysts whose laboratory this applied to, 24% (n = 20) believed that the quality does decline.
Analysts were also asked if they believed a national kit, if used by SANE nurses in every sexual assault case occurring in the United States, would help increase the quality of evidence collected. Most respondents (n = 46, 54.1%) stated that they were unsure, but 20 (23.5%) stated that they believed a national kit would be helpful. Only 27% (n = 23) of analysts thought that a national kit would help streamline the analysis or paperwork processes in their laboratory, whereas 72.6% (n = 30) were unsure or responded “no” (n = 31). One analyst felt that state-specific kits were most appropriate and stated that the best way to design a kit was through analyst and SANE nurse collaboration.
Finally, analysts were asked for recommendations for forensic science resources that would benefit SANE practitioners. Eighty-five respondents provided suggestions for texts, journals, specific articles, and websites that they thought would be good resources. A complete list of their suggestions is provided in Table 3.
Oversights and Suggestions for Improvement Identified by Analysts
The following section will outline the oversights frequently seen and suggestions for improvement made by analysts. Each oversight statement is followed by bulleted actions that would be helpful to analysts. As each state has its own nuances and SANE nurses must adhere to local protocols, state-specific comments have been omitted.
Illegible or Incomplete Documentation
Suggestions for improvement from analysts:
• Thoroughly label all pieces of evidence.
○ Location sample taken from
○ Suspected body fluid
○ Reason for collection
• If sample is not collected, document reasoning.
Documentation information assists the analysts in performing the correct test on the sample the first time preventing unnecessary testing, which can waste a valuable portion of the sample and increase costs. Analysts recommend that nurses take the time to be thorough when documenting. A great deal of insight is gained through the narrative documentation, as analysts do not have access to the medical record or the victim.
Suggestions for improvement from analysts:
• Be mindful of spelling and grammatical errors.
• Transcribe patient’s name, medical record #, or kit # accurately.
• Do not refer to medical record documentation in lieu of narrative.
• Ensure accuracy in documentation of items collected.
Quality of Evidence Collection
When listening to the patient’s recounting of events, the nurse will use critical thinking to decide what evidence should be collected. When unsure if a sample should be collected, analysts believe it is better to collect it than risk losing potentially probative evidence. When obtaining, preparing, and packaging samples, analysts asked nurses to remember the following guidelines.
Suggestions for improvement from analysts:
• Use enough force to transfer cellular material to the swab.
• Body surface area collection requires more vigorous swabbing.
• Collect pediatric evidence as thoroughly as adult/adolescent.
• Consider secondary and/or potential touch evidence.
○ Areas where perpetrator’s saliva may be present:
□ kissed or licked areas; and
□ bite marks
○ Areas of fluorescence seen with alternative light source
• Lubricants used during speculum insertion may
○ prevent swabs from drying thoroughly;
○ promote bacteria growth; and
○ interfere with trace analysis for condom lubricant
• Do not collect too many swabs from one area.
○ Dilutes sample and analysts prefer concentrated sample.
○ If more than one swab from an area is needed
□ document the order in which swabs taken
• Making slides or smears1*
○ Place dime- to penny-sized circle of material in center of slide.
○ Do not cover any writing, shading, or frosted areas.
• Collecting urine or blood samples (suspected drug facilitation)
○ Document substances taken/used within past 96 hours.
□ Prescription medications
□ Nonprescription medications
□ Illicit drugs
• When packaging evidence
○ If placing more than one swab in same box, face in same direction (prevents analyst touching tips when removing).
○ Package all swab boxes in separate envelopes, label, and seal.
○ Allow wet items time to dry before packaging.
○ Do not package evidence in plastic bags (fosters bacterial growth, rendering samples unsuitable for analysis).
○ Package clothing items separately to prevent cross-contamination.
○ Do not attempt to force all items into the kit box.
□ Seal larger items in separate bags outside of kit (decreases risk of sample damage).
○ Seal the kit properly.
Legibly sign full name with credentials.
□ Initial over all tape seals.
○ Maintain chain of custody.
Positive and constructive feedback has long been used as a way for nurses to improve the care they provide to their patients. In the field of forensic nursing, SANEs can improve their practice by gaining feedback from many sources, including patients, SANE colleagues, and forensic analysts.
Most feedback mechanisms described by analysts surveyed were checklists. The receiving analyst fills out the checklist and returns it to the SANE coordinator or program director. The forms are then forwarded to the SANE nurses. These forms address topics such as proper collection and labeling of samples, whether biological screening produced results, and information regarding chain of custody integrity. Many also provide a section for comments.
Other analysts described the use of a prepaid postcard system or an e-form that is returned, via e-mail, to the nurse who completed the kit. One state utilizes a secure feedback system developed through interagency cooperation (Lopez-Bonasso & Smith, 2006) to track trends and collect information pertinent to its program.
It should be noted that these feedback forms are not considered case related, are not discoverable, and are not placed in the case file. Most analysts also have the option of directly contacting the SANE nurse via telephone or e-mail with any questions or concerns.
In addition to these forms, many programs host a monthly meeting or an annual conference where nurses, program coordinators, and analysts can share opinions through open communication. Crime laboratory tours and lectures are provided during these events to ensure everyone is aware of new developments that could lead to areas of improvement or challenges that may cause confusion. Many analysts also stated that they were actively involved in their state’s SANE educational program.
The common thread woven through all of the information regarding feedback was communication. Open communication, constructive comments, and positive reinforcement were listed as extremely important aspects of a feedback mechanism. It is recommended that SANEs form a relationship with the crime laboratory, because as one analyst wrote, “(They) are here to help!” Every professional involved with the evidence wants to ensure the best possible analysis for the victims.
Many analysts commented on the desire for more continuing education and competency-based evaluations for all SANE nurses, regardless of years of experience. Analysts would also like to see information on the longevity of DNA evidence and updates on new DNA technology become part of the SANE educational requirements. A few analysts felt that developing a system for nurses to review prior cases, including evidence analysis results and case outcomes, could be beneficial.
Although the authors were unable to gain participation from forensic analysts in every state, the information presented may be valuable to SANE nurses throughout all areas of the United States. The suggestions from the forensic analysts are not geographically based; every SANE can use these suggestions to better his or her practice.
On the basis of the findings of this study, analysts thought SANE nurses provided quality evidence collection and documentation, within the appropriate time frames, in most cases when a sexual assault kit is completed. This supports previous research (Burgess et al., 2006; Ledray, 2001; Ledray & Simmelink, 1997; Lewis-O’Connor, 2009; Littel, 2001; Sievers et al., 2003). Guidance taken from the narrative documentation by analysts was also supported (Burg et al., 2011) by this study.
Many analysts wrote positive comments about their SANE nurse colleagues. Analysts remarked how much they truly appreciate the difference SANE nurses make in the collection of evidence, further stating that these nurses fill a valuable and essential role and are considered a terrific asset to the process. Many thanks were extended to all SANE practitioners for their attention to detail and commitment to excellence.
The analysts identified two main areas of improvement and provided numerous actions to address these. It was also suggested that SANE programs develop a strong relationship with the local crime laboratory and maintain open communication with the analysts through a feedback mechanism. Cultivating an open communication relationship is essential and helps ensure continued excellence in the care of sexually assaulted patients.
The National Protocol for Sexual Assault Medical Forensic Examinations recommends the use of standardized sexual assault kits within jurisdictions (U.S. Department of Justice Office on Violence Against Women, 2004). Although it is beyond the scope of this project, it is possible that every state in the nation has a different kit, which means there could be at least 50 kits currently in use in the United States. Some laboratories may receive kits from other states, if the hospital where a kit is completed is close to the border of another state where the assault occurred.
It is possible that nurses who work in hospitals close to a state border have to remain competent in handling sexual assault kits from multiple states. In this study, most analysts were unsure if a national kit would increase the quality of evidence collected because of increased consistency for nurses working in bordering states who may deal with more than one kit. Only a minority believed a national kit would help streamline the analysis or paperwork process. Because different crime laboratories have different capabilities, many analysts believe a national kit could dramatically increase the workload of the laboratory, leading to an increase in case backlog and a decrease in the quality of analysis. All of these would translate into an increase in laboratory costs. The suggestion that forensic analysts and SANE nurses collaborate on kit development would ensure kits are designed that consider crime laboratory policies, capabilities, and evidence collection time frames but also allow for valuable nurse input.
One of the limitations of this study was that the design included a convenience sample of analysts. Respondents did not represent all states in the United States, and because of the lack of identifiable data, it is not known which states were omitted from the analyses.
The authors believe this to be the first study of a national sample of forensic analysts and their perception of the quality of SANE nurse evidence collection and documentation. Further research could measure if the suggested collaborative meetings, educational resources, conferences, and feedback mechanisms further increase the quality of evidence collection and documentation, as believed by analysts.
Implications for Clinical Forensic Nursing Practice
The most important implications to the future of clinical forensic nursing practice include improved relationships with analysts, higher quality evidence collection, and ultimately, improved patient care. The timeline will be determined by each SANE program, as the implications will vary according to which suggestions are integrated into existing practice. For example, some programs may already host annual conferences or possess a strong continuing educational program. Analysts’ comments are provided in an effort to offer new ideas for all programs to review and tailor to their own needs.
If SANE programs wish to cultivate new or existing relationships with their forensic analysts, direct and open communication is key. Programs should consider coordinating an annual conference or monthly meetings with analysts in an effort to capture negative trends and make immediate changes to combat them. Developing a constructive feedback mechanism may help foster SANE nurses, ease the workload of analysts, and does not interfere with the legal process.
Programs can request analyst involvement in SANE trainings and investigate pertinent forensic science resources. By keeping abreast of new technology and fostering continuing education, SANE programs can work with analysts to tailor sexual assault kits to meet the needs of all involved. Setting up crime laboratory tours may help nurses better understand what type of testing is done on samples and how they can document more detailed information to assist in the process. While at the crime laboratory, nurses may request a demonstration of how the analysts prefer slides and smears be prepared.
All of these actions can only serve to strengthen the SANE nurse community and improve the quality of care delivered to all sexual assault patients. By implementing all or some of these changes, SANE coordinators and program directors can foster growth of individual nurses, thus strengthening their program as a whole. More questions will be raised by these clinicians, leading to more research. Evidence-based practice and research specific to forensic nursing will lead to practice changes and further development of the field.
SANE nurses provide valuable care to their patients during a vulnerable and stressful time. In addition to receiving compassionate nursing care in a safe environment, victims and suspected perpetrators alike may find comfort in the knowledge that a qualified, caring practitioner collected the potential evidence. These pieces of evidence, including narrative documentation, may become exhibits in future court proceedings. The results of this research can help forensic nurses further improve the quality of their evidence collection and documentation, which may play a role in the eventual case outcome.
SANE examinations are recommended for individuals who experience sexual assault, regardless of their intent to report to local police. This examination ensures the patient’s medical needs are met and evidence collection and documentation of the event can be preserved for possible future prosecution. This national survey on forensic analysts’ perspectives showed that SANE nurses are highly respected and valued for the quality of their evidence collection. Suggestions for improvement and educational resources were provided, which will enhance the quality of evidence collection and provide professional development opportunities. Suggestions for collaboration and exemplars were provided that will enhance the relationship between analysts and SANE nurses, which will ultimately improve the care provided to patients who experience sexual assault.
The authors would like to thank criminalist Kevin McMahon, MS, for his assistance with instrument development; Mary Jo Slattery, MS, RN, for her review of the manuscript; and each of the survey respondents for their assistance with data collection and for their ongoing collaboration with forensic nurses.
© 2014 by the International Association of Forensic Nurses. All rights reserved.