The purpose of this research was to explore Sexual Assault Nurse Examiners’ perceptions of funding challenges faced by Sexual Assault Nurse Examiner (SANE) programs. In the mid-1970s SANE programs began as a response to the criticism that rape victims received insensitive and inadequate treatment in Emergency Rooms. SANEs are specially trained forensic nurses who provide sexual assault victims with emotional support, medical care, and quality, timely collection of forensic evidence (Boykins, 2008; Brown, 2010; Campbell et al., 2005; Emergency Nurses Association, 2007; Ledray, 1999; Lewis-O-Connor, 2009). While one purpose of SANE programs is to provide objective forensic evaluation of rape victims by collecting and documenting evidence (i.e., hair, pubic hair, blood, saliva, scrapings from under fingernails) (Littel, 2001; Houmes, Fagan, & Quintana, 2003; Taylor, 2002), photographing injuries, and conducting a pelvic exam (Ledray, 1995), SANE programs have many functions that extend beyond evidence collection (American Nurses Association/International Association of Forensic Nurses (ANA/IAFN), 2009; Speck, 2005). SANEs also provide general medical treatment and evaluation, explain the examination procedure to victims, and provide victims with prophylactic treatment for pregnancy, HIV, STDs, and other medical and counseling referrals when necessary (Ahrens et al., 2000; Brown, 2010; Littel, 2001; Plichta, Clements & Houseman, 2007; Taylor, 2002). Furthermore, SANEs provide victims emotional and social support, and crisis intervention during the exam (Taylor, 2002), as well as courtroom testimony for cases that reach trial (ANA/IAFN, 2009; Ledray, 1995; Speck, 2005). As explained by the ANA/IAFN (2009):
Another distinctive aspect of the SANE role is the use of a humane and legally objective approach that integrates advocacy and observation, evidentiary collection, mitigation of and protection against adverse health outcomes, including vicarious trauma, and location of community resources to support the victim (p. 5).1
With over 600 SANE programs nationwide (IAFN, 2010; Ledray, 2010), most of which are hospital based (Campbell, 2004), specialized treatment for sexual assault victims has become more common. This is not surprising given that the number of sexual assault victims seeking care in emergency rooms has increased (CDC, 2005). Sexual assaults represented 8% of all nonfatal violence-related injury visits to emergency departments for females in 2008 (CDC, 2010a), and sexual assault was the third leading cause of nonfatal, violence-related emergency department visits for women (CDC, 2010b).
Although SANE programs are now more common, they face many challenges caused by lack of funding. While previous research has detailed the benefits of SANE programs (see Burgess, Lewis-O'Connor, Nugent-Borokove, & Fanflik, 2006; Campbell, 2004; Lewis-O'Connor, 2009; Nugent-Borokove, Fanflik, Troutman, Johnson, Burgess, et al., 2006), relatively little is known about the actual problems encountered by SANE programs that face funding challenges. Unlike previous research, this current study examines the funding problems faced by SANE programs through the eyes of Sexual Assault Nurse Examiners. While previous research has explored various challenges faced by SANE programs, including funding, these studies were limited to SANE program coordinators (Logan, Cole, & Capillo, 2007; Speck, 2005). This current research includes the perspectives of those working as SANEs as well as those who have dual roles, as SANEs and as directors of programs. As noted by Logan, Cole and Capillo (2007), “[T]alking to a nurse who is not the coordinator may provide a different picture of the program” (p. 33). Also, unlike previous research that includes programs that were started by rape crisis centers (Ahrens et al., 2000), this research includes programs that were started by hospitals as well as prosecutors’ offices and a state agency.
Review of literature
Although the first SANE program began 35 years ago, programs continue to have difficulties, and nurses continue to address various challenges. One key challenge is funding. Since securing adequate funding is essential to SANE programs (Campbell, 2004; Ledray, 1999; Littel, 2001), programs diversify funding sources (governmental funds, hospital donations, fundraising, and/or money from nongovernment agencies and other grants) (Ahrens et al., 2000; Hatmaker, Pinholster, & Saye, 2002). However, many SANE programs have faced budget cuts (Campbell, 2004).
The first federal legislation to combat violence against women, the Violence Against Women Act (VAWA), was passed by the United States (U.S.) Congress in 1994 (and reauthorized in 2000 and 2005). Vice President Joseph R. Biden, Jr., who was a Senator for Delaware and Chairman of the Senate Foreign Relations Committee at the time, helped draft, sponsored, and introduced VAWA to Congress. This groundbreaking legislation assisted victims of domestic violence, sexual assault and stalking. The U.S. Department of Justice (USDOJ) distributed funds for criminal justice initiatives, while funds distributed by U.S. Department of Health and Human Services supported social support programs as well as rape prevention and education (Boba & Lilley, 2009). One of the largest parts of VAWA, the Services and Training for Officers and Prosecutors (STOP) Grants Program, provides federal funding to promote community change for victims of sexual assault/rape, domestic violence, and stalking, and increases collaboration among agencies that serve victims.
When VAWA was passed in 1994 it allocated a total of $1.6 billion over 6 years (1994–2000). When reauthorized in 2000, a total of $3.33 billion was allocated over the next 5 years. When reauthorized in 2005, a total of $3.93 billion was allocated for 2005–2011, and funding allocated to STOP grants was increased to $225 million per year (2007–2011) (National Coalition Against Domestic Violence, 2006). In addition to funds provided by VAWA, the Victims of Crime Act (VOCA) Crime Victims Fund was created in 1984, and is funded by Federal criminal fines rather than taxpayers’ dollars. The VOCA Fund serves victims of various crimes including rape. Of the approximately 3.8 million victims served by VOCA-funded victim assistance programs, only 16% are victims of sexual assault or abuse (National Association of VOCA Assistance Administrators, 2008a).
Research has concluded that VAWA is successful because it averts the costs associated with rape (i.e., costs of medical and mental healthcare, social services, police investigation) (Clark, Biddle, & Martin, 2002), and may reduce rape (Boba & Lilley, 2009). While Clark et al. (2002) analyzed all assault and rape data from the National Crime Victimization survey, Boba and Lilley (2009) examined rape and aggravated assault data from 1996 to 2002 for 10,371 jurisdictions in the U.S. that received VAWA funding. Even after controlling for other federal funds received by these jurisdictions and demographic factors that influence crime (i.e., employment rate, income), Boba and Lilley (2009) concluded that VAWA funding is associated with the reduction of rape and aggravated assault; this may be due to the deterrent effect of tougher enforcement, stricter penalties and increased incapacitation of offenders who are violent against women. The improvement of services resulting from VAWA could have increased victim reporting and therefore increased prosecution (Boba & Lilley, 2009). Although Boba and Lilley (2009) explain that they are unable to determine whether VAWA funding caused the decline in rape and aggravated assault or was simply correlated with such reductions, the data they analyzed suggests the importance of VAWA funding in reducing rape and aggravated assault because other Uniform Crime Report Part 1 offenses did not decline in the jurisdictions over the same period of time.
Despite funding provided by VAWA and VOCA, programs assisting victims have experienced funding reductions at both the state and federal levels. Between 2006 and 2008, VOCA assistance grants had been reduced by $87 million (22%). This has resulted in the need for programs that assist crime victims to close or cut services, reduce hours or caseloads, and lay off staff (National Association of VOCA Assistance Administrators, 2008b). Based on Congress's 2009 request, state assistance grants would face an additional reduction of $53 million or 18% (National Association of VOCA Assistance Administrators, 2008a). This would total a 40% reduction in VOCA assistance grants since 2006. This reduction directly affects SANE programs that receive federal funds through state grants under VOCA to help cover victims’ exam costs (National Center for Victims of Crime, 2007). Moreover, SANE programs are expensive to start and maintain. For example, one state estimated that starting a statewide program could cost an estimated $275,000 (Connecticut Sexual Assault Crisis Services, 2009). The 2009 fiscal year spending for one statewide adult and pediatric SANE program totaled more than 3.5 million dollars (Sexual Assault Nurse Examiner and Pediatric SANE Program, 2010). Programs can also be a financial burden for hospitals that support them (Kois, 2008). Equipment necessary to conduct forensic examinations is costly (Houmes, Fagan, & Quintana, 2003; Scales, Lewchick, Bauer & Kiljanski, 2007), as is training for SANEs (Houmes et al., 2003). For example, the subsidized statewide training program in Michigan costs hospitals about $500 per nurse (Kois, 2008).
Although problems recruiting and retaining SANEs result from time commitments (Hatmaker et al., 2002), lack of financial incentives and funding for conferences and training is also problematic (Sievers & Stinson, 2002). Also, many times, SANE pay does not equal the standard for RN pay. SANEs tend to be paid a flat fee for on-call time and additional money (i.e., flat fee, time and a half pay) to examine and treat a victim and collect forensic evidence. Salaries/pay vary widely (Houmes et al., 2003). For example, nurses working for a Pennsylvania hospital receive $2.50 an hour to be on-call and receive their regular hourly pay to conduct an exam (Scales et al., 2007). Most SANEs work part-time as SANEs and have other employment in the nursing profession to supplement their incomes (Ledray, 1997; Lenehan, 1991; Seng, Sanubol, & Johnson County (Iowa) SANE Team, 2004). Insufficient and inadequate funding ultimately affects recruiting and retaining SANEs.
The limited literature that explores the funding of SANE programs concludes that lack of funding is a problem. Logan, Cole and Capillo (2007) surveyed 231 SANE programs and found that 59% indicated lack of funding is a major problem. Campbell et al. (2006) questioned the most experienced SANE from 110 SANE programs and found that victims were not consistently offered HIV testing and prophylaxis due to funding. Although victims have the right to receive HIV testing and prophylaxis regardless of whether the exam in conducted by a SANE, Campbell et al. (2006) found that many programs do not offer this because of its costs and instead refer victims to the health departments that also provide testing and prophylaxis. Other research indicates that lack of funding affects rape crisis centers by creating problems with staff recruitment and retention, and reducing or eliminating advocacy and counseling services provided to rape victims and community outreach (Macy, Giattina, Parish, & Crosby, 2009; Maier, 2011; Schauben, Frazier, & Vicarious, 1995; Ullman & Townsend, 2007).
Whether evidence is collected and whether the victim is held financially responsible for evidence collection and medical treatment may be determined by whether the victim reports to the police (Logan, Cole, & Capillo, 2007; Monroe et al., 2005). The Violence Against Women Act requires states to offer free forensic medical examinations in order to qualify for federal funds (Ahrens et al., 2000). However, Monroe et al. (2005) interviewed 125 rape victims in Maryland and 60% reported not being charged for the exam, which raises the possibility that Maryland hospitals are not complying with VAWA's requirements.
Other states prohibit victims from being held liable for treatment contained in the examination or evidence collection of forensic evidence but victims could be held liable for treatment of other injuries caused by the rapist (i.e., x-rays for broken bones) (Houmes et al., 2003). The bottom line is that victim reporting to the law enforcement determined if victims received a forensic examination or medical attention, and whether they were held financially responsible for such care (Resnick et al., 2000). Of the 231 SANE programs surveyed by Logan, Cole, and Capillo (2007) over half (56%) reported that only cases with police involvement were eligible for medical forensic examinations. In Michigan, victims can apply for compensation from the state if they did not have health insurance, but only if they reported the crime to police within 48 hours (Ahrens et al., 2000). Maryland is slightly different, requiring victims to file a police report to receive a free forensic evidence exam and medical treatment directly related to the sexual assault (Monroe et al., 2005).
Much changed in January 2009 (after this research was conducted). In order to continue to receive federal money provided under the Violence Against Women Act, states are now required to pay for “Jane Doe” rape kits (Scheck, 2008). The Violence Against Women and Department of Justice Reauthorization Act of 2005 (“VAWA 2005”) provides that states may not require sexual assault victims to participate in the criminal justice system in order to be provided with a forensic medical exam, or be reimbursed for charges resulting from the exam (U.S. Department of Justice, 2008). The SANE program or hospital determines the procedures that comply with the legislation. A sample procedure may include the following steps: evidence is collected, sealed in an envelope and identified by a number; the evidence is securely stored; and if the victim later decides to press charges, the envelope is then opened and the police are notified. There are benefits to this procedure. The victim is not forced to make a decision about reporting to the police at that immediate time when she or he is being treated at the hospital, and in the case that the victim changes his or her mind and wishes to report later, the evidence has already been collected (Ledray & Kraft, 2001). However, it remains unclear how much of the costs will be passed down to hospitals. Research conducted prior to this change found then when state or federal funding does not cover costs associated with medical forensic sexual assault examinations, there could be a “significant financial drain” on SANE programs (Ledray & Kraft, 2001, p. 397). Even if the state or county does provide funding, the costs hospitals incur to treat victims is often greater than the funding provided (Ahrens et al., 2000; Ledray, 1999).
While research indicates that SANE programs face funding challenges (see Campbell et al., 2006; Logan, Cole, & Capillo, 2007; Speck, 2005), the purpose of this research is to continue to explore the funding problems faced by SANE programs through the eyes of Sexual Assault Nurse Examiners. This research includes the voices of those working as SANEs as well as those who have dual roles both as SANEs and directors of programs, and compares the perspectives of SANEs working for programs started by hospitals, prosecutors’ offices, and a state agency.
Recruitment of participants
After review of the existing literature, an interview guide was developed. Prior to recruiting participants, the research was approved by the University's Institutional Review Board. The authorization to solicit participants for this research was in effect from October 3, 2006 to October 3, 2007. Beginning in October 2006, 78 letters or e-mails explaining the research and requesting participation were sent to directors/coordinators of Sexual Assault Nurse Examiner programs in four states, which will remain confidential, and will be referred to as States A, B, C, and D. SANE programs were selected after review of the programs listed in the database of the Sexual Assault Resource Service, funded by the U.S. Department of Justice's Office for Victims of Crime and the U.S. Department of Commerce's National Telecommunications and Information Administration (www.sane-sart.com). Letters or e-mails requesting participation were sent to all 78 programs listed on the SANE-SART website. All directors who responded to the e-mail stated that they forwarded the request to other SANEs, announced the research at staff meetings or trainings, or passed along the information through word-of-mouth. Because of the method of recruitment used, I was unable to determine a response rate. To be included in the research, participants had to be trained SANEs, 18 years of age or older, a SANE for three months or longer, and have at least one experience with a rape victim in the past year.
The four states were selected because in 2003 and 2004 I interviewed rape victim advocates from these four states. When expanding my research to include the perceptions of Sexual Assault Nurse Examiners, I included the same four states not only because of geographical convenience but also because of a general familiarity with the treatment and processing of victims in those states and because of the variety of ways SANE programs are organized in these states. In State A, the programs are funded by grant money, fundraising efforts, and primarily through hospital support. Each program is hospital based. In State B the programs are funded by a state agency and each region of the state has a coordinator. Programs are not hospital based. In State C the programs are funded by the state and county, as well as federal grant money. Programs are run out of county prosecutors’ offices and are not hospital based. In State D, the programs are funded by hospitals and are hospital based. Because of these differences, comparisons can be made (See Table 1).
At the time of the research, the compensation procedures for the four states also varied. In States A, B, and D, the victim's private insurance is billed first; in State C, the victim's private insurance is not billed first and the statewide SANE Program Fund administered by the Attorney General paid for the forensic examination even if the victim did not report the rape (American Prosecutors Research Institute, June 2006). In State A the state Victim Compensation Fund will pay for the exam that must be done for collecting evidence to be used in prosecution if the victim's insurance does not cover the cost. Previously, the Compensation Fund only paid if victims reported to police, but since SANE programs now receive federal funding (VAWA) victims do not have to pay for the kit or medical attention even if they don't report. In State B, although victim's private insurance is billed first, they are not required to report to the police in order to have a forensic examination completed.2 In State D, there was some confusion among SANEs in State D regarding who pays for the forensic examination if the victim does not report to the police. Several SANEs from State D explained that if the police are not involved a forensic examination is not completed because they do not have a secure location to hold the evidence.
Interviews and interview guide
Interviews were conducted between October 2006 and April 2007. Interviews ranged from 45 minutes to 1 hour and 45 minutes. The average interview lasted 1 hour and 15 minutes. All interviews were conducted over the phone for convenience—either to accommodate the SANE's preference or due to distance. All participants were required to sign a consent form. Most interviews were tape-recorded upon the participant's consent. Only one respondent declined to be tape-recorded so extensive notes were taken during the interview. Participants were compensated with gift cards to an establishment local to them (i.e., Starbucks, Panera). All SANEs were given $10 gift cards as a token of appreciation for their time, and SANEs who were also serving as directors of programs were given $15 gift cards because they were asked additional questions about the organization and funding of programs.
Although the focus of this paper is on SANEs’ perceptions of funding issues faced by SANE programs, the interviews consisted of approximately 70 open-ended questions about: training to become a SANE; roles and responsibilities as a SANE; perceptions of rape, rape victims and rapists; perceptions of multicultural or multiethnic issues surrounding rape; SANEs’ assessment of their interaction with Emergency Department doctors, rape victim advocates, police, and prosecutors; and SANEs’ perceptions of the revictimization of rape victims by the criminal justice, legal, and medical systems (see also Maier, 2011b). Directors of programs were also asked about the history of their SANE program, the past and present mission of the program, how the program has changed over time, how SANEs are recruited, and if there are problems with SANEs “burning out.” Data for this manuscript primarily come from the following questions asked of all SANEs: Are you aware of budget cuts or financial struggles faced by the SANE program? If so, what is the extent of the problem? Directors were also asked: How is the program funded? Are services provided or functions that the program serves ever tied to funding requirements or satisfying bureaucratic exigencies? Is there ever competition among agencies for funding? Has the program been affected by decreases in public funding? If so, how has it been affected by these changes and how is the program handling the reduction in public funding?
Description of sample
Forty SANEs were interviewed; 17 also serve as directors or coordinators of programs, and one served as a director of a program but resigned 10 months prior to the interview. Of the 40 SANEs, five were from State A, seven were from State B, 15 were from State C, and 13 were from State D. Of the 18 SANEs who also served as directors, four directors were from State A, two were from State B, five were from State C, and seven were from State D. There were fewer participants from States A and B because those states had fewer SANE programs.3 Data represent the views of SANEs treating sexual assault victims at 43 hospitals in four states. The sample was between the ages of 21 and 62 years of age (mean, 45 years old; median, 46.5 years old). Refer to Table 2 for a description of the sample.
I transcribed most interviews verbatim with the help of five undergraduate research assistants. After interviews were transcribed qualitative analysis began. Analysis included several steps including open coding and axial coding (Miles & Huberman, 1994; Strauss & Corbin, 1990). This first stage of analysis is referred to as open coding as it is the researcher's intent to “open up the data to all potentials and possibilities” (Corbin & Strauss, 2008, p. 160). At this stage, core themes were identified based upon multiple readings of the interview data (see Patton, 1990; Rubin & Rubin, 1995). Themes were simply ideas or phrases that appeared in multiple interviews. The more frequently the same concept occurs in a text, the more likely it is a theme (Ryan & Bernard, 2003). All codes were written in the margins of the transcripts. These initial codes allowed me to better manage the data. Following the initial review of complete transcripts, I focused on questions asked specifically pertaining to SANEs’ perceptions of funding issues. As Miles and Huberman (1994) stress the benefits of a clear display of data, I copied and pasted all data pertaining to funding into one document Codes were re-written in the margins and at this time I used different colors to highlight text. Codes were also further developed at this time. For example, rather than just indicating whether the participant mentioned that funding was a problem, I also developed codes that would better manage the data. Therefore, “PROBLEM” was changed to “PROBLEM-SUST” to indicate the participant believed lack of funding was jeopardizing the sustainability of the program.
In order to systematically analyze the data and compare the responses of SANEs and directors/coordinators from the four states, the next stage of the analysis was completed using axial coding (Miles & Huberman, 1994). At this stage I attempted to make connections within the data. All responses about funding were copied into a table that also listed the respondent's position, the state where she worked, and how the SANE program was funded (state funded; hospital funded; funded by prosecutors’ offices). This allowed me to easily recognize similarities and differences in data gleaned from interviews with SANEs working in four states.
Qualitative research is more appropriate for this research since respondents were asked not only to discuss if their program has faced challenges due to lack of funding, but if so, the ways programs have been impacted on a routine basis. In qualitative research the meaning of the data, rather than frequencies, is important. However, some descriptive quantitative findings can also be found in the results section. One of the strengths of this research is that I was able to compare SANEs who reported funding challenges to those who did not. As previously stated, some of the comparisons I was able to make are related to whether they worked for programs funded by hospitals, a state agency, or a prosecutor's office, or if the SANE also served as a director of a program.
Perceptions of funding problems
Directors and SANEs not serving as directors were asked if the program faced any problems with funding. Most directors (72%) and slightly more than two-thirds (36%) of SANEs not serving as directors indicated there were problems with funding. It is important to recognize that most (72%) directors believed funding was a problem at least to an extent; it is possible that SANEs not serving as directors were simply not aware of budget cuts or financial struggles faced by the program because the funding of the program is not their responsibility. Conversely, given that budget issues are not the responsibility of SANEs not serving as directors, it is surprising that 36% are unaware of financial struggles.
A few of the directors who indicated funding was a problem also explained why funding was an issue: budget cuts at the state and national level for all social services and lack of political interest in sexual violence. For example, Krista (all names are pseudonyms), a director in State D (hospital funded) explained that she believed that the reduction in grant money reflected a lack of government interest, “You have this peak where there is a lot of government support and things are going along well and then the interest moves to another focus.” Mary, a director from State C, agreed, “It comes down to what the politicians think is important and what they vote on.”
Table 3 highlights the participants’ perceptions of whether funding is a problem by position (director of program or SANE not in director position) and the state where the respondents work. Since programs are managed and funded differently in these states, directors in some states may be more likely than directors in others to note funding struggles. First, it is clear that directors are more likely than SANEs not serving as directors to note funding problems. Second, SANEs working in State D, where programs are funded by hospitals and SANEs do not engage in fundraising, were less likely than SANEs working in other states to indicate funding is a problem.
Concern for future funding
Several directors were vocal about their concerns about the sustainability of programs. Hospital administrators evaluated whether programs are valuable based on the money they bring in to the hospital, costs to hospitals, and number of patients treated. Lucille, who is a director in State A where the programs are primarily funded by hospitals, reflects, “They [administrators] routinely compare me to the trauma program who sees 500 patients a year easily and I see from 40 to 60.” Debra, another director in State A, agrees:
A new administration could come in and say that this is not important and it is a frivolous program because it has not much to do with patient care and everything to do with judicial care. Hospital based programs are all about the money. Unless we are making money we are not considered valuable. When you have a program that is hospital based then you are always at risk at any time not to have it.
While directors of hospital-based programs worry about new administration, directors of programs that rely on state funding worry about how political change could affect the sustainability of programs. Mary and Catherine, who both worked in State C where programs are funded by county prosecutors’ offices, worried that the county at some point was going to stop funding the program. Janeen, a program coordinator in State B where programs are funded by a state agency, also worried about sustainability: “With a state agency you know that governors change, so every four years we sometimes have to worry about where our funding is coming from.”
Eliza, also a program coordinator in State B agreed, “With state funding, with each new budget that comes out you are always hoping for the best.” Regardless of funding source, sustainability could be an issue for some programs according to directors included in this research. Most SANEs not serving as directors did not reflect on sustainability concerns.
Impact of current lack of funding
Directors as well as those not serving as directors commented that lack of funding has reduced the ability to provide both community education/outreach as well as continuing and initial education for nurses. When budgets are lacking, money tends to be dedicated to victim care rather than educating the public on sexual assault prevention or the existence and benefits of SANE programs. Sandra, a director in State A (hospital funded) who has had her hours as a coordinator cut as a result of decreases in funding, stated that securing money for education is “a big problem.” Lucille, a director from State A, agreed, “Funding has been cut tremendously. The prevention education is not there as much.” Grace, a SANE in State C where programs are funded by county prosecutors’ offices, says the reduction in funding “stinks” because there is no money for publicity, and she believed that the public is unaware of SANE programs. Jane, a SANE in State B where programs are funded by a state agency, agrees that lack of funding results in poor advertising and promotion of SANE programs. In addition, SANEs stated that with better funding resources could be printed for the community and victims.
Continuing and initial education for nurses is also unavailable or limited due to funding issues. This could result in fewer nurses being recruited to be SANEs, or receiving the initial 40 hours of SANE training, or could result in fewer SANEs receiving additional training beyond 40 hours. Gloria, a director in State C where programs are funded by prosecutors’ offices, believes lack of funding limits continuing education for nurses:
We have a very limited source of funding for continuing education. With the grants we are provided a total of $2,000 a year for continuing education for the nurses and there are 13 of us now. I think it's a problem how limited we are.
Furthermore, as explained by Catherine who is also a director in State C, without adequate funds, SANEs may not be able to attend training or conferences they need for professional development. This is important given that forensic nursing is a developing field. Lastly, a few SANEs mentioned that if programs did not face funding challenges, they could provide more education to police officers and doctors on how to best respond to victims.
Compensation for SANEs
Several SANEs reflected that they should be compensated better for their time. It is important to recognize that SANEs were compensated differently for their work. Some were paid a flat rate to be on call, to respond to a call, and to collect evidence from a victim. Others were paid to be on-call and then receive time and a half (of their regular hourly pay) to respond to a victim. A few SANEs (all from State B where programs are funded by a state agency) were paid more ($12 an hour) than other SANEs to be on-call, but did not receive additional compensation for the first victim they responded to. If they responded to a second victim in a 12-hour period, they received $200 for that case. A few SANEs were paid a flat salary by the hospital or prosecutor's office, or paid a flat rate for cases without on-call compensation. When asked why they wanted to become a SANE, only one mentioned a monetary incentive.
Not only did several SANEs reflect that they should be better compensated, they also stated that if programs provided them with the time and compensation to follow-up with victims after they left the hospital, SANEs could ensure victims received continued care and prescribed medications (STDs or HIV prophylaxis).4 Many of the SANEs who commented on the lack of compensation worked in State C where programs are funded by prosecutors’ offices. At the time of the study, SANEs in State C received from $2.00 to $4.00 an hour to be on-call during weekdays, $4.00 an hour to be on-call overnight or on weekends or holidays, from $75 to $100 if they reported to the hospital but a victim changed his/her mind after the SANE arrived, and from $250 to $300 per completed case. SANEs in State C were not paid for staff meetings or to testify in court, which could be quite time consuming. Gloria, a director in State C, believed nurses were not compensated adequately for their time. Michelle, a SANE in State C, simply stated, “We should get better pay.” Carolyn, also a SANE in State C, agreed, “An improvement would be more compensation. Right now it is below the minimum wage for on-call and it requires a lot of time.”
Molly, a SANE in State C, explains:
There is no financial incentive to give time if there is coverage that is needed because now nurses make decent money. SANEs are not compensated enough and they would be more apt to further their education if there was reimbursement. It is disheartening to me that there is no financial reimbursement. Some cases take 7 or 8 hours and it is one flat rate.
Without adequate compensation, there is no financial incentive for nurses to complete SANE training, or for SANEs to cover shifts.
Other issues that result from lack of funding
A few SANEs mentioned that better funding could lead to better equipment to treat victims. For example, Rebecca, a SANE in State D (hospital funded), commented that lack of funding prevented programs from purchasing their first choice of equipment. Frances, also from State D, explained:
We just had about a year-long battle so that we could get a grant and buy equipment that actually works and would benefit our patients. The hospital would not support us so we had to find alternate means of budgeting.
Other SANEs commented that better funding could allow for the implementation or expansion of programs, such as pediatric SANE programs. Lastly, according to SANEs included in this research, dedicated SANE rooms/wards should be constructed in Emergency Departments (EDs), which could be costly.
This research found that most (72%) directors interviewed believed that funding for their SANE program was problematic. In addition, 36% of SANEs not serving as directors of programs also believed funding was a problem for their program. Given that budget issues are not the responsibility of SANEs, it is surprising that so many are aware of financial struggles, although it is possible that directors share this information with SANEs. Directors are also concerned about program sustainability. While directors in State D, where programs are funded by hospitals, were less likely than directors in other states to report that funding was a problem, funding was problematic regardless of how programs were funded. When programs rely on grants or government funding, they face problems when state or federal budgets are reduced or they lose support from politicians. On the other hand, when programs are funded by hospitals, they face problems when they lose support from hospital administration. Directors of hospital-funded programs must always justify the program since most hospitals are profit-driven. Programs can be a financial burden for hospitals that support them (Kois, 2008; see also Speck, 2005). If victims are uninsured and do not report to the police, it is possible that the hospital absorbs the cost for the forensic examination, including the nurse's salary and cost for any prophylactic treatment. Research supports that these nonreimbursable costs can financially drain SANE programs and hospitals (Ledray & Kraft, 2001; Littel, 2001). In light of the recent economic downturn and the implantation of the Affordable Care Act, there may be even more concerns as efficiency, service coordination, and cost containment are going to be essential.
When discussing the specific impact that lack of funding routinely has on SANE programs, research participants mentioned the inability to provide education in the community and training and continuing education for nurses. Inability to provide education in the community is particularly problematic given that researchers suggest that education could change false perceptions about rape (i.e., rapists tend to be strangers). Education could also lead to an increase in help-seeking by victims who come to believe that their experiences are similar to other victims’ experiences (Patterson, Greeson, & Campbell, 2009).
Although training nurses is expensive (Houmes et al., 2003), other research supports that lack of funding negatively impacts compensation of nurses and availability of training and continuing education (Logan et al., 2007; Sievers & Stinson, 2002). Lack of money to provide training and continuing education for nurses is problematic for several reasons. First, having enough SANEs to meet the demand of the program is essential. With an insufficient number of trained SANEs, victims are not treated as high-priority cases in Emergency Departments and often must wait several hours to receive medical or police attention (Littel, 2001; Thompson, Yarnold, Williams, & Adams, 1996). Research has found that victims treated by SANEs waited less time to be seen than victims treated by regular emergency room doctors (Stermac & Stirpe, 2002; see also Sampsel et al., 2009). In addition, when there are only a few SANEs they are forced to cover all the shifts, possibly contributing to burnout. Burnout causes them to leave their positions, creating a vicious cycle, not to mention the expense of training additional SANEs. Challenges of balancing full-time employment and personal responsibilities with the on-call responsibilities of a SANE often can lead to uncovered shifts for SANE programs. One strategy to improve staff retention is to reduce the number of shifts covered by SANEs, but more SANEs are required to achieve this goal. This is a challenge when funding for training is insufficient (Logan et al., 2007).
Second, research has highlighted the importance of training. Training improves cultural awareness and competence, essential for nurses working with patients of color (Majumdar et al., 2004). More education also results in less burnout and secondary traumatic stress (Townsend & Campbell, 2009) as well as positive experiences testifying in court (Campbell et al., 2007). Third, other research has supported the need for sexual assault education within the community (Logan et al., 2007). The fact that SANEs included in this research mentioned the inability to provide education in the community because of lack of funding is especially problematic, since 43% of this sample believed members of the community were completely unaware of SANE programs or nurses. Lastly, these SANEs also mentioned that because of budget cuts or inadequate funding, programs cannot expand (i.e., pediatric programs), and newer equipment cannot be purchased.
Although this study revealed important information about the problems with funding based on the perceptions of Sexual Assault Nurse Examiners, many of whom are in leadership positions, it also has several limitations. First, only two African American SANEs were included in this sample. This most likely is because nurses from minority groups are under-represented in general healthcare (Ahmann, 2002), and most SANEs are Caucasian (Campbell, 2005; Patterson, Campbell, & Townsend, 2006). Nonetheless, future efforts should not only attempt to include more SANEs of color in research but efforts to recruit more individuals of color to work as SANEs are also necessary. Second, a methodological limitation is that only one researcher coded the data in its entirety so it is possible that others would interpret SANEs’ responses differently. Third, it is possible that SANEs interviewed do not share the perceptions of those who chose not to participate in the research or were unaware that the recruitment for research was taking place. In addition, the sample is limited to SANEs in four states. Generalizability is limited; it is impossible to determine if these findings would have differed if interviews had been conducted with SANEs from other states or even SANEs working at different hospitals in these states.
Despite limitations, the results add to current research on SANEs and offer suggestions for future research. The Violence Against Women Act (VAWA) requires states to offer free forensic examinations in order to qualify for federal funds (Ahrens et al., 2000), and the January 2009 federal requirement states that in order to continue to receive federal money provided under VAWA, states are now required to pay for “Jane Doe” rape kits (Scheck, 2008). First, future research should explore if victims are ever billed after the January 2009 federal requirement, especially since this research found that victims in State D (hospital funded) were possibly still being billed for treatment even though VAWA requires states to offer free forensic examinations in order to qualify for federal funds. Second, although victims should never be financially responsible for any part of the forensic or medical examination, the costs of SANE programs and evidence collection kits are a reality, and more research needs to be conducted on the financial struggles of SANE programs after this 2009 change. Third, additional challenges for all SANEs and SANE programs may arise because of the Patient Protection and Affordable Health Care Act (ACA) and the Health Care and Education Affordability Reconciliation Act (2010). The ACA is expected to result in the provision of health insurance for an additional 32 million Americans who previously did not have insurance (Institute of Medicine, 2011). While it is possible that this reform will result in more people seeking medical attention in the community setting rather than the hospital (O'Neil, 2009), and may not impact the number of rape victims seeking services in Emergency Departments, the nursing profession will certainly change (Institute of Medicine, 2011). Changes could exacerbate the nursing shortage (Schmidt, 2010) and result in changes in nursing education (Benner, Sutphen, Leonard, & Day, 2009; Institute of Medicine, 2011). Although it is not possible to accurately predict the outcomes of the drastic changes to the healthcare system, future research should consider how such changes could affect SANEs and SANE programs.
In addition, given the extant literature that highlights the benefits of SANE programs to victims, doctors, prosecutors and law enforcement (Campbell, Patterson, & Lichty, 2005; Ledray & Simmelink, 1997; Littel, 2001), state and federal funding of SANE programs must increase. As indicated by Boba and Lilley (2009) VAWA funding is associated with the reduction of rape and aggravated assault. Hence, it is important not only that VAWA is reauthorized in 2011, but also that budget allocations increase. However, given the shrinking budget for all social services and our current economic recession, this may be unlikely.
While SANEs included in this research did not provide specific suggestions for improving funding, strategies used by other SANE programs and even rape crisis centers to increase funding could be helpful. For example, some rape crisis centers have reduced their funding challenges by holding fundraising events such as walks or galas, making more contacts with potential funders, and increasing collaboration with other organizations and agencies (Maier, 2011a). Logan et al. (2007) suggests that SANE programs: seek grants and services of grant writers to improve chances of receiving grants; renegotiate contracts with funding sources such as prosecutors’ offices; reach out to potential funding sources to diversify funding sources; fundraise (SANEs as well as hospital administration); solicit donations from community members and businesses, and advocate for legislation at all levels that would increase money for programs (Logan et al., 2007, p. 30). While such strategies may be helpful to SANE programs, reducing financial challenges may not be an easy task for SANE programs.
I would like to thank all of the directors and coordinators of Sexual Assault Nurse Examiner programs who helped me gain access to their SANEs. Also, this project would not have been possible without the SANEs who allowed me to interview them. This research was funded by a Provost's Grant and Faculty Development Grant from Widener University.
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1According to the ANA/IAFN (2009), a SANE is an “expert” in assessment (p. 5). This includes interaction with patients, family members, community members, healthcare providers, law enforcement agencies, and judicial systems. Assessment may also include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, cultural, and lifestyle (p. 49).
2As of January 2009, this should be the case in all states.
3The SANE-SART website listed eight hospital-based programs in State A, 16 programs managed by the county prosecutor's office in State C, and 48 hospital-based programs in State D. Programs in State B are funded by a state agency and there are six regional coordinators.
4However, it is important to recognize that most SANEs are unable to track cases after victims leave the hospital. Prosecutors discourage SANEs from following-up with victims because they do not want SANEs to appear to be biased in favor of the prosecution if called to testify (Scalzo, 2006). Lack of ability of SANEs to provide follow-up care may be problematic for victims since most are never seen for follow-up care (Logan, Cole, & Capillo, 2007).