Factors Affecting Telemedicine Implementation in Emergency Departments and Nurses’ Perceptions of Virtual Sexual Assault Nurse Examiner Consultation for Sexual Assault Survivors

Abstract

Introduction 

Emergency department (ED) nurses play a critical role in caring for sexual assault patients, but many have not received training on how to conduct a proper sexual assault forensic medical examination. Live or real-time sexual assault nurse examiner (SANE) consultation provided via telemedicine (known as “teleSANE”) during sexual assault examinations is a promising new practice to address this issue.

Purpose 

The purpose of this study was to assess ED nurses' perceptions of influences on telemedicine use, as well as the utility and feasibility of teleSANE, and identify potential influences on teleSANE implementation in EDs.

Methods 

Guided by the Consolidated Framework for Implementation Research, this developmental evaluation involved semistructured qualitative interviews with 15 ED nurses from 13 EDs.

Results 

Interviews revealed facilitators and barriers to current telemedicine use across Consolidated Framework for Implementation Research levels. Facilitators included state-level grant funding and technical assistance. Barriers included clinician discomfort being on video and access to ongoing training. Participants believed teleSANE consultation would improve patient care and forensic evidence collection but had concerns for patient privacy and acceptability. Most participants worked in EDs that have the information technology support and telemedicine equipment needed to support teleSANE implementation, although many requested ongoing education and trainings on teleSANE and sexual assault care to improve clinician confidence and account for high staff turnover.

Discussion 

Findings highlight the unique needs of sexual assault survivors receiving telemedicine services in EDs, particularly those in rural communities with heightened privacy concerns and limited access to specialty care.

In 2018, an estimated 734,630 people were victims of rape or sexual assault in the United States (^{Morgan & Oudekerk, 2019}). Emergency departments (EDs) are critical in caring for sexual assault survivors because they are often the first point of entry to care (^{Chandramani et al., 2020}). However, many EDs do not have resources in place to assist survivors (^{Plichta et al., 2007}; ^{Thiede & Miyamoto, 2021}), such as trained sexual assault nurse examiners (SANEs). SANEs are specially trained to conduct sexual assault evidentiary examinations for persons who have been sexually assaulted. Recent studies show that SANE training improves nurses' attitudes toward sexual assault patients (^{Nielson et al., 2015}) and is associated with increased likelihood of prosecution in the criminal justice system (^{Campbell et al., 2014}). However, most nurses in the United States who care for these patients are not SANE trained (^{Nielson et al., 2015}). Here, we describe the results of a formative evaluation to increase access to SANEs in EDs via telemedicine implementation in a largely rural, underresourced state.

Telemedicine and EDs

A national survey reported that approximately half of EDs in the United States had telemedicine services (^{Zachrison, Boggs, Hayden, Espinola, & Camargo, 2020}). These services are becoming more common in EDs, particularly in certain regions: By 2018, three of four EDs in New England were using telemedicine (^{Zachrison, Boggs, Hayden, Cash, et al., 2020}). Telemedicine can lower ED costs (^{Williams et al., 2020}) and provide rural patients with urgent specialty care not otherwise available (^{Thiede & Miyamoto, 2021}). However, there are many known barriers to implementing telemedicine in the ED. Barriers at the system level include cost and reimbursement (^{Scott Kruse et al., 2018}), including lack of funding, and technology issues (^{Einolghozati, 2018}). Barriers at the clinician level include challenges with technology (^{Scott Kruse et al., 2018}), resistance to change (^{Einolghozati, 2018}; ^{Scott Kruse et al., 2018}), workload and time, lack of training, concerns with liability (^{Einolghozati, 2018}), and concerns with patient privacy (^{Balestra, 2018}). Many providers also believe that they can communicate more empathy and that patients better understand and are motivated by information presented face-to-face (^{Ayre et al., 2019}). Finally, factors at the patient level include older patient age, level of education, and lack of experience with the Internet (^{Call et al., 2015}; ^{Scott Kruse et al., 2018}). Indeed, despite rapid growth in telemedicine implementation, before the COVID-19 pandemic, few Americans had used telemedicine. However, patients in rural areas are especially amenable to telemedicine (^{Call et al., 2015}).

Emergency Sexual Assault Care via Telemedicine

ED nurses play a critical role in caring for sexual assault patients, but many have not received training on how to conduct a proper sexual assault forensic medical examination (^{Nielson et al., 2015}). Live or real-time SANE consultation provided via telemedicine (known as “teleSANE”) during sexual assault examinations is a promising new practice to address this issue (^{Walsh et al., 2019}). Such a consultation service allows remote SANEs (i.e., teleSANE consultants) to provide consultation to non-SANE clinicians, as well as support to the patient, during the forensic medical examination. The teleSANE consultant can be brought into the room with the site nurse and the patient via a telemedicine cart, which includes a webcam and a colposcope. TeleSANE consultants can provide as much or as little needed assistance with forensic photography, evidence collection, resources, and continual education.

A recent systematic review identified seven studies on teleSANE programs, revealing themes impacting teleSANE implementation, including process factors (e.g., space limitations, lack of staff training, and low patient volume), patient experience and acceptance, and quality of examinations and the assistance provided (^{Walsh & Meunier-Sham, 2020}). However, only one of these seven U.S. studies included programs with adult patients; most of the programs included children and adolescents. In 2012, the Massachusetts Department of Health's National TeleNursing Center was the first to provide teleSANE services for adolescent and adult sexual assault patients in the United States. Pilot implementation at six sites in three states found that teleSANE was successful in supporting clinicians and improving the quality of sexual assault care (^{Walsh et al., 2019}). More research is needed to assess barriers and facilitators when implementing a teleSANE program and to identify strategies for larger-scale implementation.

The Current Study

To prepare for teleSANE implementation in Arkansas, as part of a program funded by the Department of Justice, we conducted a developmental formative evaluation to assess possible influences on implementation in EDs from the perspective of nurses, including (a) determinants of current (non-SANE) telemedicine practices, (b) feasibility and perceived utility of teleSANE, and (c) potential facilitators and barriers to implementing teleSANE (^{Stetler et al., 2006}). This evaluation was informed by implementation science, which offers an opportunity to identify determinants of the uptake and sustained use of telemedicine. Recognizing that many evidence-based interventions either never make it into routine care or are disseminated slowly (^{Morris et al., 2011}), implementation science approaches attempt to identify and address barriers that may affect intervention implementation. This study was guided by the Consolidated Framework for Implementation Research (CFIR; ^{Damschroder et al., 2017}), a framework that describes types of factors that often influence implementation outcomes at multiple levels.

Design/Methods

Study Setting

This study took place at the University of Arkansas for Medical Sciences (UAMS), in a state that ranks above the national average for lifetime sexual violence victimization among women (^{Black et al., 2011}). At the time of the study, most sexual assault forensic medical examinations completed in rural Arkansas EDs were conducted by nurses lacking SANE certification. In 2019, the Department of Justice Office for Victims of Crime funded four programs, including the UAMS Institute for Digital Health and Innovation, to develop and implement teleSANE programs. Using a hub-and-spoke model, these programs would provide 24/7 SANE consultation via telemedicine in participating sites.

Sampling and Recruitment

Between August and December 2020, 48 ED nurses at 16 Arkansas EDs were recruited via email by the first author, using contact information provided by their ED leadership. These nurses were informed about the study aims and methods and invited to contact the first author if they were interested in participating in a phone interview. Participants were eligible if they were currently employed in an Arkansas ED, were not SANE trained, and had completed a sexual assault forensic medical examination within the last year. We achieved a 31% individual response rate and an 81% ED response rate. Data analysis was ongoing during data collection, and participants were recruited until saturation of themes was reached.

Data Collection

Data collection consisted of a one-time phone interview using a semistructured interview guide informed by the CFIR (^{Damschroder et al., 2017}). CFIR specifies five domains to consider when implementing an intervention in a new setting: intervention characteristics, inner setting (organizational level), outer setting (community or societal level), characteristics of individuals involved with the implementation process, and the implementation process itself. Participants were given a brief description of teleSANE, including a description of the role of the teleSANE consultant in providing assistance during the forensic medical examination, and the goals of the UAMS TeleSANE Program. The interview guide explored facilitators and barriers of current telemedicine implementation, feasibility and perceived utility of teleSANE, and potential influences on teleSANE implementation. Interviews were audio recorded and transcribed verbatim. The UAMS Institutional Review Board approved study procedures. All participants gave informed consent. Each participant was compensated $50 for their time participating. Interviews lasted for an average of 63 minutes (range: 43–82 minutes).

Data Analysis

Interviews were analyzed using MAXQDA qualitative software. Segments were deductively coded by CFIR construct by the first and last author as well as inductively coded with descriptive summaries and subcodes. The subcodes of the codebook were created in an iterative process of discussion and refinement. Intercoder agreement was achieved on 20% of the data set. The remaining data were coded independently and reviewed by a second team member. Coding discrepancies were discussed by the research team and resolved through consensus or by a third reviewer. Emergent themes were noted during analysis.

Results/Findings

Sample

Fifteen non-SANE nurses from 13 Arkansas EDs (11 rural, two urban) participated in interviews. On average, participants had been in nursing practice for 15.7 years (range: 3–35 years), with their current ED for 9.7 years (range: 1–20 years), and in their current role for 9 years (range: 2–18 years). Nearly half of the participants (46%) had worked in previous roles in their current hospital before becoming a nurse.

Results presented below describe the nurses' perceptions of (a) determinants of current telemedicine use, (b) feasibility and perceived utility of teleSANE, and (c) potential facilitators and barriers to teleSANE implementation.

Determinants of Current Telemedicine Use

Most participants (93%, n = 14) currently worked at a hospital that participates in a telemedicine program, including specialty consultations for stroke, traumatic injury, burns, and/or mental health. Before discussing potential influences on teleSANE implementation, participants described factors across all levels of CFIR that affect implementation of current telemedicine use in their ED.

Characteristics of Individuals

Participants had generally positive attitudes toward telemedicine in the ED and perceived they had the knowledge and confidence to use the telemedicine equipment and consultation service. Some said that, early in implementation, some clinicians were resistant to change their practices, but most became likely to use the service over time. One factor that many participants said contributed negatively to their overall comfort with the service initially was feeling self-conscious on video. In discussing a telemedicine program her ED currently participates in, one participant said, “It wasn't well received in the beginning. It is different now. It's nobody's favorite thing to have to do because nobody wants to get in front of the camera and perform. But it's much better. We're all more trained in it and more comfortable with it.”

Inner Setting

Participants who worked at small, rural EDs said that specialty care was not often available locally and therefore perceived that participating in specialty telemedicine programs was a benefit to both their clinicians and patients. Many participants were motivated to use telemedicine by the prospect of improving patient outcomes. One said, “But I think when you really prove to them [clinicians] that something works and it's going to improve patient care, most of them get behind it pretty quickly.” In addition, most participants were at hospitals that had been given telemedicine equipment and were receiving support from UAMS Institute for Digital Health and Innovation information technology (IT); they were also supported by resources such as outreach nurse coordinators and access to education in the form of in-service training, online modules, monthly mock scenarios, and annual conferences and therefore felt prepared to participate in other telemedicine programs.

Outer Setting

Rural patients' need for urgent specialty care motivated participants to use telemedicine consultation services. Participants described beneficial collaborations with state-level organizations, including UAMS's telemedicine programs and IT support, that improved their experience with telemedicine. Participants also suggested that state-level grant funding facilitates local telemedicine implementation.

Innovation Characteristics

Because they perceived that their rural patients often had no other option for specialty care in their communities, participants perceived that such care provided via telemedicine was beneficial. Some participants expressed concerns with technology issues, but none said that these issues affected their use of telemedicine. One participant said, “We've had some problems with our machine on occasion, like connection issues that we've had, which has delayed getting ahold of somebody. The machine wouldn't turn on correctly or we couldn't connect correctly.”

Process

Some participants spoke of the importance of engaging all key stakeholders (e.g., ED leadership, nurses, physicians, and IT staff) in the implementation process and training the staff to use the telemedicine equipment. Many also said that it was advantageous to appoint an internal implementation leader for each telemedicine program.

Feasibility and Perceived Utility of TeleSANE

Participants were then asked to reflect on the feasibility and utility of telemedicine consultation specifically for sexual assault care. Participants had generally positive views of the proposed UAMS TeleSANE Program and believed that it would help them perform their jobs. One participant said, “Consultation on something that's not your expertise is always beneficial, especially in that situation where if you don't do an evidence collection correctly you could ruin any chances that patient has of getting their case heard and something settled.” Other participants shared this desire to properly collect evidence for prosecution and the belief that teleSANE would improve evidence collection. One participant summarized the overall positive influence of the program, saying, “I definitely think it would improve the care, improve the process, and probably could improve the prosecution. I mean, you have better collection of evidence because you have a more improved process to do that.”

Participants were less concerned about clinicians' acceptance of virtual SANE consultation and more concerned about patients' acceptance. One said,

I think the biggest part will be getting patients on board with it, especially in that intimate situation where they've already been assaulted and then being on camera. So, I think it may be utilized more by staff to get more expert guidance as to what to do, how to do it, that sort of thing. Versus actually someone actually walking them through the exam, although I'm sure that would be very nice in some situations.

Potential Facilitators and Barriers to Implementing TeleSANE

In addition to discussing the feasibility and utility of teleSANE, participants described factors they believed would influence teleSANE implementation across four CFIR domains. The “Process” domain was excluded because this was a preimplementation study. Identified CFIR factors associated with each domain are described below, as well as in Table 1 with additional exemplary quotations.

TABLE 1 - Potential Factors Influencing TeleSANE Implementation

CFIR Domain	CFIR Construct	Description	Exemplary quotation
Characteristics of individuals	Knowledge and beliefs about the intervention	Knowledge and beliefs about teleSANE	“I mean, I can only see it enhancing their care. I can't see that it would make anything worse. I suppose it all depends on how the program is managed and what services are provided, but I can't see that it would do anything but enhance it. To what extent or how, I don't know, but I've never seen a patient that suffered because there were more people that were experts involved. I mean, … I've never seen a patient who suffered a negative outcome because a true expert was involved and consulted in their care, you know?”
	Self-efficacy	Lack of comfort with sexual assault examinations	“There's always discomfort in the staff unless [experienced nurse] or I are there, and our doctors are still not comfortable. So I can see where that might increase comfort levels. I can see a great educational opportunity in it…. I can see where contacting a SANE nurse through telemedicine would increase the comfort level of definitely the nurse and the doc but potentially even the patient because you're dealing with somebody who deals with it every day and a personable person can come across that video and reach out to that patient where one of may not be connecting.”
Inner setting	Structural characteristic	Small department with small staff	“We work in a small ER. It is a busy ER. Unfortunately, we're not staffed but with two nurses and a physician, and when we have other patients in there, we're not always able to sit and just listen, and listen to the client that's experienced such a traumatic event like we want to. I think with maybe the telemedicine…that would give them someone that they could talk with and would relieve our staff to move on.... While they're talking with that staff on the Tandberg, they could move on and take care of someone that's come in with chest pain.”
	Compatibility	Compatible with sexual assault care processes	“I think that people are resistant to change if they feel threatened, you know? And this wouldn't take away anybody's.... There's no one in this system that is SANE certified or who I would say, ‘Oh yeah, they consider themselves an expert.’ So it's not like you are coming in to take something away from someone, you're adding something that would be beneficial, so I don't think that there would be a barrier.”
	Implementation climate—relative priority	Telemedicine became a priority because of the COVID-19 pandemic	“Yeah, since COVID has started, really, telehealth has been big in our hospital.”
	Implementation climate—goals and feedback	Success stories	“And maybe hearing about other success stories, other places have had that might use it more often, just might give us that little extra pat on the back type of thing, to encourage us to use it when we can.”
	Readiness for implementation—available resources	Equipped for telemedicine	“Well, we already have the machine, and it's already setup going. This is just an extra service that we would have to provide. It's already in place. I mean, IT already knows about the machine, the staff knows how to use it. All we need is the binders and instructions and then do some education and we'd be ready to roll.”
	Readiness for implementation—access to education	Ongoing training on telemedicine program and sexual assault care	“So I think having a lot of in-person education would be...I think that is the most useful resource is when that patient comes in, to have practiced so much that it's just next to routine.”
Outer setting	Needs and resources of those served by the organization	Considerations for sexual assault survivors	“The only issue I would worry about with it is privacy. Patient's already been assaulted and it's hard enough sometimes just to encourage them to have an advocate in the room…. It's a very intimate exam and I think it's going to.... Like I said, it's very hard sometimes to even encourage patients to have the exam let alone with a camera, with somebody else on the other end of the camera also. I think that's going to be difficult.”
	Cosmopolitanism	Supportive relationship with university	“Bottom line, UAMS coming in and setting up the Tandberg machines and starting out using their system because everything was laid out. How to use it, what numbers to call, who to call…they made the program easy.”
Innovation characteristics	Complexity	Concerns with technology issues	“As far as complications that could come up, I could see it not being able to connect, and that relates to an IT issue.” “The simpler it is to use, the more people are going to use it.”
	Relative advantage	No other options for specialty care locally	“I think just actually the necessity for it, because I mean, I live up there in [rural county], and there isn't a lot of hospitals with a lot of resources, so they need those resources to be able to [provide] good quality care of the patients up here.”

CFIR = Consolidated Framework for Implementation Research; teleSANE = telemedicine sexual assault nurse examiner.

Characteristics of Individuals

Self-efficacy

Although all participants had experience with evidence collection as part of the sexual assault forensic medical examination, most believed that nurses without SANE training can be intimidated by the process and lack comfort and confidence in their ability to collect evidence properly. One participant said, “Our hospital is very small. We don't have any SANE nurses…. I think it would be really, really beneficial for the staff so that they would feel more comfortable to make sure that they're doing appropriate steps.” Participants said having expert advice via teleSANE consultation would improve their self-efficacy and confidence in the process. One noted,

To have an expert that would be consistently available would be, I think, so helpful for everyone in the department, just to have some peace of mind that there was someone who could guide the exam. We have had a pretty large turnover in our staff... And so that would be such a help, especially to these younger nurses who have never done an exam, to have someone who could help guide them through that, to teach them the appropriate way.

Inner Setting

Structural characteristic

Most participants worked at small, rural EDs with limited staffing and space. The size of the ED rooms, particularly at hospitals with only one obstetric bed for sexual assault examinations, was described as a potential barrier for teleSANE implementation because the telemedicine carts are bulky and may be hard to move into those rooms. However, staffing challenges, especially in small EDs with high staff turnover, travel nurses, and mostly male nurses, were suggested to be facilitators for implementation, as they indicate the need for specialty consultation for sexual assault care.

Compatibility

Most participants agreed that teleSANE consultation would be compatible with their existing workflows and practices, particularly because of their experience using other telemedicine programs. In addition, they expressed that it would be compatible with their processes for sexual assault care and would benefit that care.

Implementation climate—relative priority

The COVID-19 pandemic was occasionally mentioned as both a facilitator and barrier to implementation. Although the pandemic burdened EDs nationwide, it also made telemedicine a priority. One participant said, “Since COVID has started, really, telemedicine has been big in our hospital.”

Implementation climate—goals and feedback

The desire to improve patient outcomes and satisfaction was consistently reported as a factor that would influence teleSANE implementation. Participants said that knowing if the program positively impacted the patients' experience receiving sexual assault care and improved the progression of the case in the criminal justice system would be valuable feedback and encourage use of the service. When asked what kind of outcome data would be helpful, one participant said,

I think that just showing the data is helpful, just showing…positive outcomes that we've had from what we're doing versus if we hadn't done this. Patient outcomes would be great. And successful rape kits—I think that a lot of our rape kits get just thrown away because they're not done correctly.

Readiness for implementation—available resources

Most participants said that their ED has the resources available to implement teleSANE, including telemedicine carts and IT support. Most participants worked at EDs that do not have SANEs on staff; some stated this would make them more likely to use teleSANE.

Readiness for implementation—access to education

Participants perceived that implementation would be facilitated by having more access to education and training on topics including sexual assault care, forensic evidence collection, testifying in court, follow-up resources, and telemedicine programs, as well as in a range of formats, including self-guided online training, in-person in-service training, annual conferences, and mock scenarios.

Outer Setting

Needs and resources of those served by the organization

The needs of patients were commonly described as factors that would influence teleSANE implementation. Many participants believed that patients might have concerns with being on camera but felt that teleSANE consultation would provide more support, care, and compassion. In addition, participants stated that rural patients need to be able to access sexual assault care at their local hospital, and teleSANE services could provide that high-quality care. One participant noted, “We are in a rural area and with limited resources.” Another said, “Plus they're getting a specialty care at that time, and it's being treated as a specialty care just like a heart attack or a stroke or something. It's just as important.” Participants also stated that patients need information about follow-up services that could be provided through the UAMS TeleSANE Program—information that nurses may have limited knowledge of; one participant said, “It's a resource for us and for our patient.”

Cosmopolitanism

Many participants spoke of the importance of the strong relationship between UAMS telemedicine programs and the participants' local ED and how it improves implementation efforts and supports sustainability of telemedicine programs. Having access to centralized, 24/7 IT support through UAMS has reduced their anxiety about technical issues. Most participants also described strong connections with the State Crime Laboratory, local advocacy centers, and local law enforcement—all key partners in providing quality sexual assault forensic medical examinations.

Innovation Characteristics

Complexity

Reflecting on the utility of teleSANE, one participant said, “I think that will come down to how the program is introduced and how simple it is to use. The simpler it is to use, the more people are going to use it.” Some participants had concerns with potential IT issues and suggested that the technology needs to be accessible and easy to use; however, participants noted that that they were able to overcome IT issues with telemedicine in the past. One said, “We had some technical issues with [the telemedicine equipment] in the beginning, and nurses learning how to get access to certain areas of imaging. But that's been hammered out.”

Relative Advantage

Some participants compared teleSANE with the sexual assault care currently provided, suggesting that teleSANE examinations would better serve patients. One said, “I think that it's going to take time to tell but I think that it is better than what we have now.”

Discussion

The COVID-19 pandemic rapidly increased telemedicine use in EDs (^{Bains et al., 2021}; ^{Koonin et al., 2020}); therefore, virtual SANE consultation for sexual assault forensic medical examinations is timely, having the potential to improve forensic evidence collection and patient satisfaction. Before implementing virtual SANE consultation, or “teleSANE,” we conducted a formative evaluation to explore determinants of current telemedicine practices, perceptions of feasibility and utility of teleSANE, and potential determinants of teleSANE implementation in EDs.

Our study revealed ED nurses' reported barriers to using existing telemedicine services across CFIR domains as well as strategies used to overcome those barriers. Whereas past studies have often cited lack of start-up funds (^{Williams et al., 2020}), cost, and reimbursement (^{Scott Kruse et al., 2018}) as system-level barriers to telemedicine implementation, our participants reported that state-level grant funding has facilitated telemedicine implementation in Arkansas EDs. Similarly, telemedicine programs participating in ^{Whitten et al.'s (2010)} study often had start-up funding through grant mechanisms, but many believed that there would be a shift from outside sources to internally based sources to sustain telemedicine programs over time, potentially because of changes in reimbursement for telemedicine in the United States—changes that have become particularly pertinent in the wake of the COVID-19 pandemic.

ED telemedicine initiatives in Arkansas have overcome issues with technology often cited as provider- and system-level implementation barriers through 24/7 state-level IT support provided by UAMS. Clinicians can be resistant to change and acceptance of new technological innovations (^{Einolghozati, 2018}; ^{Scott Kruse et al., 2018}), as well concerns for patient privacy with virtual consultation services (^{Balestra, 2018}), but our study revealed that these concerns were overcome by observed improvements in patient care and outcomes with existing telemedicine services. In addition, having no other option for specialty care locally may encourage telemedicine uptake among providers and patients in rural areas (^{Call et al., 2015}). Participants in this study, as well as those of other telemedicine programs (^{Alverson et al., 2004}), said that having competent staff is critical and recommended having telemedicine coordinators and technical assistance provided to telemedicine sites.

Our participants generally had positive attitudes toward using virtual SANE consultation for sexual assault care and perceived that the expert guidance would help them to collect better forensic evidence for prosecution. In exploring the potential barriers to teleSANE implementation in EDs, our study confirmed many themes identified by ^{Walsh and Meunier-Sham's (2020)} systematic review, including space limitations, lack of staff training, patient experience and acceptance, and quality of examinations. In addition, we not only found that ED nurses have concerns about patient acceptability of virtual SANE consultation but also believe this service would help nurses feel more confident in providing a quality forensic examination and would help support the patient. These findings suggest that teleSANE programs should share success stories and report patient outcomes, including patient perspectives on acceptability of the service, to encourage uptake and sustained teleSANE use by rural ED nurses.

Many participants believed that patients would be unwilling to have a SANE live on video during the examination. However, in a pilot study by ^{Walsh et al. (2019)}, most patients (86%) who sought evidence collection consented to the live video; notably, most of the patients who declined teleSANE were at a military site. They also reported that the consent process was “straightforward and patients had no issues having a SANE on a video monitor during the examination” (^{Walsh et al., 2019}, p. 156). TeleSANE programs should consider providing a verbal script to facilitate the conversation between the local nurse and the patient about informed consent for teleSANE consultation, regularly communicating rates of patients consenting to teleSANE, and providing a clear and accessible protocol for teleSANE for nurses to know when and how to use it.

Consistent with findings from ^{Walsh and Meunier-Sham's (2020)} systematic review, our participants suggested that space in their small EDs may be an issue if telemedicine equipment is bulky and hard to move. Thus, efforts should be made to reduce the size of equipment and work with EDs to identify the best space for it. In addition to overcoming inner setting barriers related to physical space in the ED, our participants suggested that access to education would facilitate implementation of teleSANE. ^{Alverson et al. (2004)} also identified the need for regular training provided to ED staff. Our participants requested training on a range of topics related to virtual SANE services, as well as sexual assault care, on an ongoing basis. Participants perceived that training provided for other telemedicine programs improved their skills and willingness to use the service; therefore, ongoing education on teleSANE should be provided to ED staff throughout implementation.

Implications for Clinical Nursing Practice

A number of implications emerged for EDs interested in exploring the utility of telemedicine to care for sexual assault patients. Preimplementation lessons include allowing adequate time for staff to practice and become comfortable with the process, engaging all stakeholders involved (e.g., hospital administrators, victim advocates, law enforcement) so that there are champions of the model, and acknowledging and overcoming staff fears and hesitancy related to technology. There is a dearth of research that describes training when implementing telemedicine services. Best practices related to this are unknown. One of the key issues is having the opportunity to practice the skills often to continue to feel competent. Other critical issues are addressing how staff turnover and underutilization impact competency and comfort.

Limitations

This formative study had several limitations. First, the study involved in-depth interviews with nurses on their perspective of telemedicine in the ED. The perspective of other clinicians and patients may have identified different or additional barriers. Second, the assessment of potential barriers to virtual SANE consultation was conducted before its implementation, and actual barriers may differ. Finally, this study took place in a predominantly rural, Southern state; therefore, these findings should be considered within this context, as they may differ in other states or regions.

Conclusion

This study highlights the perceived feasibility and utility of teleSANE consultation in EDs. Treating sexual assault survivors is fundamentally different than treating other patients in the ED because of their unique needs related to privacy, confidentiality, sensitivity to the impact of trauma, and forensic evidence collection; therefore, special considerations should be made in the implementation of virtual SANE services in the ED. By identifying potential barriers before implementation, efforts can be tailored to address known barriers and meet the specific needs of providing teleSANE consultation as part of sexual assault care.