Joan Sham, RN, MS
The role of the pediatric sexual assault nurse examiner (SANE).
[Editor's Note: This is the second of two interviews with nurses working in the Massachusetts Sexual Assault Nurse Examiner Program.]
Joan Sham, RN, MS, is the Pediatric SANE Associate Director of the Massachusetts Sexual Assault Nurse Examiner Program (SANE). In that role, she manages pediatric SANEs who provide direct care for victims of child sexual abuse. This care includes forensic examinations, medical care, and emotional support for children and their families. The nurses work in collaboration with other agencies including DSS, law enforcement, and mental health providers.
Q. How did you become involved in the pediatric SANE Program?
A. When I worked as a pediatric clinical nurse specialist in the emergency department at Boston Medical Center, I cared for many child and adolescent sexual assault victims. I also served as the liaison for the adult and adolescent SANE program, participating in policy and protocol development for child and adult sexual assault victims and for victims of domestic violence. I recognized that children needed specialized treatment, so I joined the multi-disciplinary pediatric SANE advisory group.
The group met for seven years to address the unique needs of sexually abused children. Part of our work involved conducting a national needs assessment which examined other pediatric SANE programs throughout the country. The Massachusetts Children's Alliance [http://www.machildrensalliance.org/] conducted a simultaneous needs assessment and found that fewer than ten medical providers in Massachusetts had specialized training to care for child victims of sexual assault. In this state, child sexual abuse investigations are conducted by a multi-disciplinary team within a Children's Advocacy Center (CAC). CACs had limited access to medical expertise in this area, and there was clearly a need for more providers with such expertise.
Eventually, we established the pediatric SANE protocols, Pediatric SANE Training Curriculum and created the Massachusetts Pediatric Sexual Assault Evidence Collection Kit (MPSAECK). This kit is child-friendly and the first of its kind in the country. It is used for forensic evidence collection working with children 11 years old and younger.
The first Massachusetts pediatric SANE training was held in 2004. As a result of our efforts, more children and families are able to receive appropriate care and support when concerns of sexual abuse are disclosed.
Q. How do the needs of children differ from those of older adolescents and adults?
A. First, because sexual abuse of children is usually chronic, the majority of children do not present in an emergency department. Or they present to an ED outside of the time period - 72 hours - when evidence collection is indicated. The perpetrator is frequently a person the child knows and trusts. There is usually less physical trauma in child sexual abuse cases because the perpetrator may avoid hurting the child in order to have on-going access to the child. Sexual abuse can be disclosed at school or in other settings and it is crucial that the situation is handled in a way that decreases further physical and emotional trauma. This is where the role of specialized pediatric services becomes so important.
What we have done is focused our program's initial development on having pediatric SANEs based in Children's Advocacy Centers. We currently have pedi SANEs in 7 of the state's 11 CACs. At the same time, we have one emergency based response at Lawrence General Hospital, and we are distributing the MPSAECK statewide - because on the occasion that a child presents with an acute sexual assault, timely evidence collection with the MPSAECK is critical.
The MPSAECK is only used within 72 hours of an assault. The kit is designed to be non-threatening and is colorful and interactive. Following "Do No Harm" principles, DNA is collected by swabbing the buccal mucosa, rather than by drawing blood or collecting hair samples as in adult cases. Exams on children involve examination of the external genitalia, and it is never appropriate to perform a speculum exam on young children. In the rare event that an internal pelvic exam is indicated - for example, if there is a vaginal foreign body - then it is done under general anesthesia by an MD.
The pedi SANEs use a MedScope Camera during their exams for video documentation of physical findings and injuries. The MedScope magnifies the viewed area and is not painful for the child. The images obtained also preserve evidence of injuries which often heal quickly. This type of evidence contributes to more successful prosecutions.
Q. I imagine the whole process must make children uncomfortable. How do you deal with a child's discomfort during the examination?
An important concept of caring for children who have been sexually abused is the "Stop Rule." This means the child can say "stop" at any time during the exam and the practitioner will follow the child's directive. The child is encouraged to practice saying "stop" and to experience the result as the exam is halted. This lets the child know that they are safe and in control, and greatly reduces anxiety and the potential for re-traumatization.
It should also be noted that when there is actual or suspected sexual abuse of a child, the entire family is affected and needs ongoing support. Therefore, collaborating with other agencies such as DSS and law enforcement is a key element in treatment. With the permission of the child's guardian, pedi SANEs will also communicate directly with the child's primary care clinician. Naturally, ongoing counseling for the child and family is also indicated and requires appropriate referrals. Finally, it is essential to reassure the child and family that they are safe, that the child's body is healthy, and that support will be continued.
Q. What is the training like for pediatric SANEs?
A. Pediatric SANEs working in Children's Advocacy Centers are advanced practice nurses. Those working in the Emergency Response System are seasoned emergency department nurses. Both groups have a great deal of experience dealing with children and families. They receive six days of didactic education as well as competency training at skills stations. There is also a mock examination that must be completed. In addition, a clinical rotation is completed at designated hospitals with a child abuse expert, either a physician or a nurse practitioner. Pedi SANEs also participate in continuing education and training programs.
Q. What about support for the caregivers? It must be especially stressful to work with sexually abused children and their families.
A. We recognize the psychological impact of doing this work. Therefore, support for the pediatric SANEs is ongoing. We meet monthly to review and process cases. Emotional support is essential and is always available to the pediatric SANEs. This helps to restore and refresh the caregivers and reduces the chance of burnout.
Q. Can you describe a typical case and how the pediatric SANE's involvement benefited the client and family?
A. We will use a composite case here. A six year old girl (we will call her Kayla) woke up crying and told her mother that she does not want Uncle Joe to babysit her anymore because he does bad things to her. She says that last night, he was touching her private parts, and licking her, and also that she was scratched "down there."
Kayla's mom immediately took her to the emergency department and a pediatric SANE was called in. The pedi SANE used the MPSAECK to obtain external swabs of Kayla's body. The pedi SANE did not interview Kayla in detail, knowing that this would be done by a specially trained child interviewer. The examination was conducted in a gentle and supportive manner, and Kayla was given control of the pace of the exam.
The MedScope Camera was used to illuminate and magnify Kayla's external genitalia to look for signs of injuries. The scratch mark was identified and images were obtained. The pedi SANE reported the abuse to the Department of Social Services by filing a 51A. The DSS worker spoke with Kayla's mom. Together, they discussed a plan to keep Kayla safe until DSS could complete their investigation.
This plan required that Uncle Joe be kept out of the house. The police were also notified with Kayla's mom's consent and a detective took minimal information from Kayla regarding the abuse. Upon discharge, Kayla was referred to the advance practice pedi SANE at the county's Children's Advocacy Center. A forensic interview was scheduled by DSS at the same CAC.
After her forensic interview, Kayla was examined by the pedi SANE who assured Kayla that her scratch was healing well and that she was normal and healthy. She spoke with Kayla's mom about ways to support Kayla and a mental health referral was made to a local program for crisis support for Kayla and her family.
Q. What is your biggest challenge at the present time?
A. We are focusing on getting the word out about the importance of pedi SANEs and the importance of the MPSAECK as a tool for child safety. We recently conducted several day-long training sessions across the state that targeted medical directors, nurse managers, and nurse educators of emergency departments who care for children. This was a mandatory training in order for emergency departments to receive a supply of MPSAECK kits. Pediatric kits are now available in 86% of Massachusetts hospitals that treat children, and an instructional DVD is being developed to support the use of the kit.
We are always looking for ways to increase funding to expand our program to all areas of the state. Most of all, we are looking to educate providers about the value of pedi SANEs who, with a holistic approach, and with the benefit of highly specialized training, are able to provide optimal care and support for victims of child sexual abuse and the people who love them.
How to find out more
To learn more about the SANE program, visit the Massachusetts Office of Health and Human Services Web site.
Kim Jordan, RN, is a freelance writer and a regular contributor to On Call.
