Original Article
With Care and Compassion: Adolescent Sexual Assault Victims' Experiences in Sexual Assault Nurse Examiner Programs Rebecca Campbell, PhD, Megan R. Greeson, MA, and Giannina Fehler-Cabral, PhD
ABSTRACT In this study, we conducted in-depth qualitative interviews with 20 adolescent sexual assault patients aged 14–17 years who sought postassault medical forensic examinations at one of two Midwestern Sexual Assault Nurse Examiner programs. Our goals were to examine how adolescent victims characterized the quality of the emotional/interpersonal care they received and to identify specific aspects of Sexual Assault Nurse Examiner nursing practice that were helpful and healing. Overall, the patients had very positive experiences with both programs. The nurses were sensitive to their patients’ physical and emotional needs throughout the examination. The adolescents also noted that the nurses were compassionate, caring, and personable. Finally, the survivors deeply appreciated that the nurses believed and validated their accounts of the assault. These findings suggest that compassionate care must be developmentally informed, such that basic patient-centered practices (e.g., belief and validation) are age sensitive and age appropriate. KEY WORDS: adolescent patients; emotional well-being; psychological health outcomes; rape; sexual assault; Sexual Assault Nurse Examiner (SANE) programs
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dolescents aged 12–17 years are at high risk for sexual assault (Finkelhor, Turner, Ormrod, & Hamby, 2009; Howard, Wang, & Yan, 2007; McCart et al., 2010; McCauley et al., 2009; Raghavan, Bogart, Elliott, Vestal, & Schuster, 2004; Young, Grey, & Boyd, 2009). The National Juvenile Justice Center has found that adolescents are the largest group of sexual assault victims and are twice as likely to be sexually victimized as adults (Snyder, 2000; Snyder & Sickmund, 2006).1 Yet, adolescents are less likely than adults to seek postassault help from the medical or legal systems (BromanFulks et al., 2007; Casey & Nurius, 2006; Kogan, 2004;
Nofziger & Stein, 2006). Teens may be reluctant to seek help because of shame and stigma (Rickwood, Deane, Wilson, & Ciarrochi, 2005; Wilson & Deane, 2001) but also because they simply do not know what services are available. To address these barriers and improve healthcare outcomes for adolescent patients, many Sexual Assault Nurse Examiner (SANE) programs have made concerted outreach efforts so that their communities are aware of the services they provide. Nearly all SANE programs serve adolescent patients (IAFN, 2012), but little is known about this specific population and their experiences seeking sexual assault care.
Author Affiliation: Michigan State University. This research was supported by a grant from the National Institute of Justice awarded to the first author (2007-WG-BX-0012). The opinions or points of view expressed in this document are those of the authors and do not reflect the official position of the U.S. Department of Justice. The authors declare no conflicts of interest. Correspondence: Rebecca Campbell, PhD, Department of Psychology, Michigan State University, 127 C Psychology Building, East Lansing, MI 48824–1116. E-mail: [email protected]. Copyright © 2013 International Association of Forensic Nurses DOI: 10.1097/JFN.0b013e31828badfa
1 We recognize that there are multidisciplinary differences in the terms used to refer to those who have been raped/sexually assaulted: Law enforcement and prosecutors tend to use the term “victim” to reflect the criminal nature of this act, forensic nurses use the term “patient” to reflect their primary role of providing health care to these individuals, and rape crisis center advocates and mental health professionals use “survivor” to convey the strength of those who have been raped/sexually assaulted. In this manuscript, we will use the terms “victim” and “survivor” interchangeably to reflect that sexual assault is a violent crime that takes tremendous strength and courage to survive; we will also use the term “patient” in presenting results regarding the interactions between the nurses and the victims they treated.
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Original Article To date, most research on SANE programs has focused on legal and forensic outcomes among adult patients (Campbell, Patterson, & Bybee, 2012; for reviews, see Campbell, Patterson & Lichty, 2005a). Given the tremendous utility of SANE programs to the criminal justice system (Campbell, Patterson & Fehler-Cabral, 2010), it is not surprising that there has been such a strong interest in this topic. However, most victims seeking postassault medical care do so for health-related reasons (e.g., emergency contraception, care of injuries, STI prophylaxis, crisis intervention; DuMont, White, & McGregor, 2009). Indeed, the field of forensic nursing defines its primary role as that of healthcare providers (Lynch, 2006). Prior research has found that SANE programs provide more comprehensive care to sexual assault patients than what is typically offered in non-SANE hospital-based emergency departments (Campbell et al., 2006). Yet, how SANE programs address the emotional health needs of their patients is still an understudied topic. Only a handful of studies have examined the extent to which patients feel SANE care was psychologically beneficial, and all of this work has been conducted with adult samples. For instance, Ericksen et al. (2002) conducted semistructured qualitative interviews with eight adult sexual assault patients who sought care from a Canadian specialized sexual assault treatment center. They identified nine major themes in the patients’ narratives regarding how the program affected their emotional well-being: (1) they felt their needs were met and they were treated with dignity and respect; (2) the nursing staff provided information about what to expect and listened to the survivors; (3) they felt safe; (4) they appreciated how the nurses were careful about how they physically touched their patients; (5) they felt in control and were given options and were not pushed toward certain choices; (6) they felt reassured, believed and supported by the staff; (7) they felt they were cared for by people with expertise (i.e., the providers were knowledgeable and well-trained); (8) they were given needed information, but the staff were careful not to overwhelm them; and (9) they felt cared for beyond the hospital in that they received information on follow-up care. Similar results were obtained in qualitative studies by DuMont et al. (2009) in Canada and by Fehler-Cabral, Campbell, and Patterson (2011) in the United States. Both research teams found that adult survivors were overwhelmingly positive about the quality of the care they received, noting that, although the examination itself was difficult, the nurses treated them with care and respect. These qualitative findings are consistent with the results of a quantitative study by Campbell, Patterson, Adams, Diegel, and Coats (2008) with adult sexual assault survivors who sought care from an American SANE program. In this project, adult patients used a 4-point scale (1 = not at all, 2 = a little, 3 = somewhat, and 4 = a lot/completely) Journal of Forensic Nursing
to indicate the degree to which they felt cared for, treated with compassion and respect, supported, believed, and informed by the nurses. All patients (100%) used the highest rating (a lot/completely) for outcomes regarding care and compassion, feeling informed, clear instructions for medication, and recontacting the program if they had problems or concerns. Somewhat lower ratings were obtained for the items regarding feeling in control during the examination process (71% endorsed this item with the highest rating), although patients noted that they did feel well-informed and knew they had the option to refuse any portion of the examination. Whether these same positive psychological outcomes occur for adolescent patients is unknown. This issue is important to examine because, although the forensic components for adult and adolescent examinations are similar, recent research has found that adolescents differ from adults with respect to anogenital injuries (Jones, Rossman, Wynn, Dunnuck, & Schwartz, 2008), indicating that these populations may have distinct healthcare needs. It is possible that the emotional healthcare needs may also differ for adolescents given their stage of psychological development (Saarni, 1999; Saarni, Campos, Camras, & Witherington, 2006). Adolescence is a unique developmental period, often characterized by resistance to adult authority figures, which could include adult forensic nurses. In addition, adolescents may engage in behaviors before an assault that may be illegal (or illegal for their age; e.g., drinking and using drugs), and it is critical that service providers know how to respond to these issues in ways that are perceived as supportive and patient centered. Understanding how adolescents perceive the care they have received from SANE programs and the extent to which they feel it was psychologically beneficial can inform recommendations for nursing practice as well as outreach efforts to this vulnerable population. To that end, this study was a qualitative investigation of adolescent survivors who obtained medical forensic examinations from one of two Midwestern SANE Programs. Our goals were to examine how adolescent sexual assault patients characterized the quality of the emotional/interpersonal care they received and to identify specific aspects of SANE nursing practice that were helpful and healing.
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Methods Sample We collaborated with two Midwestern SANE programs and their rape crisis center (RCC) affiliates to identify adolescents who had been recently sexually assaulted. Both SANE programs were in the same state and were equivalent with respect to program practices, staffing, population served, and patient demographics (Campbell, Greeson, Bybee, Kennedy, & Patterson, 2010). The target sample for www.journalforensicnursing.com
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Original Article this study was adolescent sexual assault victims 14–17 years old who received a full medical forensic examination from one of the two focal SANE programs. The age of our sample was restricted to 14–17 years because, in the state in which the study was conducted, minors are able to consent to certain services, including mental health and STI treatment, at the age of 14 years. Therefore, the research team, in collaboration with our community partners and our university’s institutional review board (IRB), decided to limit the sample to adolescents at least 14 years old so that this study would be in congruence with state laws regarding minors’ ability to consent. A prospective sampling strategy was used to recruit adolescent sexual assault victims, whereby nurses in both programs provided all eligible patients with information about the study. It was mutually decided by the IRB, the nurses, and the evaluation team that the nurses should be the ones to introduce the study to their patients, emphasizing that the evaluation team was not affiliated with the program and the patients’ participation (or nonparticipation) in the evaluation would not affect their care/services from the SANE program. Patients were then asked whether they were willing to be contacted at a later date by a member of the research team; if so, patients completed an “Agree to be Contacted Form,” which asked them to provide guidance on how and when they could be reached so that their privacy and safety would be protected. This paperwork emphasized that, by providing their information, patients were only agreeing to be contacted about the study but were not committing to participate. Victims who agreed to be contacted were called by a research assistant (who was not affiliated with the SANE program) approximately 3–4 weeks after the date they completed the form. All interviews were conducted by PhD-level graduate students in psychology who had extensive prior experience interviewing sexual assault survivors. Participant recruitment and interviewing continued until we achieved saturation, whereby the same themes were repeated, with no new themes emerging among participants (Guest, Bunce, & Johnson, 2006; Sandelowski, 1995; Starks & Trinidad, 2007). All 20 adolescents were female; most were White (n = 15, 75%), three participants were African-American (15%), one was Asian-American (5%), and one was multiracial (5%). Survivors’ ages were fairly evenly distributed. At the time of the assault, 15% were 14 years old, (n = 3), 30% were 15 years old (n = 6), 30% were 16 years old (n = 6), and 25% were 17 years old (n = 5). Most survivors were assaulted by one person (n = 17, 85%), but three of the participants were victimized by multiple assailants (15%). Most often, the assailant was an acquaintance (n = 9), dating partner or ex-partner (n = 6), or a friend (n = 3). One survivor was assaulted by a stranger, one was assaulted by a family member, and two survivors 70
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were unsure who had assaulted them.2 Most survivors stated that physical force had been used against them during the assault (n = 12, 63%), and a weapon was used in one assault (5%). Half of the sample (n = 10, 50%) disclosed that they had been drinking alcohol at the time of the assault.
Procedures In research with minors, it is typical to seek parental consent for participation, but in this study, we obtained IRB approval for a substitute in loco parentis consent process. An alternative consent mechanism was necessary for two key reasons: (1) if the survivors had been assaulted by their parents or persons who have close relationships to their parents (e.g., a parent’s dating partner), seeking parental permission could have put them at risk; and (2) many adolescents do not disclose the assault to their parents, and asking parental permission could have seriously deterred their participation in the study. Therefore, the research team worked together with our IRB, the SANE program directors, and the affiliated RCC directors to construct an alternative consent process. During the assent/consent process, a RCC counselor sat with the interviewer and the participant while the interviewer explained the components of informed consent (e.g., participation risks, benefits, etc.). The interviewer then left the room so the counselor and the adolescent could talk privately. During this time, the counselor assessed whether the adolescent understood her rights as a research participant. If, in the counselor’s assessment, the adolescent indeed understood all elements of consent and was willing to participate, the counselor signed as a witness to the adolescent's assent signature. The counselor then left, and the interview was conducted privately between the participant and the interviewer. Interviews were conducted in-person by two female interviewers at the RCCs affiliated with the focal SANE programs. Both interviewers had extensive prior experience interviewing adult survivors of violence (Campbell, et al., 2010). Interviews were typically 90 minutes to 2 hours in duration. Participants received $30 in compensation for their time and a booklet of resources for sexual assault victims. Interviews were transcribed verbatim, and the research team met weekly to discuss each interview as a group. These procedures were approved by Michigan State University’s IRB.
Measures The interview was based on a prior study of adult sexual assault survivors’ experiences with SANE programs and the 2 These numbers do not sum to the total sample size (N = 20) because some survivors were victimized by multiple people with whom they had varying relationships (e.g., one was assaulted by a friend and an acquaintance).
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Original Article criminal justice system (Campbell, Bybee, Ford, Patterson, & Ferrell, 2009) but was modified to be developmentally appropriate for adolescent participants. The revised interview was reviewed by the SANE program directors and RCC directors for their input and approval. The final semistructured interview consisted of four main topics: (1) the assault itself, (2) the survivors’ initial disclosures, (3) their experiences with the SANE program, and (4) their interactions with the criminal justice system. This manuscript examines the portions of the transcripts pertaining to the adolescent victims’ experiences with the SANE programs.
Analytical Plan Data analysis proceeded in a two-phase process. First, consistent with Miles and Huberman’s (1994) concept of “data reduction,” three analysts independently read the transcripts and identified a preliminary list of themes mentioned by participants in regards to their experiences receiving services in the two focal SANE programs. In the second phase of data analysis, we used Erickson’s (1986) analytic induction method, which is an iterative procedure for developing and testing empirical assertions in qualitative research (see also Patton, 2002). In this approach, analysts review the data multiple times with the goal of arriving at a set of assertions that are substantiated based on a thorough understanding of the data. The next task is to establish whether each assertion is warranted by going back to the data and assembling, confirming, and disconfirming evidence. Analysts must look for five types of evidentiary inadequacy: (1) inadequate amount of evidence, (2) inadequate variety in the kinds of evidence, (3) faulty interpretative status of evidence (i.e., doubts about the accuracy of the data because of social desirability bias), (4) inadequate disconfirming evidence (i.e., no data were collected that could disconfirm a key assertion), and (5) inadequate discrepant case analysis (i.e., no cases exist that are contrary to a key assertion) ( Erickson, 1986, p. 140). Assertions are revised or eliminated based on their evidentiary adequacy until a set of well-warranted assertions remain. Three analysts worked together to develop assertions, and then one analyst tested the assertions for evidentiary inadequacy. After this process, the team met again to discuss which assertions needed modifications. This process continued until all three analysts were satisfied that the assertions were warranted by the data. Consistent with procedures recommended by Lincoln and Guba (1985), we used several strategies to enhance the credibility, confirmability, and dependability of our findings. To establish credibility (confidence in the “truth” of the findings), we had prolonged engagement in the research settings. Although direct observation of program services (i.e., sexual assault medical forensic exams) is not appropriate, several members of our team had extensive experience as community-based volunteer sexual assault Journal of Forensic Nursing
advocates. In addition, the research team had worked on multiple collaborative research projects with the focal SANE programs before the inception of this study (Campbell, Bybee, Ford, Patterson, & Ferrell, 2009). Throughout the study, research team members also regularly attended SANE program staff meetings. To ensure that the findings were grounded in the data (confirmability), we used open coding techniques to familiarize ourselves with the data before development of the analytical induction assertions. Furthermore, during the analyses, we repeatedly conducted a systematic search for disconfirming evidence (negative case analysis) as well as lack of sufficient evidence to support the assertions until only findings that were well-supported remained. Confirmability was also enhanced by the use of multiple analysts (MacQueen, McLellan-Lemal, Bartholow, & Milstein, 2008). Using a team process, the analysts discussed whether cases and quotes presented as evidence for findings truly supported the findings. Finally, dependability, or the stability of the research process, is typically shown through an audit trail. The analysts kept an audit trail documenting the various rounds of assertions, the problems that were identified with the assertions, and the corresponding revision.
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Results
The adolescent sexual assault victims we interviewed reported that they had consistently positive experiences with the focal SANE programs. It is important to note that both SANE programs work closely with their affiliate RCCs so that community-based victim advocates are onsite and available to help survivors throughout the examination process. As such, the SANE program is in fact a combined effort of both the forensic nurses and the victim advocates. In the interviews, we sought clarification as to whether the survivors’ positive experiences were with the nurses or the advocates, and invariably, we were met with the answer: It was both of them. The adolescents recognized that the nurses’ and advocates’ roles were different, but overall, they saw them as “the ladies” who took care of them.3 In our analyses below, we have highlighted quotations and findings specific to nursing practice, but it must be remembered that the patients’ positive regard for the program was because of the combined care of both professions (see also Campbell, 2006). We identified three specific aspects of SANE care that were particularly helpful and healing to the adolescent patients we interviewed. First, the nurses were sensitive to their patients’ physical and emotional needs throughout the examination. Second, the adolescents noted that the nurses were compassionate, caring, and personable. Finally, 3 At the time these data were collected, both SANE programs were staffed by female providers only (both nurses and advocates).
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Original Article the survivors deeply appreciated that the nurses believed and validated their accounts of the assault. Each of these three major findings will be described in detail below. Nearly all of the adolescents commented that a sexual assault medical examination is just plain awkward and uncomfortable, so the nurses’ sensitivity to their distress, embarrassment, and physical discomfort was appreciated. The teens noted that the nurses took the time to establish trust before conducting the examination and evidence collection. For example, a 15-year-old patient who was sexually assaulted after being drugged with gamma hydroxybutyrate (GHB) said: It was just like at first and stuff, it was just awkward and stuff. But the more we went into the process of it and all—she started off very calmly, and she did the hair and stuff, and then she went into the more touchy places and stuff, and I think that helped a lot, because it wasn’t like she went right for it. She just slowly got to into it. And she got my confidence and trust and stuff. The nurses’ sensitivity to their patients’ emotional needs was particularly important to the teens for whom the medical forensic examination was their first pelvic examination. Having the nurses explain each step carefully helped mitigate their confusion and embarrassment. For example, a 17-year-old survivor who was assaulted by an ex-boyfriend noted: She (the nurse) told me everything else she was doing, so it was very, it was my first gynecologist exam, so I was, it was very, they were very nice about it and told me exactly what they were doing and that sort. More than just explaining the examination (which was itself instrumental in addressing patients’ informational needs), the nurses let their adolescent patients decide for themselves whether they wanted each procedure/ step performed. The survivor quoted above went on to say:
the positive nature of their interpersonal interactions with the nurses and advocates. Addressing victims’ physical, informational, and emotional needs (as described previously) could be done in a very formal, professionalized way, but the teens we interviewed noted how much they appreciated that their nurses were “real” with them. Many of the adolescents we interviewed appreciated how the nurses expressed interest in them as people, not just patients. When nurses engaged in chit-chat about movies, clothes, friends, school, interests, and hobbies, it helped victims feel safe and comfortable. In particular, teens appreciated when their nurses could make them laugh or otherwise distract them, however briefly, from the discomfort of the examination and the psychological upheaval from the assault itself. For example, a 15-year-old survivor who had been assaulted by an acquaintance said: [The nurse] was able to make me laugh and kind of preoccupy my mind a little bit through the whole thing…the ladies there were really nice and like comforting…it is obviously not like fun at all to get examined, but she like made it so it , was like less bad, cause she would like talk to me…. So she is pretty cool. These “simple” things mattered so much to the victims because they were often emotionally overwhelmed—from the assault itself and from answering questions about the assault—and even a brief break to talk about anything else was helpful for their emotional regulation. One of the young women we interviewed was a 17-year-old survivor who was raped by her boyfriend. She was pregnant at the time, and the perpetrator assaulted her not only to harm her but also to threaten the sustainability of the fetus. Not surprisingly, she was emotionally spent during the examination, and she liked how her nurse was able to lighten the mood, respectfully and carefully, during such a difficult time:
She just like making sure that I knew what she was doing and I was like comfortable with it. Making sure that I knew that if it wasn’t something that I was comfortable with I didn’t have to do it.
Because I think through the whole depression part of it, and the whole sickening, sad part of when you feel all those emotions and stuff, just to have something preoccupy your mind for a few minutes helps.... It helped a lot for them to be nice, to be able to tell them the story and not feel uncomfortable or nervous.
Empowering patients to decide the scope of their care helps reinstate victims’ control and choice, which is important for all rape survivors, and it may be particularly meaningful to adolescent patients who are often struggling with autonomy and independence more generally. A second theme in the adolescents’ narratives about their experiences with these SANE programs emphasized
Attention to these interpersonal dynamics was important because, although the adolescents certainly wanted and needed information about the examination and wanted to be active participants in their care, they also needed “breaks,” moments of regular conversation, and reminders of their lives outside of the examination room.
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Original Article Finally, these young women, like nearly all rape survivors, were struggling with shame and self-blame from the assault, so when the nurses conveyed their belief in their patients’ accounts of what had happened in the assault, it was a tremendous relief. Many victims were trying to reconcile their experiences, and having an adult, particularly one in a position of knowledge and power, validate that what had happened to them was in fact a crime was inordinately helpful. To be clear, there was no indication in any of the interviews that the victims misinterpreted the nurses’ roles as that of legal fact-finders. Rather, they appreciated that someone believed them and that the nurse conveyed that belief to them directly. For instance, a 14-year-old survivor who had been assaulted by multiple perpetrators multiple times noted that, when her nurse and advocate directly told her that the assaults were not her fault, she said: Like that’s what made me like started to feel like a little bit better about it and stuff. Similarly, a 17-year-old who was assaulted by an acquaintance at a party was struggling with feelings of selfblame, which she expressed to her nurse and advocate: I told them that like I felt like, like I could have done something to change it, you know, like they kept telling me, no it is not your fault, that is not supposed to happen, you know… (it was good to hear that)…because it makes you feel like, you know, like you are not all alone, like you are not the only person that goes through it. The adolescents were also grateful that the nurses did not judge them for any of their choices or behaviors that preceded the assault, such as drinking or drug use. Many were expecting judgment or admonishment from the nurses, and when it did not happen, they noticed—and appreciated—its absence. The exchange below with 15-year-old young woman who had been assaulted by an acquaintance highlights this issue: Yeah, just something about them made me feel like I could tell them and they weren’t going to tell anybody and they weren’t going to judge me. Interviewer: Was there anything in particular that made you feel like they weren’t going to judge you or.... Just that after I told them what happened, their voices didn’t change, the way that they looked at me, like they didn’t give me dirty looks or just kind of brush me off or nothing. Journal of Forensic Nursing
Similarly, another 15-year-old survivor noted: They hardly brought it up (the fact that she had been drinking prior to the assault). The nurse didn't bring it up at all…But then, [the advocate], and stuff we were talking about, like how all teenagers drink and stuff. And she was all like, yeah, I was the teenager 15 years ago, and I was doing it. So it’s not like they were judging me. They were more like on my side and stuff, like, “Everybody does it, it's not your fault.” This young woman was grateful that her nurse did not comment upon the fact that she had been drinking before the assault—it was a welcome relief from how others had questioned her about it and judged her behavior. And yet, the victim did have lingering concerns about it, which she was able to air with the advocate who was able to listen sympathetically and reassure that, whatever choices she had made, it was not her fault that she had been sexually assaulted.
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Discussion
Adolescents are at high risk for sexual assault, but unfortunately, most do not seek postassault medical care (Bromann-Fulks et al., 2007; Nofziger & Stein, 2006). SANE programs are well positioned to address adolescent survivors’ physical and emotional needs, provided that care is patient centered and developmentally appropriate. In this study, we identified three aspects of SANE care that adolescents found particularly helpful and healing: sensitivity to needs, compassionate care, and belief and validation. These findings are consistent with prior research with adult patients (Campbell et al., 2008; DuMont et al., 2009; Ericksen et al., 2002) yet highlight some specific aspects of emotional care that may be unique to adolescent victims.
Implications for Forensic Nursing Practice First, sensitivity to patients’ physical information and emotional needs is paramount, and for pubescent patients, healthcare practitioners must be attuned to the possibility that the medical forensic examination may be the patients’ first pelvic examination and, as such, they may be wholly unprepared to communicate with healthcare practitioners about gynecological/sexual health issues. The adolescents we interviewed appreciated that nurses explained these issues in ways that were informative, without being condescending. Second, providing compassionate care is essential for all sexual assault patients, and with adolescents, nurses should keep in mind that emotion regulation can be difficult in adolescence generally (Saarni, 1999; Saarni et al., 2006), which will be further challenged during traumatic events. The emotional intensity of the assault itself plus the medical forensic examination can be overwhelming www.journalforensicnursing.com
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Original Article and taxing to adolescents’ still-developing coping mechanisms. The adolescents we interviewed stated that it was particularly helpful when the nurses would help them “check out” for a moment to talk about other topics, which is a well-established crisis intervention strategy for dealing with individuals in crisis (Ruzek et al., 2007). Finally, many of these young women had engaged in illegal and/or risky behavior before the assault (e.g., alcohol/drug use), and they were expecting not only judgment from the nurses but, possibly, punishment as well. Reminding patients that such behaviors do not make the victim at fault is important for all patients, but for teen victims, the worry about additional repercussions is paramount. The survivors we interviewed were pleasantly surprised that both the nurses and advocates did not judge them for their behavior and assured them that they would not get them in trouble for it. Taken together, these findings suggest that compassionate care must be developmentally informed, such that basic patient-centered practices (e.g., belief and validation) are age sensitive and age appropriate. However, given the dearth of research specific to adolescent populations, we do not yet know what exactly those developmental differences are and how they should be attended to in practice. This study helps address this gap in the literature, but future research is needed to delineate the specific practice differences between adult and adolescent populations.
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Limitations
There are two significant limitations of this study that must be noted. First, the two focal SANE programs are community-based programs that have strong organizational linkages with their partner RCC. These programmatic features are not limitations, but they are somewhat unusual with respect to national data regarding SANE programs' structure, function, and operations (Campbell et al., 2005; Logan, Cole, & Capillo, 2007). Most SANE programs are hospital based, and although most work with victim advocates, it is unclear how many programs have the kind of deep organizational commitment to advocacy as did the programs studied in this research project. As noted previously, victims’ positive perceptions of the care they received were because of the combined efforts of both the nurses and the advocates. Whether these same results would occur in programs with different philosophies, organizational affiliations, and practice principles is unknown. It would be premature to conclude from this study that SANE programs are effective in addressing adolescent patients’ emotional need as there are over 600 SANE programs in existence (IAFN, 2012), and this project was in-depth study of patient outcomes in two programs. Future research is needed to examine if differences in SANE program structure, function, and practice are associated with different patient outcomes. 74
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Second, the racial/ethnic diversity of this sample was limited (75% were White). Whereas these demographics are consistent with the racial/ethnic makeup of the focal counties, the underrepresentation of ethnic minority survivors is a serious limitation. Previous studies have established that ethnic minority victims have markedly different help-seeking experiences, most notably, increased negativity to disclosures of sexual assault and decreased provision of help (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001; Ullman & Filipas, 2001). As such, there is a pressing need for qualitative research with ethnic minority adolescent survivors to understand how these forms of oppression shape their help-seeking experiences. Despite these limitations, the results of this research can help inform outreach efforts to adolescent populations.
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Conclusion
Over the past 20 years, there have been substantial national efforts to increase rape awareness education and rape prevention programming for youth (Centers for Disease Control, 2004). Our findings suggest that such efforts need to emphasize not only the services provided by SANE programs (i.e., what is provided) but their patientcentered philosophy as well (i.e., how it is provided). The results of this study highlight some of teens’ key concerns about seeking help: confusion, shame, self-blame, judgment, and the risk of punishment. Community outreach efforts that directly address these concerns may be particularly helpful in linking this vulnerable population to needed postassault services.
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References
Broman-Fulks J. J., Ruggiero, K. J., Hanson, R. F., Smith, D. W., Resnick, H. S., Kilpatrick, D. G., & Saunders, B. E. (2007). Sexual assault disclosure in relation to adolescent mental health: Results from the national survey of adolescents. Journal of Clinical Child and Adolescent Psychology, 36, 260–266. Campbell, R. (2006). Rape survivors’ experiences with the legal and medical systems: Do rape victim advocates make a difference? Violence Against Women, 12, 1–16. Campbell, R., Bybee, D., Ford, J. K., Patterson, D., & Ferrell, J. (2009). A systems change analysis of SANE programs: Identifying mediating mechanisms of criminal justice system impact. Washington, DC: National Institute of Justice. Campbell, R., Greeson, M. R., Bybee, D., Kennedy, A., & Patterson, D. (2010). Adolescent sexual assault victims’ experiences with SANE-SARTs and the criminal justice system. Washington, DC: National Institute of Justice. Campbell, R., Patterson, D., Adams, A. E., Diegel, R., & Coats, S. (2008). A participatory evaluation project to measure SANE nursing practice and adult sexual assault patients’ psychological well-being. Journal of Forensic Nursing, 4, 19–28. Campbell, R., Patterson, D., & Bybee, D. (2012). Prosecution of adult sexual assault cases: A longitudinal analysis of the impact of a sexual assault nurse examiner (SANE) program. Violence Against Women, 18, 223–244. Campbell, R., Patterson, D., & Fehler-Cabral, G. (2010). Using ecological theory to evaluate the effectiveness of an indigenous Volume 9 • Number 2 • April-June 2013
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Original Article community intervention: A study of sexual assault nurse examiner (SANE) programs. American Journal of Community Psychology, 46, 263–276. Campbell, R., Patterson, D., & Lichty, L. F. (2005). The effectiveness of sexual assault nurse examiner (SANE) program: A review of psychological, medical, legal, and community outcomes. Trauma, Violence, & Abuse: A Review Journal, 6, 313–329. Campbell, R., Townsend, S. M., Long, S. M., Kinnison, K. E., Pulley, E. M., Adames, S. B., & Wasco, S. M. (2005). Organizational characteristics of sexual assault nurse examiner programs: Results from the national survey of SANE programs. Journal of Forensic Nursing, 1, 57–64. Campbell, R., Townsend, S. M., Long, S. M., Kinnison, K. E., Pulley, E. M., Adames, S. B. , & Wasco, S. M. (2006). Responding to sexual assault victims' medical and emotional needs: A national study of the services provided by SANE programs. Research in Nursing & Health, 29, 384–398. Campbell, R., Wasco, S. M., Ahrens, C. E., Sefl, T., & Barnes, H. E. , (2001). Preventing the “second rape”: Rape survivors experiences with community service providers. Journal of Interpersonal Violence, 16, 1239–1259. Casey, E. A., & Nurius, P. S. (2006). Trends in the prevalence and characteristics of sexual assault: A cohort analysis. Violence & Victims, 21, 629–644. , Centers for Disease Control. (2004). CDC s rape prevention and education grant program: Preventing sexual violence in the United States 2004. Atlanta, GA: National Center for Injury Prevention and Control, U.S. Centers for Disease Control. Retrieved from http://www.cdc.gov/ncipc/pub-res/pdf/RPE%20AAG.pdf DuMont, J., White, D., & McGregor, M. J. (2009). Investigating the medical forensic examinations from the perspectives of sexually abused women. Social Science & Medicine, 68, 774–780. Ericksen, J., Dudley, C., McIntosh, G., Ritch, L., Shumay, S., & Simpson, M. , (2002). Clients experiences with a specialized sexual assault service. Journal of Emergency Nursing, 28, 86–90. Erickson, F. (1986). Qualitative methods in research on teaching. In M. C. Wittrock (Ed.), Handbook of research on teaching (pp. 119–161). London, UK: Macmillan. Fehler-Cabral, G., Campbell, R., & Patterson, G. (2011). Adult sexual assault survivors' experiences with sexual assault nurse examiners (SANEs). Journal of Interpersonal Violence, 26, 3618–3639. Finkelhor, D., Turner, H., Ormrod, R., & Hamby, S. L. (2009). Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics, 124, 1411–1423. Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18, 59–82. Howard, D. E., Wang, M. Q., & Yan, F. (2007). Prevalence and psychosocial correlates of forced sexual intercourse among U.S. high school students. Adolescence, 42, 629–643. IAFN. (2012). Data base of the international association of forensic nurses. Retrieved from http://www.forensicnurse.org Jones, J. S., Rossman, L., Wynn, B. N., Dunnuck, C., & Schwartz N. (2008). Comparative analysis of adult versus adolescent sexual assault: Epidemiology and patterns of anogential injury. Academic Emergency Medicine, 10, 872–877. Kogan, S. M. (2004). Disclosing unwanted sexual experiences: Results from a national sample of adolescent women. Child Abuse & Neglect, 28, 147–165. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage. Logan, T., Cole, J., & Capillo, A. (2007). Sexual assault nurse examiner program characteristics, barriers, and lessons learned. Journal of Forensic Nursing, 3, 24–34.
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Lynch, V. A. (2006). Forensic nursing science. In R. M. Hammer, B. Moynihan, & E. M. Pagliaro (Eds.), Forensic nursing: A handbook for practice (pp. 1–40). Sudbury, MA: Jones and Bartlett. MacQueen, K. M., McLellan-Lemal, E., Bartholow, K., & Milstein, B. (2008). Team-based codebook development: Structure, process, and agreement. In G. Guest & K. M. MacQueen (Eds.), Handbook for team-based qualitative research (pp. 119–136). Lanham, MD: Altamira/Rowman & Littlefield. McCart, M. R., Zajac, K., Danielson, C. K., Strachan, M., Ruggiero, K. J., Smith, D. W., … Kilpatrick, D. G. (2010). Interpersonal victimization, posttraumatic stress disorder, and change in adolescent substance use prevalence over a ten-year period. Journal of Clinical Child & Adolescent Psychiatry, 40, 136–143. McCauley, J. L., Conoscenti, L. M., Ruggiero, K. J., Resnick, H. S., Saunders, B. E., & Kilpatrick, D.G. (2009). Prevalence and correlates of drug/alcohol-facilitated and incapacitated sexual assault in a nationally representative sample of adolescent girls. Journal of Clinical Child & Adolescent Psychology, 38, 295–300. Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook. Thousand Oaks, CA: Sage. Nofziger, S., & Stein, R. E. (2006). To tell or not to tell: Lifestyle impacts on whether adolescents tell about violent victimization. Violence & Victims, 21, 371–382. Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Raghavan, R., Bogart, L. M., Elliott, M. N., Vestal, K. D., & Schuster, M. A. (2004). Sexual victimization among a national probability sample of adolescent women. Perspectives on Sexual and Reproductive Health, 36, 225–232. Rickwood, D., Deane, F. P., Wilson, C. J., & Ciarrochi, J. (2005). Young , people s help-seeking for mental health problems. Australian E-Journal for the Advancement of Mental Health, 4, 1–34. Ruzek, J. I., Brymer, M. J., Jacobs, A. K., Layne, C. M., Vernberg, E. M., & Watson, P. J. (2007). Psychological first aid. Journal of Mental Health Counseling, 29, 17–49. Saarni, C. (1999). The development of emotional competence. New York, NY: Guilford. Saarni, C., Campos, J. J., Camras, L., & Witherington, D. (2006). Emotional development. In W. Damon & R. Lerner (Eds.), Handbook of child psychology (6th ed.). New York, NY: Wiley. Sandelowski, M. (1995). Sample size in qualitative research. Research in Nursing & Health, 18, 179–183. Snyder, H. N. (2000). Sexual assault of young children as reported to law enforcement: Victim, incident, and offender characteristics. Washington, DC: National Center for Juvenile Justice, U.S. Department of Justice. Snyder, H. N., & Sickmund, M. (2006). Juvenile offenders and victims: 2006 national report. Washington, DC: National Center for Juvenile Justice, U.S. Department of Justice. Starks, H. & Trinidad, S. B. (2007). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17, 1372–1380. Ullman, S. E., & H. H. Filipas (2001). Predictors of PTSD severity and social reactions in sexual assault victims. Journal of Traumatic Stress, 14, 369–389. Wilson, C. J., & Deane, F. P. (2001). Adolescent opinion about reducing help-seeking barriers and increasing appropriate help engagement. Journal of Educational and Psychological Consultation, 12, 345–364. Young, A. M., Grey, M., & Boyd, C. J. (2009). Adolescents’ experiences of sexual assault by peers: Prevalence and nature of victimization occurring within and outside of school. Journal of Youth and Adolescence, 38, 1072–1083.
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With Care and Compassion: Adolescent Sexual Assault Victims' Experiences in Sexual Assault Nurse Examiner Programs Rebecca Campbell, PhD, Megan R. Greeson, MA, and Giannina Fehler-Cabral, PhD
ABSTRACT In this study, we conducted in-depth qualitative interviews with 20 adolescent sexual assault patients aged 14–17 years who sought postassault medical forensic examinations at one of two Midwestern Sexual Assault Nurse Examiner programs. Our goals were to examine how adolescent victims characterized the quality of the emotional/interpersonal care they received and to identify specific aspects of Sexual Assault Nurse Examiner nursing practice that were helpful and healing. Overall, the patients had very positive experiences with both programs. The nurses were sensitive to their patients’ physical and emotional needs throughout the examination. The adolescents also noted that the nurses were compassionate, caring, and personable. Finally, the survivors deeply appreciated that the nurses believed and validated their accounts of the assault. These findings suggest that compassionate care must be developmentally informed, such that basic patient-centered practices (e.g., belief and validation) are age sensitive and age appropriate. KEY WORDS: adolescent patients; emotional well-being; psychological health outcomes; rape; sexual assault; Sexual Assault Nurse Examiner (SANE) programs
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dolescents aged 12–17 years are at high risk for sexual assault (Finkelhor, Turner, Ormrod, & Hamby, 2009; Howard, Wang, & Yan, 2007; McCart et al., 2010; McCauley et al., 2009; Raghavan, Bogart, Elliott, Vestal, & Schuster, 2004; Young, Grey, & Boyd, 2009). The National Juvenile Justice Center has found that adolescents are the largest group of sexual assault victims and are twice as likely to be sexually victimized as adults (Snyder, 2000; Snyder & Sickmund, 2006).1 Yet, adolescents are less likely than adults to seek postassault help from the medical or legal systems (BromanFulks et al., 2007; Casey & Nurius, 2006; Kogan, 2004;
Nofziger & Stein, 2006). Teens may be reluctant to seek help because of shame and stigma (Rickwood, Deane, Wilson, & Ciarrochi, 2005; Wilson & Deane, 2001) but also because they simply do not know what services are available. To address these barriers and improve healthcare outcomes for adolescent patients, many Sexual Assault Nurse Examiner (SANE) programs have made concerted outreach efforts so that their communities are aware of the services they provide. Nearly all SANE programs serve adolescent patients (IAFN, 2012), but little is known about this specific population and their experiences seeking sexual assault care.
Author Affiliation: Michigan State University. This research was supported by a grant from the National Institute of Justice awarded to the first author (2007-WG-BX-0012). The opinions or points of view expressed in this document are those of the authors and do not reflect the official position of the U.S. Department of Justice. The authors declare no conflicts of interest. Correspondence: Rebecca Campbell, PhD, Department of Psychology, Michigan State University, 127 C Psychology Building, East Lansing, MI 48824–1116. E-mail: [email protected]. Copyright © 2013 International Association of Forensic Nurses DOI: 10.1097/JFN.0b013e31828badfa
1 We recognize that there are multidisciplinary differences in the terms used to refer to those who have been raped/sexually assaulted: Law enforcement and prosecutors tend to use the term “victim” to reflect the criminal nature of this act, forensic nurses use the term “patient” to reflect their primary role of providing health care to these individuals, and rape crisis center advocates and mental health professionals use “survivor” to convey the strength of those who have been raped/sexually assaulted. In this manuscript, we will use the terms “victim” and “survivor” interchangeably to reflect that sexual assault is a violent crime that takes tremendous strength and courage to survive; we will also use the term “patient” in presenting results regarding the interactions between the nurses and the victims they treated.
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Original Article To date, most research on SANE programs has focused on legal and forensic outcomes among adult patients (Campbell, Patterson, & Bybee, 2012; for reviews, see Campbell, Patterson & Lichty, 2005a). Given the tremendous utility of SANE programs to the criminal justice system (Campbell, Patterson & Fehler-Cabral, 2010), it is not surprising that there has been such a strong interest in this topic. However, most victims seeking postassault medical care do so for health-related reasons (e.g., emergency contraception, care of injuries, STI prophylaxis, crisis intervention; DuMont, White, & McGregor, 2009). Indeed, the field of forensic nursing defines its primary role as that of healthcare providers (Lynch, 2006). Prior research has found that SANE programs provide more comprehensive care to sexual assault patients than what is typically offered in non-SANE hospital-based emergency departments (Campbell et al., 2006). Yet, how SANE programs address the emotional health needs of their patients is still an understudied topic. Only a handful of studies have examined the extent to which patients feel SANE care was psychologically beneficial, and all of this work has been conducted with adult samples. For instance, Ericksen et al. (2002) conducted semistructured qualitative interviews with eight adult sexual assault patients who sought care from a Canadian specialized sexual assault treatment center. They identified nine major themes in the patients’ narratives regarding how the program affected their emotional well-being: (1) they felt their needs were met and they were treated with dignity and respect; (2) the nursing staff provided information about what to expect and listened to the survivors; (3) they felt safe; (4) they appreciated how the nurses were careful about how they physically touched their patients; (5) they felt in control and were given options and were not pushed toward certain choices; (6) they felt reassured, believed and supported by the staff; (7) they felt they were cared for by people with expertise (i.e., the providers were knowledgeable and well-trained); (8) they were given needed information, but the staff were careful not to overwhelm them; and (9) they felt cared for beyond the hospital in that they received information on follow-up care. Similar results were obtained in qualitative studies by DuMont et al. (2009) in Canada and by Fehler-Cabral, Campbell, and Patterson (2011) in the United States. Both research teams found that adult survivors were overwhelmingly positive about the quality of the care they received, noting that, although the examination itself was difficult, the nurses treated them with care and respect. These qualitative findings are consistent with the results of a quantitative study by Campbell, Patterson, Adams, Diegel, and Coats (2008) with adult sexual assault survivors who sought care from an American SANE program. In this project, adult patients used a 4-point scale (1 = not at all, 2 = a little, 3 = somewhat, and 4 = a lot/completely) Journal of Forensic Nursing
to indicate the degree to which they felt cared for, treated with compassion and respect, supported, believed, and informed by the nurses. All patients (100%) used the highest rating (a lot/completely) for outcomes regarding care and compassion, feeling informed, clear instructions for medication, and recontacting the program if they had problems or concerns. Somewhat lower ratings were obtained for the items regarding feeling in control during the examination process (71% endorsed this item with the highest rating), although patients noted that they did feel well-informed and knew they had the option to refuse any portion of the examination. Whether these same positive psychological outcomes occur for adolescent patients is unknown. This issue is important to examine because, although the forensic components for adult and adolescent examinations are similar, recent research has found that adolescents differ from adults with respect to anogenital injuries (Jones, Rossman, Wynn, Dunnuck, & Schwartz, 2008), indicating that these populations may have distinct healthcare needs. It is possible that the emotional healthcare needs may also differ for adolescents given their stage of psychological development (Saarni, 1999; Saarni, Campos, Camras, & Witherington, 2006). Adolescence is a unique developmental period, often characterized by resistance to adult authority figures, which could include adult forensic nurses. In addition, adolescents may engage in behaviors before an assault that may be illegal (or illegal for their age; e.g., drinking and using drugs), and it is critical that service providers know how to respond to these issues in ways that are perceived as supportive and patient centered. Understanding how adolescents perceive the care they have received from SANE programs and the extent to which they feel it was psychologically beneficial can inform recommendations for nursing practice as well as outreach efforts to this vulnerable population. To that end, this study was a qualitative investigation of adolescent survivors who obtained medical forensic examinations from one of two Midwestern SANE Programs. Our goals were to examine how adolescent sexual assault patients characterized the quality of the emotional/interpersonal care they received and to identify specific aspects of SANE nursing practice that were helpful and healing.
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Methods Sample We collaborated with two Midwestern SANE programs and their rape crisis center (RCC) affiliates to identify adolescents who had been recently sexually assaulted. Both SANE programs were in the same state and were equivalent with respect to program practices, staffing, population served, and patient demographics (Campbell, Greeson, Bybee, Kennedy, & Patterson, 2010). The target sample for www.journalforensicnursing.com
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Original Article this study was adolescent sexual assault victims 14–17 years old who received a full medical forensic examination from one of the two focal SANE programs. The age of our sample was restricted to 14–17 years because, in the state in which the study was conducted, minors are able to consent to certain services, including mental health and STI treatment, at the age of 14 years. Therefore, the research team, in collaboration with our community partners and our university’s institutional review board (IRB), decided to limit the sample to adolescents at least 14 years old so that this study would be in congruence with state laws regarding minors’ ability to consent. A prospective sampling strategy was used to recruit adolescent sexual assault victims, whereby nurses in both programs provided all eligible patients with information about the study. It was mutually decided by the IRB, the nurses, and the evaluation team that the nurses should be the ones to introduce the study to their patients, emphasizing that the evaluation team was not affiliated with the program and the patients’ participation (or nonparticipation) in the evaluation would not affect their care/services from the SANE program. Patients were then asked whether they were willing to be contacted at a later date by a member of the research team; if so, patients completed an “Agree to be Contacted Form,” which asked them to provide guidance on how and when they could be reached so that their privacy and safety would be protected. This paperwork emphasized that, by providing their information, patients were only agreeing to be contacted about the study but were not committing to participate. Victims who agreed to be contacted were called by a research assistant (who was not affiliated with the SANE program) approximately 3–4 weeks after the date they completed the form. All interviews were conducted by PhD-level graduate students in psychology who had extensive prior experience interviewing sexual assault survivors. Participant recruitment and interviewing continued until we achieved saturation, whereby the same themes were repeated, with no new themes emerging among participants (Guest, Bunce, & Johnson, 2006; Sandelowski, 1995; Starks & Trinidad, 2007). All 20 adolescents were female; most were White (n = 15, 75%), three participants were African-American (15%), one was Asian-American (5%), and one was multiracial (5%). Survivors’ ages were fairly evenly distributed. At the time of the assault, 15% were 14 years old, (n = 3), 30% were 15 years old (n = 6), 30% were 16 years old (n = 6), and 25% were 17 years old (n = 5). Most survivors were assaulted by one person (n = 17, 85%), but three of the participants were victimized by multiple assailants (15%). Most often, the assailant was an acquaintance (n = 9), dating partner or ex-partner (n = 6), or a friend (n = 3). One survivor was assaulted by a stranger, one was assaulted by a family member, and two survivors 70
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were unsure who had assaulted them.2 Most survivors stated that physical force had been used against them during the assault (n = 12, 63%), and a weapon was used in one assault (5%). Half of the sample (n = 10, 50%) disclosed that they had been drinking alcohol at the time of the assault.
Procedures In research with minors, it is typical to seek parental consent for participation, but in this study, we obtained IRB approval for a substitute in loco parentis consent process. An alternative consent mechanism was necessary for two key reasons: (1) if the survivors had been assaulted by their parents or persons who have close relationships to their parents (e.g., a parent’s dating partner), seeking parental permission could have put them at risk; and (2) many adolescents do not disclose the assault to their parents, and asking parental permission could have seriously deterred their participation in the study. Therefore, the research team worked together with our IRB, the SANE program directors, and the affiliated RCC directors to construct an alternative consent process. During the assent/consent process, a RCC counselor sat with the interviewer and the participant while the interviewer explained the components of informed consent (e.g., participation risks, benefits, etc.). The interviewer then left the room so the counselor and the adolescent could talk privately. During this time, the counselor assessed whether the adolescent understood her rights as a research participant. If, in the counselor’s assessment, the adolescent indeed understood all elements of consent and was willing to participate, the counselor signed as a witness to the adolescent's assent signature. The counselor then left, and the interview was conducted privately between the participant and the interviewer. Interviews were conducted in-person by two female interviewers at the RCCs affiliated with the focal SANE programs. Both interviewers had extensive prior experience interviewing adult survivors of violence (Campbell, et al., 2010). Interviews were typically 90 minutes to 2 hours in duration. Participants received $30 in compensation for their time and a booklet of resources for sexual assault victims. Interviews were transcribed verbatim, and the research team met weekly to discuss each interview as a group. These procedures were approved by Michigan State University’s IRB.
Measures The interview was based on a prior study of adult sexual assault survivors’ experiences with SANE programs and the 2 These numbers do not sum to the total sample size (N = 20) because some survivors were victimized by multiple people with whom they had varying relationships (e.g., one was assaulted by a friend and an acquaintance).
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Original Article criminal justice system (Campbell, Bybee, Ford, Patterson, & Ferrell, 2009) but was modified to be developmentally appropriate for adolescent participants. The revised interview was reviewed by the SANE program directors and RCC directors for their input and approval. The final semistructured interview consisted of four main topics: (1) the assault itself, (2) the survivors’ initial disclosures, (3) their experiences with the SANE program, and (4) their interactions with the criminal justice system. This manuscript examines the portions of the transcripts pertaining to the adolescent victims’ experiences with the SANE programs.
Analytical Plan Data analysis proceeded in a two-phase process. First, consistent with Miles and Huberman’s (1994) concept of “data reduction,” three analysts independently read the transcripts and identified a preliminary list of themes mentioned by participants in regards to their experiences receiving services in the two focal SANE programs. In the second phase of data analysis, we used Erickson’s (1986) analytic induction method, which is an iterative procedure for developing and testing empirical assertions in qualitative research (see also Patton, 2002). In this approach, analysts review the data multiple times with the goal of arriving at a set of assertions that are substantiated based on a thorough understanding of the data. The next task is to establish whether each assertion is warranted by going back to the data and assembling, confirming, and disconfirming evidence. Analysts must look for five types of evidentiary inadequacy: (1) inadequate amount of evidence, (2) inadequate variety in the kinds of evidence, (3) faulty interpretative status of evidence (i.e., doubts about the accuracy of the data because of social desirability bias), (4) inadequate disconfirming evidence (i.e., no data were collected that could disconfirm a key assertion), and (5) inadequate discrepant case analysis (i.e., no cases exist that are contrary to a key assertion) ( Erickson, 1986, p. 140). Assertions are revised or eliminated based on their evidentiary adequacy until a set of well-warranted assertions remain. Three analysts worked together to develop assertions, and then one analyst tested the assertions for evidentiary inadequacy. After this process, the team met again to discuss which assertions needed modifications. This process continued until all three analysts were satisfied that the assertions were warranted by the data. Consistent with procedures recommended by Lincoln and Guba (1985), we used several strategies to enhance the credibility, confirmability, and dependability of our findings. To establish credibility (confidence in the “truth” of the findings), we had prolonged engagement in the research settings. Although direct observation of program services (i.e., sexual assault medical forensic exams) is not appropriate, several members of our team had extensive experience as community-based volunteer sexual assault Journal of Forensic Nursing
advocates. In addition, the research team had worked on multiple collaborative research projects with the focal SANE programs before the inception of this study (Campbell, Bybee, Ford, Patterson, & Ferrell, 2009). Throughout the study, research team members also regularly attended SANE program staff meetings. To ensure that the findings were grounded in the data (confirmability), we used open coding techniques to familiarize ourselves with the data before development of the analytical induction assertions. Furthermore, during the analyses, we repeatedly conducted a systematic search for disconfirming evidence (negative case analysis) as well as lack of sufficient evidence to support the assertions until only findings that were well-supported remained. Confirmability was also enhanced by the use of multiple analysts (MacQueen, McLellan-Lemal, Bartholow, & Milstein, 2008). Using a team process, the analysts discussed whether cases and quotes presented as evidence for findings truly supported the findings. Finally, dependability, or the stability of the research process, is typically shown through an audit trail. The analysts kept an audit trail documenting the various rounds of assertions, the problems that were identified with the assertions, and the corresponding revision.
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Results
The adolescent sexual assault victims we interviewed reported that they had consistently positive experiences with the focal SANE programs. It is important to note that both SANE programs work closely with their affiliate RCCs so that community-based victim advocates are onsite and available to help survivors throughout the examination process. As such, the SANE program is in fact a combined effort of both the forensic nurses and the victim advocates. In the interviews, we sought clarification as to whether the survivors’ positive experiences were with the nurses or the advocates, and invariably, we were met with the answer: It was both of them. The adolescents recognized that the nurses’ and advocates’ roles were different, but overall, they saw them as “the ladies” who took care of them.3 In our analyses below, we have highlighted quotations and findings specific to nursing practice, but it must be remembered that the patients’ positive regard for the program was because of the combined care of both professions (see also Campbell, 2006). We identified three specific aspects of SANE care that were particularly helpful and healing to the adolescent patients we interviewed. First, the nurses were sensitive to their patients’ physical and emotional needs throughout the examination. Second, the adolescents noted that the nurses were compassionate, caring, and personable. Finally, 3 At the time these data were collected, both SANE programs were staffed by female providers only (both nurses and advocates).
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Original Article the survivors deeply appreciated that the nurses believed and validated their accounts of the assault. Each of these three major findings will be described in detail below. Nearly all of the adolescents commented that a sexual assault medical examination is just plain awkward and uncomfortable, so the nurses’ sensitivity to their distress, embarrassment, and physical discomfort was appreciated. The teens noted that the nurses took the time to establish trust before conducting the examination and evidence collection. For example, a 15-year-old patient who was sexually assaulted after being drugged with gamma hydroxybutyrate (GHB) said: It was just like at first and stuff, it was just awkward and stuff. But the more we went into the process of it and all—she started off very calmly, and she did the hair and stuff, and then she went into the more touchy places and stuff, and I think that helped a lot, because it wasn’t like she went right for it. She just slowly got to into it. And she got my confidence and trust and stuff. The nurses’ sensitivity to their patients’ emotional needs was particularly important to the teens for whom the medical forensic examination was their first pelvic examination. Having the nurses explain each step carefully helped mitigate their confusion and embarrassment. For example, a 17-year-old survivor who was assaulted by an ex-boyfriend noted: She (the nurse) told me everything else she was doing, so it was very, it was my first gynecologist exam, so I was, it was very, they were very nice about it and told me exactly what they were doing and that sort. More than just explaining the examination (which was itself instrumental in addressing patients’ informational needs), the nurses let their adolescent patients decide for themselves whether they wanted each procedure/ step performed. The survivor quoted above went on to say:
the positive nature of their interpersonal interactions with the nurses and advocates. Addressing victims’ physical, informational, and emotional needs (as described previously) could be done in a very formal, professionalized way, but the teens we interviewed noted how much they appreciated that their nurses were “real” with them. Many of the adolescents we interviewed appreciated how the nurses expressed interest in them as people, not just patients. When nurses engaged in chit-chat about movies, clothes, friends, school, interests, and hobbies, it helped victims feel safe and comfortable. In particular, teens appreciated when their nurses could make them laugh or otherwise distract them, however briefly, from the discomfort of the examination and the psychological upheaval from the assault itself. For example, a 15-year-old survivor who had been assaulted by an acquaintance said: [The nurse] was able to make me laugh and kind of preoccupy my mind a little bit through the whole thing…the ladies there were really nice and like comforting…it is obviously not like fun at all to get examined, but she like made it so it , was like less bad, cause she would like talk to me…. So she is pretty cool. These “simple” things mattered so much to the victims because they were often emotionally overwhelmed—from the assault itself and from answering questions about the assault—and even a brief break to talk about anything else was helpful for their emotional regulation. One of the young women we interviewed was a 17-year-old survivor who was raped by her boyfriend. She was pregnant at the time, and the perpetrator assaulted her not only to harm her but also to threaten the sustainability of the fetus. Not surprisingly, she was emotionally spent during the examination, and she liked how her nurse was able to lighten the mood, respectfully and carefully, during such a difficult time:
She just like making sure that I knew what she was doing and I was like comfortable with it. Making sure that I knew that if it wasn’t something that I was comfortable with I didn’t have to do it.
Because I think through the whole depression part of it, and the whole sickening, sad part of when you feel all those emotions and stuff, just to have something preoccupy your mind for a few minutes helps.... It helped a lot for them to be nice, to be able to tell them the story and not feel uncomfortable or nervous.
Empowering patients to decide the scope of their care helps reinstate victims’ control and choice, which is important for all rape survivors, and it may be particularly meaningful to adolescent patients who are often struggling with autonomy and independence more generally. A second theme in the adolescents’ narratives about their experiences with these SANE programs emphasized
Attention to these interpersonal dynamics was important because, although the adolescents certainly wanted and needed information about the examination and wanted to be active participants in their care, they also needed “breaks,” moments of regular conversation, and reminders of their lives outside of the examination room.
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Original Article Finally, these young women, like nearly all rape survivors, were struggling with shame and self-blame from the assault, so when the nurses conveyed their belief in their patients’ accounts of what had happened in the assault, it was a tremendous relief. Many victims were trying to reconcile their experiences, and having an adult, particularly one in a position of knowledge and power, validate that what had happened to them was in fact a crime was inordinately helpful. To be clear, there was no indication in any of the interviews that the victims misinterpreted the nurses’ roles as that of legal fact-finders. Rather, they appreciated that someone believed them and that the nurse conveyed that belief to them directly. For instance, a 14-year-old survivor who had been assaulted by multiple perpetrators multiple times noted that, when her nurse and advocate directly told her that the assaults were not her fault, she said: Like that’s what made me like started to feel like a little bit better about it and stuff. Similarly, a 17-year-old who was assaulted by an acquaintance at a party was struggling with feelings of selfblame, which she expressed to her nurse and advocate: I told them that like I felt like, like I could have done something to change it, you know, like they kept telling me, no it is not your fault, that is not supposed to happen, you know… (it was good to hear that)…because it makes you feel like, you know, like you are not all alone, like you are not the only person that goes through it. The adolescents were also grateful that the nurses did not judge them for any of their choices or behaviors that preceded the assault, such as drinking or drug use. Many were expecting judgment or admonishment from the nurses, and when it did not happen, they noticed—and appreciated—its absence. The exchange below with 15-year-old young woman who had been assaulted by an acquaintance highlights this issue: Yeah, just something about them made me feel like I could tell them and they weren’t going to tell anybody and they weren’t going to judge me. Interviewer: Was there anything in particular that made you feel like they weren’t going to judge you or.... Just that after I told them what happened, their voices didn’t change, the way that they looked at me, like they didn’t give me dirty looks or just kind of brush me off or nothing. Journal of Forensic Nursing
Similarly, another 15-year-old survivor noted: They hardly brought it up (the fact that she had been drinking prior to the assault). The nurse didn't bring it up at all…But then, [the advocate], and stuff we were talking about, like how all teenagers drink and stuff. And she was all like, yeah, I was the teenager 15 years ago, and I was doing it. So it’s not like they were judging me. They were more like on my side and stuff, like, “Everybody does it, it's not your fault.” This young woman was grateful that her nurse did not comment upon the fact that she had been drinking before the assault—it was a welcome relief from how others had questioned her about it and judged her behavior. And yet, the victim did have lingering concerns about it, which she was able to air with the advocate who was able to listen sympathetically and reassure that, whatever choices she had made, it was not her fault that she had been sexually assaulted.
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Discussion
Adolescents are at high risk for sexual assault, but unfortunately, most do not seek postassault medical care (Bromann-Fulks et al., 2007; Nofziger & Stein, 2006). SANE programs are well positioned to address adolescent survivors’ physical and emotional needs, provided that care is patient centered and developmentally appropriate. In this study, we identified three aspects of SANE care that adolescents found particularly helpful and healing: sensitivity to needs, compassionate care, and belief and validation. These findings are consistent with prior research with adult patients (Campbell et al., 2008; DuMont et al., 2009; Ericksen et al., 2002) yet highlight some specific aspects of emotional care that may be unique to adolescent victims.
Implications for Forensic Nursing Practice First, sensitivity to patients’ physical information and emotional needs is paramount, and for pubescent patients, healthcare practitioners must be attuned to the possibility that the medical forensic examination may be the patients’ first pelvic examination and, as such, they may be wholly unprepared to communicate with healthcare practitioners about gynecological/sexual health issues. The adolescents we interviewed appreciated that nurses explained these issues in ways that were informative, without being condescending. Second, providing compassionate care is essential for all sexual assault patients, and with adolescents, nurses should keep in mind that emotion regulation can be difficult in adolescence generally (Saarni, 1999; Saarni et al., 2006), which will be further challenged during traumatic events. The emotional intensity of the assault itself plus the medical forensic examination can be overwhelming www.journalforensicnursing.com
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Original Article and taxing to adolescents’ still-developing coping mechanisms. The adolescents we interviewed stated that it was particularly helpful when the nurses would help them “check out” for a moment to talk about other topics, which is a well-established crisis intervention strategy for dealing with individuals in crisis (Ruzek et al., 2007). Finally, many of these young women had engaged in illegal and/or risky behavior before the assault (e.g., alcohol/drug use), and they were expecting not only judgment from the nurses but, possibly, punishment as well. Reminding patients that such behaviors do not make the victim at fault is important for all patients, but for teen victims, the worry about additional repercussions is paramount. The survivors we interviewed were pleasantly surprised that both the nurses and advocates did not judge them for their behavior and assured them that they would not get them in trouble for it. Taken together, these findings suggest that compassionate care must be developmentally informed, such that basic patient-centered practices (e.g., belief and validation) are age sensitive and age appropriate. However, given the dearth of research specific to adolescent populations, we do not yet know what exactly those developmental differences are and how they should be attended to in practice. This study helps address this gap in the literature, but future research is needed to delineate the specific practice differences between adult and adolescent populations.
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Limitations
There are two significant limitations of this study that must be noted. First, the two focal SANE programs are community-based programs that have strong organizational linkages with their partner RCC. These programmatic features are not limitations, but they are somewhat unusual with respect to national data regarding SANE programs' structure, function, and operations (Campbell et al., 2005; Logan, Cole, & Capillo, 2007). Most SANE programs are hospital based, and although most work with victim advocates, it is unclear how many programs have the kind of deep organizational commitment to advocacy as did the programs studied in this research project. As noted previously, victims’ positive perceptions of the care they received were because of the combined efforts of both the nurses and the advocates. Whether these same results would occur in programs with different philosophies, organizational affiliations, and practice principles is unknown. It would be premature to conclude from this study that SANE programs are effective in addressing adolescent patients’ emotional need as there are over 600 SANE programs in existence (IAFN, 2012), and this project was in-depth study of patient outcomes in two programs. Future research is needed to examine if differences in SANE program structure, function, and practice are associated with different patient outcomes. 74
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Second, the racial/ethnic diversity of this sample was limited (75% were White). Whereas these demographics are consistent with the racial/ethnic makeup of the focal counties, the underrepresentation of ethnic minority survivors is a serious limitation. Previous studies have established that ethnic minority victims have markedly different help-seeking experiences, most notably, increased negativity to disclosures of sexual assault and decreased provision of help (Campbell, Wasco, Ahrens, Sefl, & Barnes, 2001; Ullman & Filipas, 2001). As such, there is a pressing need for qualitative research with ethnic minority adolescent survivors to understand how these forms of oppression shape their help-seeking experiences. Despite these limitations, the results of this research can help inform outreach efforts to adolescent populations.
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Conclusion
Over the past 20 years, there have been substantial national efforts to increase rape awareness education and rape prevention programming for youth (Centers for Disease Control, 2004). Our findings suggest that such efforts need to emphasize not only the services provided by SANE programs (i.e., what is provided) but their patientcentered philosophy as well (i.e., how it is provided). The results of this study highlight some of teens’ key concerns about seeking help: confusion, shame, self-blame, judgment, and the risk of punishment. Community outreach efforts that directly address these concerns may be particularly helpful in linking this vulnerable population to needed postassault services.
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