Planning and implementation of the Sexual Assault Nurse Examiner course to assist victims of sexual violence: an experience report

1 Hospital Universitário da Universidade Federal de Sergipe, Aracaju, SE, Brazil. 2 Monmouth University, Nursing School, Monmouth, NJ, United States of America. 3 Clinical Practice Resources for Training and Education, Hardwick, NJ, United States of America. 4 Cedars-Sinai Medical Center, Nursing Education, Los Angeles, CA, United States of America. 5 Helping Hand of Los Angeles, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America. 6 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Psiquiátrica e Ciências Humanas, Ribeirão Preto, SP, Brazil. ABSTRACT Objective: To describe the authors’ experiences in planning and implementing a training course based on the Sexual Assault Nurse Examiner. Method: This is an experience report with qualitative characteristics of a descriptive nature and cross-sectional cut. In 2019, nurses were trained to care for victims of sexual violence through a course known in the United States as Sexual Assault Nurse Examiner. The course lasted 40 hours and was offered to nurses. The didactic strategies used were dialogued exposure, group dynamics and realistic simulation for clinical-gynecological examination with volunteers. Results: For five days, 20 nurses underwent training. The contents covered Brazilian legislation, protocols for assisting victims, anamnesis, physical examination, collection and preservation of forensic remains. The practical classes took place in the last two days of training. At the end of the course, a written assessment was applied. Conclusion: The course provided the opportunity for the consolidation of important knowledge for nurses to care for victims of sexual violence, collection and preservation of traces and participation in the chain of custody.


INTRODUCTION
The World Health Organization (WHO) notes that the term sexual violence is applied to any unwanted or nonconsensual actual or tentative of sexual activity, sexual innuendo, with or without profit benefits for the perpetrators (1) .
In this context, women are among the groups vulnerable to this type of violence, having a strong relationship with high rates of morbidity and mortality for females in different age groups and socioeconomic levels. In Brazil, between 2017 and 2018, 66,041 cases of sexual violence were registered, with the majority of victims being female (81.8%). It was found that 85.5% of the perpetrators were male and known to the victims (2) .
The consequences of sexual violence are diverse, when they are physical, genitoanal injuries, lacerations and fissures are recurrent as well as sexually transmitted diseases (3) . Moreover, psychosocial consequences are present in this context and can be illustrated by psychiatric disorders, learning difficulties, drug abuse, perpetuation of violence, and prostitution (4)(5) .
Health services are spaces that often assist victims of sexual violence. Nurses, the most present members of health teams, have great potential to provide more humane and resolving care to these patients (6) . However, most nurses feel unprepared to deal with these situations, either due to the limited knowledge during anamnesis and physical examination of victims of sexual violence, or because they do not understand the intersectoral network of protection for victims and their role in this context (7) .
Thus, nursing care in the face of care for victims of sexual violence, in most situations, is palliative and restricted to care of injuries. Moreover, one of the major obstacles to the visibility of the problem is the lack of notification by professionals, which contributes to its underdiagnosis and undersizing (8) .
In the United States, since 1970, nurses have become leading agents in caring for victims of sexual violence. The Sexual Assault Nurse Examiner (SANE) emerges as a forensic nursing subspecialty, in which professionals are qualified to provide health care to victims of sexual assault as well as in the collection and preservation of forensic remains, in order to collaborate with criminal investigations (9) .
Nurses qualified with SANE receive specialized training for: recognition of sexual assaults, including forensic techniques for collecting traces without contamination and preservation of the chain of custody; interview with patients, identification, evaluation and documentation of injuries (10) . Considering the exposed setting and the importance of nurses' training for comprehensive care for victims of sexual violence, the present manuscript aimed to describe the authors' experiences in planning and implementing a training course based on SANE.

Study deSign
This is an experience report with qualitative characteristics of a descriptive nature, with a cross-sectional time frame.

Scenario
The present experience report refers to a training course for Brazilian nurses in caring for victims of sexual violence. The course proposal started in February 2019, when members of a non-profit organization of Brazilian forensic nurses contacted a forensic nurse responsible for coordinating the program to assist victims of sexual violence in New Jersey, United States of America (USA) and an instructor in a "living models" training program, the Forensic Gynecologic Teaching Associate (GTA), in order to propose the realization of SANE.
For this training, 10 online meetings were held, in order to organize the course that took place in May 2019. In the planning phase, a schedule was elaborated with the sequence and distribution of the theoretical contents, didactic approach and the necessary materials for each class. The written didactic material went through a process of translation from English into Brazilian Portuguese by three translators.
The course was taught for five calendar days, with the presence of two professional English translators, in the morning and afternoon, which totaled 40 hours, divided into 30 hours of theoretical classes and 10 hours of practical classes. The didactic strategies used were dialogued exposition of content, dynamics in small groups, reading, and discussion of forensic cases. For practical classes, the study applied in human models for realistic simulation.
To carry out realistic simulations, a group of 14 volunteer women were "living" models and played victims of violence during practical classes. These volunteers were undergraduate nursing students at a private institution to which one of the SANE organizers was linked and underwent 30-hour training (four online and four one-to-one meetings) to develop the ability to act as users during the performance of all physical and gynecological exams on their bodies.

ethical aSpectS
The present experience report reflects the text authors' opinions on the experience reported and discussed in the sections of this article.

courSe overview
For five days, 20 nurses participated in the course, with an American forensic nurse as their instructor. During the theoretical classes, a Brazilian nurse, responsible for building the care network for victims of sexual violence www.scielo.br/reeusp Rev Esc Enferm USP · 2021;55:e03739 in the state of Sergipe, a criminal lawyer, and a Police Station for Vulnerable Groups delegate participated in the course. The theoretical contents addressed covered: the history of forensic nursing in the world and its insertion in Brazil; the role of SANE in the USA and its evidence-based practices; resources and materials for the performance of SANE; ethics in assisting victims of violence; forensic traumatology; knowledge related to Brazilian legislation; victim assistance protocols; survivors' history (anamnesis) and physical examination; collection and preservation of forensic remains; injury assessment and documentation.
With regard to practical classes, they took place in the last two days of training in the university's nursing laboratories, covering the performance of gynecological exams in women volunteers during the realistic simulation of care for cases of sexual violence. At the end of the course, a written learning assessment, containing 20 closed-ended questions, was applied to the 20 nurses who participated in all stages of SANE as well as a reaction assessment to assess the quality of training.

theoretical and practical approach
The content organization, during the theoretical classes, was established seeking to follow a gradual and logical sequence of information necessary for the development of nurses' skills and abilities during care of victims of sexual violence (Chart 1), taking place during the first four days of the course. SANE is guided by standards and protocols developed by specialists in the field of the International Association of Forensic Nurses (IAFN), consolidated through the publication of a guide entitled SANE Education Guidelines. The components of these guidelines serve to: define the patient population; establish instruction length; include recommendations for students and educators; establish a detailed description of content and specify recommendations for clinical preceptorship (10) .
Through various discussions, program planners were able to create content that met or exceeded the minimum requirements of the identified guidelines, but also adapted to meet the unique needs of the public of pioneering nurses who participate in this inaugural program. From the early stages of planning, it was clear that nurses were willing to overcome any obstacles encountered. Participants showed enthusiasm with the approach of new concepts and skills presented and the expectation of innovating service in their own communities. The course materials were prepared and distributed in advance, allowing participants to become familiar with the theoretical and scientific content that make up SANE.
Based on an understanding of the variety of successful adult learning styles, the instructional course agenda was presented in a variety of methodologies. A verbal lecture, slide and video presentation, visual demonstration, group discussion and group projects were held. The 30 hours of content (Chart 1) in the classroom integrated theory and research with demonstrations of clinical skills. In the classroom, great emphasis was placed on the education of nurses on the exclusive aspects of working with patients with trauma suggestive of sexual assault.
The importance of informing the victims about the approach focused on the informed trauma for communication and physical assessment was explained and discussed in detail with the students. The introduction of concepts associated with the neurobiology of trauma was presented, along with a review of psychology of victimization. Local and regional experts from the law enforcement and legal communities instructed on how the legal system operates in such cases, while nursing instructors focused on what these nurses could do to assist the investigation process while focusing on the victims. Specific skills and techniques have been taught and demonstrated to collect legally permissible specimens, photograph wounds and thoroughly document signs and symptoms.
The practical activities were carried out in the last two days of training. On the first day of practice, the instructor performed a classroom demonstration on the use of the necessary materials during care for victims of sexual violence as well as of a kit used in the USA for the collection of the collected traces and the correct preservation of the chain of custody. At that time, nurses were able to touch and handle some materials, such as swabs and specula. The instructor then divided the nurses into 4 groups for the complete practical demonstration of the exam on a live model in the laboratory.
The laboratory space, provided by a private higher education institution, was divided into sections by curtains and partitions to create four different simulated exam rooms, and each of the eight different forensic GTA participated in two consecutive physical exam sessions. Each group of nurses in the SANE training program met with a GTA responsible for passing the correct technique to perform the gynecological exam.
Approximately 10 hours of visual and experimental learning were provided with the GTA through instructional demonstration of forensic genital inspection, forensic photography and evidence collection. Students had the opportunity to demonstrate technical and verbal and non-verbal communication skills appropriate to assisting victims.
The last day of SANE training consisted of a simulation of nursing care by professionals, with the participation of GTA who played the role of survivors of sexual violence. At that time, nurses were able to put into practice the knowledge necessary to conduct the interviews and use the forensic evidence collection kit.
Each group went to a simulation environment and assignments were delegated to each member. A nurse was responsible for carrying out the anamnesis; another was in charge of physical examination; another was in charge of trace collection; another nurse observed all the procedures to provide feedback, in the end, with the others. Despite the division of tasks, all nurses performed a gynecological examination on the volunteers, and this process was supervised by one of the instructors, responsible for the practical class.
At the conclusion of the course agenda, each student was required to take a written exam to assess the knowledge acquired. A particular focus was placed on nurses' ability to critically assess the unique details they could find and to develop a personalized patient care plan. All students in the inaugural course successfully completed the assessment.

DISCUSSION
SANE nurses, with the skills for forensic interview, physical examination and collection of traces, is the intersection between health and justice, objectively using parts of the concepts that make up the forensic nursing specialty (11) . Studies in literature show the effectiveness of SANE programs in many aspects, such as psychological recovery of patients, the institution of early treatment (emergency contraception, prophylaxis for sexually transmitted infections), and the complete and accurate recording of forensic traces (10)(11)(12) .
In the USA, sexual assault examinations completed by SANE can help in the process of investigating the acquittal or conviction of a suspect due to better collection of traces. In order to obtain results such as those previously described, it is necessary that these professionals undergo a theoretical-practical training process with an effective didactic approach and consistent with state and national protocols (13) .
This training usually includes a 40-hour workload between theoretical and scientific content and the practice of simulated gynecological examination. It may also include the performance of three exams on sexual assault victims, accompanied by an experienced SANE preceptor in the field (10) .
It is worth mentioning that learning is a process in which knowledge is also learned through practical experience. In this sense, realistic simulation is a methodology that allows the student to apply the theory addressed in the classroom with greater ease in practice and safely (14) .
Traditional teaching methods based on realistic simulation using robots, corpses, or even untrained actors, have more limitations when compared to practical teaching in "living models" such as the GTA training program. In this program, "living models" are empowered to communicate and instruct students, through real-time feedback on invasive clinical skills exam techniques (15) .
In Brazil, nurses participate in care of victims of sexual violence, especially in reference services, but their actions are still focused on treatment and not on preserving forensic remains and their participation in the chain of custody is still questioned. Although Decree N. 7,958/2013 (16) and Ordinance N. 288/2015 (17) contemplate the preservation and collection of traces as a stage of comprehensive care in the health service, these procedures are identified as medical activities, with the necessary presence of another health professional according to the 2015 Technical Standard (18) , created for this purpose.
However, new perspectives of professional improvement for caring for victims of sexual violence appear in the country with the recognition of the forensic nursing specialty by the Federal Nursing Council (Conselho Federal de Enfermagem -Cofen), in 2011, by Resolution N. 389 (19) and the regulation of fields of practice of forensic nurses in 2017, through Resolution N. 556 (20) .

CONCLUSION
In Brazil, SANE was held for the first time on May 6 to 8, 2019, as reported in this article, being a high-performance training initiative for nurses to assist victims of sexual violence. The objectives contemplated in the course converge with the guidelines recommended by Brazilian legislation for comprehensive care for victims of violence, such as the participation of health professionals in the preservation and collection of forensic remains as well as ensuring the integrity of the chain of custody in health services. This experience report is important because it synthesizes a Brazilian experience that counted on professionals with extensive experience in training SANE nurses in the USA, in addition to being composed of nurses with extensive knowledge in the field.