A male emergency room nurse, who had never done a rape kit or exam for a female, was ordered to do so by his ED charge nurse or face insubordination charges.
Although he had practiced nursing for 28 years, he had never done such an exam nor did he have any training to do so. He asked if he was right to refuse to conduct the exam. He also wondered if female victims of sexual assault should only be examined by female sexual assault nurse examiners or SANEs.
As you may know, the use of specially trained RNs to conduct exams or work with rape kits of victims of sexual assault or abuse is a growing trend across the U.S.
Several titles are used for these specially-trained RNs, including SANEs, forensic nurse examiners, sexual assault forensic examiner and sexual assault examiner.
- SANEs are “RNs who have completed specialized education and clinical preparation in the medical forensic care of the patient who has experienced sexual assault or abuse,” according to the International Association of Forensic Nurses.
- Forensic nurse examiners obtain special education and fulfill clinical requirements, which allow them to collect forensic evidence when the commission of a crime has occurred.
- Sexual assault forensic examiners and sexual assault examiners are broad titles used for a healthcare provider who has been specially educated and completed clinical requirements to perform these important exams.
In view of these titles and their requirements, the reader does have a realistic concern about conducting the exam and doing the rape kit with no training or experience with which to handle the procedures. Doing so may result in evidence being compromised, if not totally unusable in prosecuting a case. In addition, a patient’s need for support, crisis intervention and information specific to this type of assault may not be provided due to the lack of theoretical theories of how individuals respond to trauma of this nature.
It is interesting to point out that the reader stated in his question that he has done “male sexual assault” exams. Without questioning the reader’s ability to conduct these exams, it seems only reasonable that any victim of any type of sexual assault or abuse should be examined by a healthcare provider with special training and expertise.
Reader has right to refuse
From a legal perspective, the reader was right to refuse to perform something for which he had no training or experience. Accountability and responsibility for one’s actions is the hallmark of a professional, and he was correct that if he did do the exam, he might “be a risk to the outcome of the case” for the victim.
Unfortunately, being accountable and responsible for one’s actions is not something some employers relish. Most likely, at a minimum, he was written up for his refusal. It is hoped that if he were disciplined by the charge nurse, he grieved that discipline and, as part of the grievance, also requested he and his colleagues be given the training needed to conduct these exams in the future.
The reader’s gender in no way prohibits him from conducting an exam and rape kit once he is properly trained to do so. A 2012 study of 728 SANE respondents (four of which were male) titled, “Do Men Belong in Sexual Assault Nursing?,” that, among other topics, explored perceptions of male SANEs, the needs of patients and care of a sexual assault victim by male SANEs, and the level of care by male and female SANEs. The study reported that only one patient declined to be treated by a male SANE.
Moreover, the study contained comments by the four male SANE respondents that incorporated positive approaches to the use of male SANEs. One of those comments is quite telling: “Professionalism, empathy, honesty, competence (and on-and-on) are the skills needed to be a SANE. Gender is not a skill.”
The study encouraged further research be done to determine patient satisfaction when cared for by both male and female SANEs.
In answer to this reader’s uneasiness about males treating female victims of sexual assault, male SANEs do exist and provide care consistent with their special training and expertise. You can read more about their contributions to this specialty area of nursing practice on the International Association of Forensic Nurses website.
Victim always comes first
One last comment. Although the reader did not raise this issue, nor was it discussed in the research study, it is important to stress the comfort level of the victim of a sexual assault when undergoing a rape examination.
If he or she is “uncomfortable” with the gender of the SANE, the victim should share those concerns with the nursing staff and/or the ED nurse manager.
It may be that there are no other qualified SANE examiners in the ED where the victim receives care. Even so, sharing whatever concerns exist may result in some accommodation for the victim.
As an example, if the SANE is a female, and the patient would prefer a male SANE do the examination, a male ED staff member may be able to be present during the exam by the female SANE if agreeable to all those involved.
Courses related to ‘violence and sexual assault’
CE253-60: Sexual Assault and Rape
(1 contact hr)
The FBI indicates that 89,098 rapes were reported to law enforcement in 2015, up 6.3% from 2014. People who have been raped or sexually assaulted enter the healthcare system through many avenues. Nurses and first responders may encounter them in the field, the ED, or in obstetric or primary care settings. These patients may also be found in pain clinics; in specialty centers for GI, genitourinary, or neurological workups; or in gynecological or urologic settings as they move from specialty to specialty, seeking a medical diagnosis of their symptoms. Healthcare professionals of various disciplines who ask the right questions and assess and observe these patients can help tremendously.
60133: Domestic Violence Advocacy
(2 contact hrs)
According to the Center’s for Disease Control and Prevention’s Injury Center Division of Violence Prevention, intimate partner violence is a major public health concern, with one woman in four and one man in seven age 18 and older in the U.S. having been victims of severe physical violence by an intimate partner in their lifetime. Healthcare issues brought about from the abuse can persist for more than 15 years after the violence ends, which increases annual healthcare costs. That number accounts for more than 10 million women and men entangled in an abusive situation each year, and that doesn’t take into account stalking and rape. There needs to be a focus on recognizing abuse and prevention, as many cases go unrecognized even when victims seek out medical care, due to healthcare provider barriers to assessing for abuse. Lack of specific training in intimate partner violence is one of the leading barriers identified by nurses and physicians.
CE269-60: Adolescent Dating Violence
(1 contact hr)
Dating as a concept has an outdated meaning for today’s young people. Few report dating as it was experienced in previous years; rather, many teens report, “hooking up, going out, talking or fooling around.” Dating violence, however, does occur within the social interactions of adolescents and young adults, despite what it is called with about 10% of all adolescents reporting some form of physical violence in their dating relationship. Boys and girls are just as likely to hit a dating partner as they are to be hit by a dating partner. This educational activity will provide an update on the topic and provide tools for identification and prevention of adolescent dating violence.
It is important for advanced practice nurses and other clinicians to be aware of indicators of rape and sexual abuse in men and to be able to detect them. This is particularly important as men are much less likely than women to spontaneously disclose abuse.
Hello fellow nurses,
I am currently in the midst of the on-line SAFE/SANE training program with the Stamford (CT) Sexual Assault & Crisis Education Center, and I can tell you the training is fascinating, informative and arduously detailed. It is an evidence-based program that covers virtually every aspect of sexual assault, evidence collection, legalities, societal factors, special populations, demographics, etc. The Center was funded under a grant to offer this 40-hour on-line program, which is then followed up with a clinical component. The on-line program is a training curriculum created and taught by the International Association of Forensic Nurses. As the President of my State’s Nursing Association, after the Board, our Executive Director and I discussed it and did our due diligence on the program, we decided to help spread the word about this training opportunity to interested nurses because the need is, unfortunately, so high. In our state there is also a series of wonderful in-person training opportunities to do this full IAFN course with a nurse who has devoted her professional life to this cause and who was so instrumental in this training movement here in our state. If anyone would care to discuss this further with me, feel free to contact me and I’ll share my training experiences with you.
Stephanie Paulmeno ([email protected])
I want to thank the author for recognizing that gender is not a skill and therefore should have no bearing on a nurse’s ability to perform their job
After a 40 year career of being judged and discriminated against merely because of my gender, I am pleased to see this discussion.
If this nurse had never been trained in this particular procedure, he should have refused. All of the evidence could have been destroyed if it was not collected properly. To have a charge nurse order an untrained person to collect such evidence without having provided training was inappropriate on the part of the charge nurse. She should have known better and I’m sure she did. She just didn’t bother to think. She should have done it herself once she knew he had no training. He had the right to refuse. Gender had nothing to do with it. Lack of training did. I would have considered that first. I would not go to gender first, but it seems to be popular nowadays. Doesn’t it! Raise your heads up nurses! You’re smarter than that, and so was this man to have refused.! NP
The assault victim has a right to request a female clinician and furthermore should be given the opportunity to request one without feeling uncomfortable in doing so.
ABSOLUTELY NOT ! ! ! First of all, most facilities have a team of designated nurses who have gone through specialty training for such scenarios as this. The nurse was absolutely 100% correct and standing his ground knowing that this was out of his scope of practice. As a nurse we know what we have been trained to do and we have the basic knowledge in certain areas of our field of practice.
When I moved from Texas to Florida I took a position in the emergency room under the contingency that I was going to go through a training course in order to be familiarized with the emergency room nursing practice. I did not get that training and soon realized that without that training program I was beginning to fail as there is so much information necessary in order to be a productive nurse in the ER setting. I was familiar with the fact that there are teams of people to evaluate incoming patients for mental health issues, sexual assault cases, and many other different situations who had been through rigorous training and knew the inns and outs on how to handle such situations.
A nurse being assigned to a patient coming in with a diagnosis of being a sexual assault victim goes beyond taking vital signs, rooming a patient, putting a patient into a gallon, taking a patient statement, setting up a tray with the necessary items that I physician may request, obtaining necessary blood work, and so on. I have been fortunate enough to be in the room both as a 23-year veteran phlebotomist and as a nurse with a sexual assault victim and the process and procedure is quite detailed and the specialized nurse assigned to come and evaluate the patient clearly displays characteristics of an extensive training process that goes far beyond anything that’s tight within the ER setting. Not that a male nurse is incapable of attending to a female sexual abuse victim or a female is not capable of caring for a male sexual abuse victim; however this is a priority when assigning the nurse to care for the sexual abuse victim when the patient arrives to the emergency room regardless of the emergency room starting at that time.
Secondly the nursing approach to a sexually abused victim is going to be based on a holistic approach which is going to include the body the mind, the spirit, and the soul; and all of the emotions connected to each of these areas. In order for a nurse to even begin to do his or her job, that nurse has to use their specialized training in order to establish trust which as they know, time is of the essence and has to be established in only a few minutes after entering the patient’s room. Without that specialized training to establish such a relationship would be extremely difficult especially not knowing all of the important information needing to be obtained throughout the rest of the interview, the resources which need to be provided to the victim, pictures needing to be taken, swabs need anything taken, lab work needing to be drawn, and all other additional sexual victim policies and procedures needing to be followed in order to best protect the victim, sometimes even includes registering the patient with an anonymous name to further protect the patient from being found by the perpetrator.
If any one of these steps is messed up, performed incorrectly, labeled incorrectly, not performed in the correct order it could result in a poor legal outcome for the patient and that nurse, without the proper training could/would be held accountable for the care and or treatment he provided to a sexual abuse victim without proper training regardless of the fact that he was assigned to that patient upon the patient’s arrival.
Not one person, not a charge nurse, not the ER physician in charge, not the house supervisor is going to stand up and take responsibility for knowingly assigning him to their sexual assault victim even after he stated that he had not been trained to do so. This nurse was 100% correct in standing up for himself.
So many times nurses are flooded to different floors or asked to perform tasks which we are not suited to do and we know that we have not performed in before or Have only performed once or twice in the past and although he remember the basis of the procedure we are not 100% comfortable with performing the procedure is on our own and we are encouraged to ask a coworker for help or we are frowned upon as ours superior asked someone else to do the job instead. Our license governs what we do and what we don’t do on a daily basis, and is there to protect our patients, our community, ourselves, our employers, and the choices that we make.
If we are asked by a superior to go to a floor or a unit that we are not familiar with we are to tell them that that is out of our range at practice and that we are not comfortable with doing so, that we are not familiar with the medications on that unit, or with the patient teachings of that unit, and that is to be respected and we are to be placed on a unit that most closely resembles the unit that we are being transferred from in order to best utilize the knowledge that we have in order to maintain patient safety. This situation is no different.
This nurse exercised his right in stating that he was unfamiliar with the policy and procedures on caring for a sexually assaulted victim and was not familiar with the policies and procedures of caring for that victim type, which not only should have been acknowledged by his superiors but should have also been embraced and applauded by all members of the ER staff. And at that time another ER staff members/coworker should have offered to have taken that assignment who was familiar with the procedure and caring for a sexual assault victim if there was any, and if not, then the hospitals designated and specially trained sexual assault nurse should have been called in to take the case and the ER charge nurse should have cared for that patient until the specialized nurse was able to get to the emergency room and start caring for the patient herself.
The male nurse should have been relieved from that patient and assigned to another patient and not threatened with insubordination.
I took a travel position which was explained to me as a MedSurg position and upon my arrival to that unit it was an extreme burn unit, which I had never been exposed to such extreme burns and women’s on any unit although I had transferred from a liver and kidney transplant unit where I was extremely comfortable. After speaking to my recruiter it was communicated to the unit manager that the unit I was on was out of my scope of practice and the care I was being asked to provide was something I felt for sure I needed specialized training in order to perform satisfactorily and in order to meet the needs of the patients as I was not wanting to cause undue harm. After my fifth shift on that unit I was relieved from my travel position basically for the same type of reason “insubordination” … when in actuality I was protecting my patients to the best that I could and knowing that that care and a training that I had was not substantial enough to provide the care and treatment that they required therefore I knew that I was on a unit where my skills did not match the skills necessary to perform an outstanding job and the patients on that unit deserved such.
You may feel that this example is different than this gentleman’s story, but it’s not, because this is healthcare, and this is how healthcare treats nurses. We are trained for the unit that we decide to commit ourselves to and that unit may be a very special and/or specialized unit and we may not learn a huge amount of procedures the way that other units do. We focus on the procedures that are important and necessary to our unit and we perfect those policies and procedures and make sure that we can do them quickly and well, and as far as other procedures that come up we learn to do those as they come along. We may not do them except for once or twice a month, but we’re still learning how to do them and we maintain our knowledge on how to do them so that we are prepared the next time that they come up. There are nurses that do go above and beyond and outside of their main unit and get other certifications above and beyond what’s required of their specialized unit in order to be utilized in other situations, and it provides them with a larger knowledge base or they may also be in a position where they work two jobs and their second job they work in a completely different unit as well which allows them to have a larger but knowledge base. In this situation, if anything, the hospital failed this nurse and not making sure that he had no knowledge base to at least begin the intake for this sexual assault victim. The superiors also failed. They should’ve listened to him when he said that he did not have the training, as a nurse we know what we are capable of doing, we don’t just say that we don’t have a training because we don’t want to take on the extra assignment.
I know for myself that yes there are nurses out there who are lazy, and there are nurses who don’t want to do anything other than what’s comfortable for them. They don’t want to step outside of the box and do something new. But when I tell you that I don’t have a training for something or I’m not qualified to do that task, or I have not done that before, or I’m not trained to do that, or anything to that effect I need to be respected just as this gentleman should have been respected regardless of what people thought of him. If we say that we are not able to do something it needs to be the end of the story. It needs to be respected. I know that I can speak for myself and many others who would gladly take over somebody else’s assignment in order to have somebody who is familiar with this type of situation. Quite honestly if I ever met this nurse I would gladly let him take care of my family members, based on his ability to know and do what’s right. There’s too little of that.
So if this Nurse has done a male rape kit without training, then this is discrimination. Interesting. It is more important that it gets done; if there is a SANE Nurse or other trained nurse, of course they should do it. If the patient says no to a male, then of course it should be a female nurse, but if it is a choice of the guy Nurse or none, the guy Nurse needs to take it. It is better than nothing. All that being said, the charge nurse (if female) should have done it unless the patient specifically asked for a male. What is wrong with these people. So unprofessional.
It was obviously a power trip for the Charge Nurse. I have seen it too many times in other situations.
I would be surprised if she did not write him up. if she did then he certainly should involve his state board of nursing.
I don’t think men should examine sexually assaulted females, say what you want.
Not only no but NO WAY. It puts the nurse at risk for performing a clinical activity for which he has NOT been trained and it puts the patient at risk to have a procedure performed incorrectly and potentially invalidating data. It is unfair to both parties. The facility should have [as ours does] very clear standards for this procedure.
The owness shouldn’t be placed on the victim. I think the victim should be ASKED if they are ok with the nurse doing the exam. The statement that the victim should speak up is insensitive. This person has been violated and feels powerless, now is burdened with having to advocate for themselves in the midst of such horror. Being male is not a skill but can be a factor in the patient’s comfort. If there is no SANE nurse that is the gender preferred, I think that should be explained to the patient sensitively beforehand.
Male or female really should be up to the patient especially in this critical and sensitive situation.
I am aghast that any E.D. would operate without training many nurses to do a forensic post rape exam.
The victim has just gone through a traumatic experience and has to undergo a sensitive procedure. The best move would be to ask the victim if he/she prefers a male or a female nurse to handle the process. But definitely, training is paramount and is even more crucial than the gender of the nurse. Even if the preferred gender for a nurse by the victim is available, if the nurse is untrained to handle the procedure, then the process could fail.