Emergency Departments and the Victim of Sexual Assault

Sexual violence is a major health concern and as healthcare providers we must do all that we can to provide proper care for this patient population. The purpose of this article is to bring awareness to the lack of preparedness, and that emergency departments are not ready to meet this growing health concern in our communities. Heath care organizations and professionals must get stakeholders involved and acquire the funds and educational tools to enable them to meet this need. Research suggests that emergency department nurses are ill-prepared to care for victims of assault, and must be trained to care for these patients, not only their physical injuries, but also in the collection of evidence, psychological support, prophylaxis of sexually transmitted infections, prevention of pregnancy, education, and follow up care.


Introduction
Sexual assault is a serious concern that impacts all nations, generations, cultures, age groups, and genders and in order to care for these patients properly, emergency departments must have policies and guidelines clearly in place. Florence Nightingale's legacy of effective nursing was portrayed when caring for soldiers and the sick and dying [1]. Historically, forensic nursing developed as an art of caring for survivors and offenders of interpersonal violence, crime, and sudden traumatic death. Before the forensic nurse evolved nurses provided care to victims and perpetrators of violence. In the 14th century, midwives performed gynecological examinations, collected evidence, and testified before the King's court. In the 1980s there was a need for nursing to care for victims of violence with specific handling of evidence. In 1985, the US surgeon general recognized violence as an emerging healthcare issue.
The purpose of this paper is to develop an educational plan for teaching emergency room nurses the critical steps in the identification and care of victims of sexual assault and to expose the gap analysis in the healthcare system in the care and treatment for victims of assault. Forensic nursing is a very critical link in the administration of justice and a significant resource for the multidisciplinary approach to caring for victims of violent crimes. In 1992 the International Association of Forensic Nurses was founded, led by Virginia Lynch and 70 registered nurses [2,3]. Virginia Lynch was in a psychiatric education program when she chose the Tarrant County Rape Crisis program for her clinical practicum. After caring for sexual assault victims Virginia initiated the first rape crisis program, which became the first sexual assault nurse-training program in Fort Worth, Texas [3]. According to Lynch, "violence and its associated trauma are widely recognized as a critical health problem in North America and throughout the world. Forensic nursing represents a new era in nursing practice that is evolving in direct response to the squeal of criminal and interpersonal violence" [4].
Victims of violence may enter the healthcare system in primary care, community clinics, urgent care, or emergency departments. In this paper the target audience for the education of treatment for victims of sexual assault is intended for nurses and other healthcare professionals in the emergency department. A term used in this paper is sexual violence, which is a major health and human rights concern worldwide. Sexual violence is defined as any sexual activity in which consent has not been obtained or cannot be given freely. The term victim is often associated with the immediate trauma following an assault, and implies that a crime has been committed against an individual [5].

Improved Patient Outcomes
Evidenced based practice is the backbone behind the nursing profession and in health care in general, and it is imperative that the profession understands it. Evidenced based practice is "the integration of the best research evidence with clinical expertise and patient values" [6]. Research utilization is using research based literature findings to support data collection, interventions, and evaluation in providing patient care. The ultimate goal of evidenced based nursing is to establish evidenced based data for practicing nurses in which to deliver high quality effective care based on the best and most current research. To be able to resolve problems while in the clinical setting, achieving superior patient care, surpassing quality assurance standards, and an ongoing commitment to change [6].
The area where healthcare needs collide with the law is expanding, and forensic nurses have risen as leaders in the response to violence [7]. Research and theory are key values that guide a safe, effective, and comprehensive forensic nursing practice and the profession continues to grow and evolve with more evidenced based research enhancing the care of victims. The rigorous research and critical theory analysis will aid in building the foundation for advances in the care of offenders and survivors of interpersonal violence, crime, and traumatic death [1]. The International Association of Forensic Nurses seeks to advance the practice of forensic nursing, and incorporate forensic nursing science into basic and graduate nursing programs in Colleges and Universities around the globe [2].
The goal in this evidenced based practice project is to educate health care professionals on how to better treat and plan healthcare services for victims of sexual assault. The care for these patients is comprehensive and includes psychological support; evaluation of injuries; assistance with the collection of evidence; prophylaxis of sexually transmitted infections; prevention of pregnancy; education; and referrals for follow-up care [8]. Patients of sexual assault rely on nurses, physicians, and other healthcare professionals to treat their physical injuries, provide resources and support for the severe emotional trauma they face, the difficult road to recovery, and to assist them in seeking justice and the prosecution of those that assaulted them.

Learning Domains
The American Association of Colleges of Nursing (n.d.) states, that the first aspect of scholarship is discovery, which entails discovery of new knowledge or confirmation of existing knowledge [9,10]. It is a known fact that patients seek care in the emergency department setting after sexual assault. Discovery is generated through education, experience, evidenced based practice, and collaboration with other healthcare professionals [11]. It is important and imperative that nurses in the emergency department receive education on the treatment of sexual assault victims, and have access to patient-centered and trauma-informed care that addresses their medicolegal and psychosocial needs.
Through integration, the second component of scholarship nurse educators make connections across disciplines, interpreting knowledge, and creating new understandings. The care of the victim of assault is comprehensive, and requires extensive planning, education, and expertise on the part of the emergency department providers and their collaborative partners. The emergency nurse plays a pivotal role in the coordination of care, collaborating with community-based victim advocates, social workers, and law enforcement personnel [12].

ANCC 1st Scholarship
Through the scholarship of application and the four domains of discovery, integration, teaching, and application, nursing professionals are prompted to use theory and research to improve their nursing practice. Professional scholarship is imperative in nursing as nurses provide leadership in coordination of care in communities through education, experience, evidenced based practice, and collaboration with other healthcare professionals [11]. Nursing professionals that engage in scholarly practice demonstrate clinical leadership through empowering others with the knowledge and skill to improve their practice [10].
Leadership is a skill, a trait, and is essential to being an advanced practice nurse in education. Some attributes to being a good leader include emotional balance and control, interpersonal skills, selfconfidence, adaptability, risk-taking, independence, emotional intelligence, judgment, knowledge, and oral fluency [13]. In order to promote change in policies and guidelines the nurse educator will utilize the scholarship of integration. The integration is through education, experience, evidenced based practices, and collaboration with other healthcare professionals to improve patient care and outcomes [14].
Scholarship and evidence in nursing is needed in order to provide the highest quality, effective care to the patient population. The process includes developing and asking questions, searching for and identifying sources of information, appraising and synthesizing that information, generating the evidence through research and quality improvement outcomes, and then evaluating the results based on the evidence. As health care providers we want to apply the best evidence in our practice to ensure the best possible outcomes for our patients. We use evidence to problem solve and we use the best available evidence along with our clinical experience and patient preferences and values in the decision making process. We apply the best scientific evidence when providing care when we use evidence based nursing practice [15].

Literature Review and Gap Analysis
Delgadillo examined the preparedness for emergency departments in the care of the sexually assaulted patient when there is no sexual assault nurse examiner (SANE) or sexual assault response team (SART) available [8]. The article emphasized the importance that emergency department nurses have the tools to care for these patients, not only their physical injuries, but the collection of evidence, psychological support, prophylaxis of sexually transmitted infections, prevention of pregnancy, education, and follow up care. The article concluded that when a SANE nurse is not available, emergency room nurses would need to be educated and trained in the care of the sexually assaulted patient. The informed and confident emergency room nurse has a significant impact on how the sexual assault patient approaches recovery.
In an article by Denis et al. a prospective observational study conducted to identify the expectations of sexual assault victims after being treated in the emergency department [16]. The study found that medical doctors and nurses play a pivotal role in providing care for assault victims and it is critical to provide forensic support, trauma care, psychological support, and gynecological care. In another study by Nielson et al. concluded that nurses who were trained in the treatment of sexual assault had a more positive attitude towards treating these types of patients [17]. Nurses without the training felt burdened when caring for these patients as acute care after sexual assault requires multiple resources, significant time, and a specific set of nursing skills.
In a descriptive cross-sectional study design by Linnarsson et al. results showed that a lack of general preparedness in emergency departments will lead to many patients not receiving appropriate care and treatment [18]. There needs to be guidelines and routines in place to care for victims of violence. Further research is needed regarding the care for victims of violence in the emergency department. Two other studies done by surveys by Plichta et al. examined the extent to which emergency departments are prepared to provide care for sexual assault victims and the critical role emergency department staff play in the collection of evidence that may lead to the conviction of the perpetrator and the physical and emotional care for the victim [19,20].
The majority of the literature review provided evidence that in order to promote effective, efficient, and efficacious processes for sexual assault survivors, emergency departments must provide staff with education on the collection of evidence, working with the police, testifying in court, talking with victims and their families, and working with rape crisis centers. The research provided a summary of services available to victims of sexual violence at the emergency department. In general emergency departments provide needed medical services to victims. However, more than half do not have specially trained personnel (forensic nurses), and the majority of organizations are not training their staff about sexual violence. In addition emergency departments are not screening their patients for violence or victimization. Emergency departments are lacking in providing competent care for victims of violence and the collection of evidence. An article by Wiese et al. emphasized that policies need to be improved to meet the growing need of victims of sexual assault that present in the emergency department [21]. The establishment of a forensic specialist, referrals to sexual assault centers that offer forensic services, and psychological support is essential if emergency departments are unable to provide services to meet the needs of this population.

Gap analysis
The gap identified in the literature review revealed that although forensic nurse specialists are in dire demand in emergency departments, the literature failed to recognize that due to limited personnel and major cuts in budget, fulfilling this demand would be a difficult goal to achieve. Another gap that was recognized was the supply and demand market of healthcare. Victims of violence cost hospitals thousands of dollars annually due to their lack of insurance and inability to pay [22]. The literature failed to address the increase in costs to care for victims of violence, or how hospitals can identify a source of funds, such as grants, donations, etc. from various foundations and organizations to pay for training, materials, and personnel.
The literature expressed the need for training personnel on the discipline of forensic nursing, but did not provide the resources or organizational influence to support this projected goal [12]. The literature also conveyed the need to care for sexual assault victims both physically and from a disease related perspective, but they did not address the emotional and psychological impacts on this patient population [8]. Victims of violence are covered by law enforcement for the expense of rape examinations and care. The failure of organizations to provide education to emergency department personnel on the billing protocols for this patient population was not recognized in the article [23].

Interdisciplinary Approach
Cultural competence played a role in the educational design of the project by discussion of how other teams will be involved. The forensic nurse is absolutely an essential part of the coordination of care, treatment, collection of evidence, physical, emotional, and psychological outcome of the patient. Other important interdisciplinary members would be every person that comes in contact with that patient, which may include a security guards, registration clerks, triage nurses, primary care nurses, laboratory technicians, emergency room technicians or certified nursing assistants, radiology, social services, detectives, physicians, and social services.
All of these team members with the exception of the detectives need to be trained with an interdisciplinary approach on how to communicate with these victims. The victims may be male or female, any race, culture, age, nationality, or religion. Another valuable education topic is for those victims that do not verbalize being sexually assaulted. In order to deliver culturally competent care the nurse or caretaker needs to work with the cultural differences that exist and to be aware of them [24]. Knowledge of culture is the key to competence. The nurse can consult with family members, if present, to provide care in a way that is appropriate and acceptable for that patient. It is also important to be aware of cultural sensitivity; cultural sensitivity is recognizing the diverse ethnic, cultural, spiritual, and other specific aspects about the patient's background [25].
There is no prejudice against victims of violence; this patient population includes all walks of life. It is important for healthcare providers to have cultural competence and sensitivity when caring for victims of assault. There needs to be policies and guidelines in place so that those patients can be identified in a professional and nonjudgmental manner. Failure to recognize or identify victims of violence can contribute to misdiagnosis, inappropriate treatment and care as well as neglect of legal evidence [18].

Aspects of Adult Learning
Victims of violence may enter the healthcare system in primary care, community clinics, urgent care, or the emergency department. In this paper the target audience for the education of treatment for victims of sexual assault is intended for nurses and other healthcare professionals in the emergency department. The type of learning domains that will be utilized is the adult learning theory. Adults have a wide variety of personal and life experiences to draw on. Therefore enhance adult learning by encouraging them to use these experiences to solve problems. Adults are ultimately responsible for changing their own behavior. Assessing what the student currently knows, teaching what the student wants to know, and setting mutual goals will improve the outcomes of their education [26].
Understanding how and why adults learn is important in order to effectively teach patients and their caregivers. Educational research and theory development have identified adult learning principles that differentiate between the education of adults and that of children. These concepts provide a foundation for effectively teaching adults. Many of the theories of adult learning have risen that are important for you to consider when teaching adults. Additional characteristics of adult learners that you should consider when teaching adults include physical, psychological, and socioeconomic characteristics.
Adult students are independent and need to be involved and motivated in order to learn. Motivation can arise from intrinsic and extrinsic aspects. Intrinsic brings long lasting and self-sustaining rewards while extrinsic brings rewards from a good grade or praise from teachers, parents, and role models [27]. "The clinical teaching and learning environment is an ideal field for using adult learning theories and demonstrating their utility. Reinforcing clear thinking in both teacher and learner and considering them should improve clinical learning and even clinical outcomes" [28].
Teaching strategies should include all domains of learning, which include cognitive (thinking), psychomotor (physical/kinesthetic), and affective (emotion/feeling). Teaching strategies for the EBP project will include remembering, understanding, and comprehension, which will cover cognitive style learning. Teaching strategies using PowerPoint presentations and enduring materials for policies and procedures will help learners remember the information being taught. Hands on skilled movement activities will address the psychomotor abilities. Lastly, effective teaching strategies include receiving, responding, and valuing that which refers to the learner's beliefs and attitudes. Providing opportunities for the learner to give input and feedback on how they feel about providing care to victims of assault [29].

Summary
Literature implies that emergency departments that are not staffed with a forensic nurse examiner or sexual assault response team are not prepared to identify and properly care for the patient who is a victim of sexual assault. In order to ensure that this patient population receives the deserved standard of care organizations must staff their emergency departments with staff trained in forensic nursing. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a mandate requiring screening for patients who are victims of violence. Healthy people 2010 targeted violence and abuse prevention as a major objective. It is imperative that emergency room healthcare professionals have a working knowledge of the laws governing practice standards of the care of patients of sexual violence [22].
To improve patient outcomes for the sexually assaulted patient it is imperative for emergency department healthcare professionals to recognize that assault victims are re-traumatized when care is delayed and not addressed professionally in the emergency department. Through the application of scholarship using the four domains of discovery, integration, teaching, and application, nursing professionals can improve patient outcomes. Using evidenced based practice research, education, and the application of that knowledge will improve healthcare professionals' practice, which will enhance the standard of care provided.

Conclusion
The informed and confident emergency room nurse has an important impact on how the sexual assault patient approaches recovery. To be successful in caring for the victim of sexual assault it will take a team-based effort with shared goals, clarification of roles, responsibilities, communication, trust, and measurable processes and outcomes. "When evidence is used to define best practices rather than to support existing practices, nursing care keeps pace with the latest technological advances and takes advantage of new knowledge developments" [30]. There is a lack of trained, qualified healthcare professionals to care for the victim of sexual assault. In order to meet the standard of care for this patient population healthcare organization need to hire forensic nurse specialists or have policies and guidelines in place on the detailed care and direction for this neglected patient population.