The Purpose, Process, and Advancement of Forensic Nursing Standards.

BACKGROUND: To strengthen the nation's use of forensic science and advance professional practice, forensic practitioners and scientists in the Organization of Scientific Area Committees (OSAC) develop standards in forensic science. The Forensic Nursing Subcommittee was created by OSAC in 2021 to develop standards that improve patient outcomes through delivery of consistent practice guidelines, evidence-based techniques for preservation of evidence, and accurate representation of practice and examination findings. PURPOSE: The purpose of this article is to relate the history of forensic science standard development in the United States, discuss the rationale for forensic nursing standards, and describe the standards development process. In this article, we provide an overview of OSAC and the OSAC Forensic Nursing Subcommittee. We discuss how forensic nurses can be involved in the development and advancement of standards that define minimum requirements, best practices, and evidence-based protocols to ensure reliable and reproducible outcomes. IMPLICATIONS FOR FORENSIC NURSES: The development of forensic nursing standards is an important step in advancing the profession. It is critical that forensic nurses are actively involved in the standards development process, which includes volunteering to serve on the OSAC Forensic Nursing Subcommittee or a forensic nursing standards development organization, providing input into standards drafts during the public comment period, and implementing approved standards into practice.

Meeting Complex Needs of Sexually Assaulted Incarcerated Individuals: Impact of Expert Sexual Assault Nurse Examiner Care via Telehealth.

Sexual violence within prisons is a complex issue. The Prison Rape Elimination Act identifies standards to guide the provision of care to meet the medical and forensic needs of individuals who experience sexual assault (SA) while incarcerated. The standards include access to care by a Sexual Assault Nurse Examiner (SANE) whenever possible. Telehealth is one solution to ensure expert SANE access. This brief report addresses the pre-examination concerns/worries and immediate post-examination perceptions and experiences of six individuals who experienced SA while incarcerated. Findings show resolution of pre-examination worries, high satisfaction with care, high telehealth acceptability rates, and universal endorsement that examinations should occur outside of correctional facilities. Although not generalizable, this report provides preliminary insight into care in an understudied population with unique health care needs.

A Strengths and Needs Assessment of Campus Sexual Assault Response.

BACKGROUND: Sexual violence and sexual assault (SA) disproportionately affect the young adult population aged 18-24 years, half of which are enrolled in higher education. Campuses are tasked with providing a safe space for students and enacting an appropriate response to campus SA (CSA). AIMS: As part of a grant-funded program to strengthen SA nurse examiner (SANE) services to those who experience SA on college campuses, we conducted a campus needs assessment and a campus website review for key messaging and analyzed the responses to identify strengths and gaps in campus resources related to CSA. These findings were the basis of individualized Campus Community Summary reports shared with participants from each campus. METHODS: Guided qualitative interviews with interdisciplinary stakeholders across seven campus communities and campus website reviews were used to identify campus resource strengths, gaps, and recommendations for improvement. RESULTS: Common strengths included awareness of campus programs and community services, leadership support for CSA activities, and community CSA response. Identified opportunities for improvement included strengthening interdisciplinary collaboration, solving transportation issues to obtain care, mental healthcare and advocacy services, awareness and resource messaging, and fighting stigma and bias. Campus websites reviews indicated gaps in key information about SANE care and how to access SANE services. CONCLUSIONS: Numerous gaps and opportunities to strengthen campus SA awareness and coordination and access to a timely response to SA were identified. Addressing these gaps is essential to ensure quality care and services for individuals who experience SA on college campuses.

Pathway From Type 2 Diabetes Diagnosis to Action: How to Move People Forward.

Seven self-care behaviors-healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem-solving-are recommended for individuals with diabetes to achieve optimal health and quality of life. People newly diagnosed with type 2 diabetes may find it challenging to learn and properly incorporate all of these self-care behaviors into their life. This qualitative study explored the experiences and perceived immediate self-management and psychosocial support needs in individuals newly diagnosed with type 2 diabetes. Data analysis revealed the significant challenges individuals encounter after a type 2 diabetes diagnosis. Five main themes were identified: 1) type 2 diabetes diagnosis competes with other complex life challenges, 2) difficulty in performing behavior modification actions, 3) lack of support, 4) emergence of emotional and psychological issues, and 5) need for planned individualized follow-up support after a type 2 diabetes diagnosis. This study revealed a gap in care after type 2 diabetes diagnosis. Individualized support is needed to assist people in moving successfully from diagnosis to being well equipped with the knowledge and skills necessary to properly manage the condition.

Remodeling Type 2 Diabetes Diagnosis: What Individuals Need for Success.

The diagnosis of type 2 diabetes initiates a new health-illness transition. However, little is known about the immediate support that people need to successfully cope with this diagnosis. This qualitative study explored the experiences and immediate support needed at the point of diagnosis among individuals with type 2 diabetes. The findings suggest the need for health care professionals to render immediate emotional support in the form of reassurance and partnership to manage the condition together. Pre- and post-counseling sessions can minimize the emotional and psychological strain associated with the new diagnosis. Individuals should be given information on available resources, as well as an immediate connection with a health care partner who can provide guidance and help with the transition.

Multidisciplinary Perspectives on the Implementation of a Comprehensive Sexual Assault Telehealth Program in Rural Communities: A Qualitative Study.

Access to quality sexual assault (SA) care in rural communities is limited by challenges surrounding building and sustaining a skilled SA nurse examiner workforce. Telehealth can facilitate access to expert care while cultivating a local sexual assault response. The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center aims to decrease disparities in SA care by providing expert, live, interactive mentoring, quality assurance, and evidence-based training via telehealth. This study examines multidisciplinary perceptions of pre-implementation barriers and SAFE-T program impact using qualitative methods. Implications for the implementation of telehealth programs to support access to quality SA care are considered.

Leveraging Telehealth to Address Sexual Assault Nurse Examiner Access Disparities in Rural Communities.

BACKGROUND: There are persistent gaps in access to sexual assault nurse examiners (SANEs) in rural and underserved areas, yielding health and legal disparities for survivors. These inequities prompted federal investment in novel telehealth programs to improve SANE access. PURPOSE: The aim of this study was to examine program case studies from two sexual abuse/assault (SA) telehealth centers, illuminating successes, challenges, and lessons learned. METHODS: Two state SA telehealth program directors used a collective instrumental case study approach to understand telehealth SANE (teleSANE) program challenges/lessons learned, outcomes, and recommendations for the field. Cross-program commonalities and differences were examined, pooling experiences to derive recommendations to sustain telehealth to increase SA health equity. RESULTS: Collectively, the two programs have served 18 remote sites and provided 335 consultations. Both programs provide access to 24/7 teleSANE consultation, quality assurance, and mentoring. Unique to each program were engagement of hospital leadership in advisory boards, use of telehealth technology, training programs, and fiscal sustainability. Both programs identified flexibility, offering a tailored implementation approach, regular site support and communication, and teleSANE mentoring aligned with the Quality Caring Model as essential to success. Critical needs identified to sustain programs included (a) multilevel community and hospital buy-in, (b) sustainable funding specific to local institution needs, and (c) robust processes to oversee clinical and technology support. CONCLUSIONS: Cross-program similarities and differences show the impact telehealth can have on equitable SA care. Program evaluation showed common challenges, lessons learned, and recommendations to advance equitable SA care access in underresourced communities.

"Having One Person Tell Me I Didn't Do the Wrong Thing": The Impact of Support on the Post-Sexual Assault Exam Experience.

Social support following a sexual assault (SA) may help minimize or prevent the myriad of negative sequelae impacting individuals who experience SA. Receiving a SA exam may provide initial support during the SA exam and set up individuals with needed resources and supports post-SA exam. However, the few individuals who receive a SA exam may not stay connected to resources or support post-exam. The purpose of this study was to understand individuals' post-SA-exam social support pathways including individuals' ability to cope, seek care, or accept support following a SA exam. Interviews were conducted with individuals who experienced SA and then received a SA exam through a telehealth model. The findings revealed the importance of social support during the SA exam and in the months that followed. Implications are discussed.

Provider Attitudes and Self-Efficacy When Delivering a Child Sexual Abuse Prevention Module: An Exploratory Study.

BACKGROUND: As constant figures in children's lives, parents are key in protecting children from sexual abuse. One barrier to reaching parents is that the topic can be difficult to broach and is sensitive in nature. Such barriers can interfere with implementation and fidelity of evidence-based prevention strategies that are focused on reducing rates of childhood sexual abuse (CSA). AIMS: In this exploratory study, we examine provider attitudes about delivering CSA-specific content in an evidence-based prevention module and their self-efficacy. METHOD: Thirty-three providers participated in three surveys: prior to a skills-oriented training on how to deliver the CSA prevention module (pretraining), immediately posttraining, and 6 months posttraining. Changes in self-reported willingness to deliver content, beliefs about parents' role in CSA prevention, and confidence about their ability to deliver content were assessed over time. Open-ended questions were coded thematically to reinforce quantitative findings. RESULTS: Prior to training, providers were worried that parents would respond negatively to CSA content and were concerned about their comfort level discussing victimization and sexual development. Findings suggest that skill-oriented training and provision scripts effectively supported providers and improved confidence in delivering CSA prevention content. DISCUSSION: Provider self-efficacy is an important element of implementation fidelity. This exploratory study demonstrated that, though providers may approach CSA content with wariness and trepidation, adequate skills-oriented training can reduce negative attitudes and increase perceived efficacy in the actual delivery of CSA content that persists through implementation. CONCLUSION: Skills-based training can significantly enhance fidelity in the delivery of difficult content included in parent-focused preventative interventions.

Pathway to Healing and Recovery: Alleviation of Survivor Worries in Sexual Assault Nurse Examiner-Led Sexual Assault Telehealth Examinations.

INTRODUCTION: The purpose of this study is to understand the pre-examination worries of individuals who experience sexual assault, and whether those worries were experienced or resolved during a telehealth-enabled, sexual assault nurse examiner-led sexual assault examination. METHODS: Patient surveys were administered to understand pre-examination worries, whether those worries were ultimately experienced during the consultation, and patient perceptions of care quality, telehealth consultation, and whether the examination helped individuals feel better. Data analysis was conducted using descriptive statistics and binomial proportion tests. RESULTS: Surveys were collected from 74 adolescents and adults who obtained sexual assault care at 6 rural and 2 suburban hospitals. Study findings showed individuals overcome substantial worries to access care, with 66% having at least 1 worry and 41% endorsing 3 or more pre-examination worries. Most participants felt believed (83%) and did not feel judged (88%) or blamed (85%) during their examination. Analysis of pre-examination worries and worry resolution during the examination showed 88% to 100% resolution of worries related to being believed, judged, blamed or lacking control. Participants highly rated the quality of care received (92%) and 84% stated the examination helped them feel better, suggesting a sexual assault nurse examiner-led examination is an important step toward recovery and healing. DISCUSSION: These findings have implications for emergency department support for sexual assault nurse examiner-led care and public health messaging to demystify sexual assault care, allay fears, and highlight care benefits.

Parent-Focused Sexual Abuse Prevention: Results From a Cluster Randomized Trial.

This study tested whether a child sexual abuse (CSA) prevention program, Smart Parents-Safe and Healthy Kids (SPSHK), could be implemented as an additional module in evidence-based parent training and whether the added module might detract from the efficacy of the original program. In a cluster randomized trial, six community-based organizations were randomized to deliver Parents as Teachers (PAT) with SPSHK (PAT+SPSHK) or PAT as usual (PAT-AU). CSA-related awareness and protective behaviors, as well as general parenting behaviors taught by PAT were assessed at baseline, post-PAT, post-SPSHK, and 1-month follow-up. Multilevel analyses revealed significant group by time interactions for both awareness and behaviors (ps < .0001), indicating the PAT+SPSHK group had significantly greater awareness of CSA and used protective behaviors more often (which were maintained at follow-up) compared to the PAT-AU group. No differences were observed in general parenting behaviors taught by PAT suggesting adding SPHSK did not interfere with PAT efficacy as originally designed. Results indicate adding SPHSK to existing parent training can significantly enhance parents' awareness of and readiness to engage in protective behavioral strategies. Implementing SPHSK as a selective prevention strategy with at-risk parents receiving parent training through child welfare infrastructures is discussed.

Help-Seeking and Barriers to Care in Intimate Partner Sexual Violence: A Systematic Review.

Intimate partner sexual violence (IPSV) is a prevalent phenomenon, yet an under-researched topic. Due to the complex nature of balancing love and fear, individuals who experience IPSV have unique needs and face unique barriers to seeking care. The purpose of this systematic review was to examine the literature on help-seeking and barriers to care in IPSV. Articles were identified through PubMed, CINAHL, PsycINFO, and Web of Science. Search terms included terms related to IPSV, intimate partner violence (IPV), domestic violence, sexual assault, and rape. The review was limited to the United States, and articles that were included needed to specifically measure or identify sexual violence in an intimate relationship and analyze or discuss IPSV in relation to help-seeking behaviors or barriers to care. Of the 17 articles included in this review, 13 were quantitative studies and four were qualitative studies. Various definitions and measurements of IPSV across studies included in this review make drawing broad conclusions challenging. Findings suggest that experiencing IPSV compared to experiencing nonsexual IPV (i.e., physical or psychological IPV) may increase help-seeking for medical, legal, and social services while decreasing help-seeking for informal support. Help-seeking can also reduce risk of future IPSV and decrease poor mental health outcomes. Barriers to seeking care in IPSV included social stigma, fear, and difficulty for individuals in identifying IPSV behaviors in their relationships as abuse. More inclusive research is needed among different populations including men, non-White individuals, nonheterosexual, and transgender individuals. Suggestions for research, practice, and policies are discussed.

The Impact of COVID-19 Restrictions on Victim Advocacy Agency Utilization Across Pennsylvania.

This brief report highlights the impact of the COVID-19 restrictions on the utilization of Victim Advocacy Agencies' (VAAs') services across Pennsylvania, using VAA utilization data from 2019-2020. VAA utilization data in this report were collected from 2019-2020 by the Pennsylvania Coalition Against Rape (PCAR). VAA utilization data were anchored to COVID-19 restriction timelines, defined by the Pennsylvania Office of the Governor. For each month, a percent change in VAA utilization (e.g., Jan 2020 utilization compared to Jan 2019 utilization) was calculated. A one-way ANOVA was run to assess whether the association between restriction phase and percent change in overall VAA utilization from 2019 to 2020 was statistically significant. A substantial decrease in VAA utilization was observed once lockdown restrictions were enacted, as well as a sustained decrease in utilization between 2019 and 2020. When restrictions were eased, an increase in service utilization was noted. This pattern of findings held for the three variables assessed: hotline utilization, new client, and medical accompaniments for FREs per month. The one-way ANOVA confirmed a statistically significant decrease in overall VAA utilization when comparing the most severe COVID-19 related restrictions to both pre-COVID and less severe restrictions. A variety of barriers (e.g., financial instability, loss of childcare, technology access, chronic physical proximity to abuser, hospital visitation restrictions, fears of contracting the virus) may result in decreased utilization of VAA services. Future research should investigate the relevance of potential causal mechanisms behind VAA utilization to help inform intervention approaches.

What Individuals Want to Hear at the Point of Type 2 Diabetes Diagnosis.

Recent studies have shown that the time of diagnosis with type 2 diabetes is often not a teachable moment because of heightened emotions. Yet, research also shows that individuals who are newly diagnosed with type 2 diabetes need reassurance and a clear pathway to obtain the education and support needed to self-manage the condition. This article reports on qualitative research exploring the experiences of individuals with type 2 diabetes at the time of diagnosis, including information they wanted to hear and learn at diagnosis. The findings suggest that initial communication should offer reassurance and establish a partnership between the diagnosed individual and the health care provider to identify next steps toward self-management success.

The Implementation of the Sexual Assault Forensic Examination Telehealth Center: A Program Evaluation.

INTRODUCTION: Substantial disparities in the quality of post-sexual-assault (SA) care exist in the United States, particularly in rural areas. This study evaluates the implementation of the Sexual Assault Forensic Examination Telehealth Center, a program to improve SA care by increasing access to experienced sexual assault nurse examiners via telehealth, in three rural hospitals. MATERIALS AND METHODS: The Dynamic Sustainability Framework (DSF) guided the implementation of the intervention. Survey and implementation data were evaluated 1 year after implementation using a nonexperimental pre-post design. Outcomes include patient and nurse perceptions of telehealth, local site nurse (LSN) confidence, and hospital protocol/policy changes. RESULTS: Forty-one telehealth consultations were completed in the program's first year. An average of 34 system-level protocol changes were made per site. LSNs demonstrated statistically significant increases in confidence to provide SA care at 1 year. LSNs and telehealth sexual assault nurse examiners (expert consultants) reported that quality of SA care improved (87% and 83%, respectively). Patients highly rated the care they received (83%), reported telehealth improved care (78%), and reported feeling better after the examination (74%). DISCUSSION: Using the DSF for implementation supported a tailored approach and successful adoption and also allowed for program iteration based on lessons learned. CONCLUSIONS: The Sexual Assault Forensic Examination Telehealth model resulted in improved local nurse confidence in provision of SA care, nurse perception of improvement in care quality, and high patient care experience ratings. These findings and the use of the DSF have implications for SA specialty care implementation in rural communities.

Meaningful Engagement of Patient Advisors in Research: Towards Mutually Beneficial Relationships.

Patient engagement in research improves trustworthiness of the research findings, increases relevance, and ensures designs include the most meaningful outcomes for patients living with targeted health conditions. The Patient Centered Outcomes Research Institute (PCORI) requires engagement of patient stakeholders. There is limited description of both the context and the processes used to engage patients effectively. This paper discusses engagement activities, roles and responsibilities, value of a Patient Advisory Board (PAB), and lessons learned. Data include program notes, research team reflections, PCORI reporting, and an advisor survey.Facilitators of meaningful engagement included creating a learning community, co-defining clear roles, reimbursing advisors, establishing clear avenues for communication, and welcoming unique contributions. Lessons learned were the value of time, the importance of building trust, and the benefits of diverse perspectives. The approach to meaningful engagement of patient advisors in research has the potential to enhance the relevance and usefulness of research for improving lives.

The Sexual Assault Forensic Examination Telehealth (SAFE-T) Center: A Comprehensive, Nurse-led Telehealth Model to Address Disparities in Sexual Assault Care.

BACKGROUND: Rural and underserved communities often struggle to provide access to specialized health care, including sexual assault care. Telehealth is an effective solution for providing access to an array of specialized health care services. Prior sexual assault telehealth programs have provided evidence that telehealth is a feasible and acceptable solution. However, there is scant information about program development and considerations in the literature to guide those who may seek to implement a sexual assault telehealth program in their communities. PURPOSE: The purpose of this paper is to describe the Sexual Assault Forensic Examination Telehealth (SAFE-T) Center-a nurse-led model for providing comprehensive, high-quality sexual assault care in rural and underserved communities recently implemented at 3 hospitals in rural Pennsylvania. METHODS: Using the program's logic model, we present our community-engaged approach to the development and implementation phases of the SAFE-T Center. FINDINGS: We first describe how academic researchers partnered with multiple stakeholders to form a statewide advisory board and articulated a vision and mission for the SAFE-T Center that meets the needs of local communities. We then describe the overall design of the model, how it was informed by this academic-community partnership, and how each element relates to anticipated outcomes. We also present our plans for program evaluation, expansion, and sustainability. CONCLUSION: This detailed description of collaborative partnership, coalition-building, program design and implementation can serve as a guide for hospitals and health systems seeking to implement telehealth programs to improve the care provided to survivors of sexual assault.

Rural Availability of Sexual Assault Nurse Examiners (SANEs).

PURPOSE: Sexual assault care provided by sexual assault nurse examiners (SANEs) is associated with improved health and prosecutorial outcomes. Upon completion of SANE training, nurses can demonstrate their experience and expertise by obtaining SANE certification. Availability of nurses with SANE training or certification is often limited in rural areas, and no studies of rural certified SANEs exist. The purpose of this study is to describe rural SANE availability. METHODS: We analyze both county-level and hospital-level data to comprehensively examine SANE availability. We first describe the geographic distribution of certified SANEs across rural and nonrural (ie, urban or suburban) Pennsylvania counties. We then analyze hospital-level data from semistructured interviews with rural hospital emergency department administrators using qualitative content analysis. FINDINGS: We identified 49 certified SANEs across Pennsylvania, with 24.5% (n = 12) located in 8 (16.7%) of Pennsylvania's 48 rural counties. The remaining 37 certified SANEs (75.5%) were located in 13 (68.4%) of Pennsylvania's 19 nonrural counties. Interview data were collected from 63.9% of all eligible rural Pennsylvania hospitals (n = 63) and show that 72.5% (n = 29) have SANEs. Of these, 20.7% (n = 6) have any certified SANE availability. A minority of hospitals (42.5%; n = 17) have continuous SANE coverage. CONCLUSIONS: Very few SANEs in rural Pennsylvania have certification, suggesting barriers to certification may exist for rural SANEs. Though a majority of hospitals have SANEs, availability of SANEs was limited by inconsistent coverage. A lack of certified SANEs and inconsistent SANE coverage may place rural sexual assault victims at risk of receiving lower quality sexual assault care.

Nurse Coaching and Mobile Health Compared With Usual Care to Improve Diabetes Self-Efficacy for Persons With Type 2 Diabetes: Randomized Controlled Trial.

BACKGROUND: Type 2 diabetes is a growing public health problem amenable to prevention and health promotion. As healthy behaviors have an impact on disease outcomes, approaches to support and sustain diabetes self-management are vital. OBJECTIVE: This study aimed to evaluate the effectiveness of a nurse coaching program using motivational interviewing paired with mobile health (mHealth) technology on diabetes self-efficacy and self-management for persons with type 2 diabetes. METHODS: This randomized controlled trial compared usual care with an intervention that entailed nurse health coaching and mHealth technology to track patient-generated health data and integrate these data into an electronic health record. The inclusion criteria were as follows: (1) enrolled at 1 of 3 primary care clinics, (2) aged 18 years or above, (3) living with type 2 diabetes, and (4) English-speaking. We collected outcome measures at baseline, 3 months, and 9 months. The primary outcome was diabetes self-efficacy; secondary outcomes were depressive symptoms, perceived stress, physical functioning, and emotional distress and anxiety. Linear regression mixed modeling estimated the population trends and individual differences in change. RESULTS: We enrolled 319 participants; 287 participants completed the study (155 control and 132 intervention). The participants in the intervention group had significant improvements in diabetes self-efficacy (Diabetes Empowerment Scale, 0.34; 95% CI -0.15,0.53; P<.01) and a decrease in depressive symptoms compared with usual care at 3 months (Patient Health Questionnaire-9; 0.89; 95% CI 0.01-1.77; P=.05), with no differences in the other outcomes. The differences in self-efficacy and depression scores between the 2 arms at 9 months were not sustained. The participants in the intervention group demonstrated a significant increase in physical activity (from 23,770 steps per week to 39,167 steps per week at 3 months and 32,601 per week at 9 months). CONCLUSIONS: We demonstrated the short-term effectiveness of this intervention; however, by 9 months, although physical activity remained above the baseline, the improvements in self-efficacy were not sustained. Further research should evaluate the minimum dose of coaching required to continue progress after active intervention and the potential of technology to provide effective ongoing automated reinforcement for behavior change. TRIAL REGISTRATION: ClinicalTrials.gov NCT02672176; https://clinicaltrials.gov/ct2/show/NCT02672176.

Disparity in child welfare referrals from public schools: An example of Simpson's Paradox?

BACKGROUND: Black children continue to be found in child welfare outcome measures at rates nearly double those of White children in the United States. Researchers have turned from bias theory to risk theory, arguing that disparity disappears when considering only the subgroup of children in poverty. In this study, we consider whether this phenomenon is an example of Simpson's Paradox, where aggregate findings are confounded by a third factor. PARTICIPANTS: We created a dataset by matching child welfare data to schools in a metropolitan California county. METHODS: We consider measures of poverty and racial-ethnic student composition as possible confounders, utilizing compositional data analysis for the latter. Traditional linear and ridge regression models were used to calculate the unadjusted and adjusted effects of each independent variable. RESULTS: We find only partial evidence of Simpson's Paradox, in that Black to White disparity only disappears in the highest quartile of poverty. Holding poverty constant, only increasing student population non-White composition was significantly associated with reducing Black to White disparity ratios. CONCLUSION: In a small, exploratory study, we find that while poverty may serve as an equalizer, diversity racial/ethnic student body composition may serve as a neutralizer. We find that underlying causes of disparity are complex and caution against endorsement of single theories to explain the disproportionate representation of Black children in child welfare. We find utility in analyzing child welfare data with concepts and techniques common in other disciplines and highlight several weaknesses of current child welfare informatics which impact both program evaluation and research.