Training aims to boost ranks of sexual assault nurse examiners

“I’m glad you were here today.”

“Me too.”

That exchange between a sexual assault patient and a sexual assault nurse examiner on season two of “The Pitt” on HBO Max cast a spotlight on the vital role of forensic nursing in the medical field and the legal system. Over two episodes, viewers watch the SANE (a specialized type of forensic nurse) guide the patient through an exam to ensure her well-being, from trauma-informed care to timely evidence collection that can be used

Yet, only about 25% of U.S. hospitals have a forensic nurse on staff, according to the International Association of Forensic Nurses. In addition, a comprehensive national database to direct sexual assault patients to the nearest forensic exam doesn’t exist.

While more than half of states have SANE directories, lists can be outdated, incomplete or hard to find. A map maintained by the Indiana Department of Health shows symbols for SANE forensic health care providers stretching across the state, but rural areas display considerable gaps.

“These are patients who are in crisis,” said Angie Morris, manager of nursing at Community Hospital Anderson’s Sexual Assault Treatment Center. “In that moment, if they don’t have access to care, they might not come back.”

The number of self-reported SANEs in the Hoosier state dropped from 493 in 2021 to 423 in 2023, according to Indiana Registered Nurse Workforce data reports. A document from the IDOH’s Office of Women’s Health shows that as of 2021, only 39 of Indiana’s 92 counties had one or more facilities offering medical forensic services, and only 17 counties had pediatric SANE programs.

The Indiana SANE Training Project, which has trained nearly 500 SANEs since 2018, is working to boost those numbers with the help of a federal grant. In 2024, the Southwest Indiana Area Health Education Center at the University of Southern Indiana received $1.49 million from the Health Resources and Services Administration to increase the number of SANEs over three years.

“We have facilities that will train a whole bunch, and then they’ll be good for a while,” said Jane Friona, SWI-AHEC executive director. “And then all of those life events happen, or people go to different jobs, and they’ll be like, ‘Wow, we had 14, and now we have four.’ I don’t know that you’re ever going to get to a point where you’re like, ‘We don’t have to do this anymore.’”

The Indiana University Health Foundation and Indiana University School of Nursing secured a similar grant from HRSA in 2024 for $1.39 million, intending to train more than 340 SANEs by 2027.

“The life expectancy of a sexual assault nurse examiner on call is about three years,” said Barbra Bachmeier, nurse practitioner and advanced practice forensic nurse at IU Health Methodist Hospital. “I’ve been doing this since 1999, and I’m probably one of the older ones in the state still around doing it. But normally, if you can get a good five years out of a SANE, you’re doing very well.”

‘A first-responder situation’

The role of a SANE is twofold, with the first focus being the patient’s immediate medical needs. This care includes a physical examination with a trauma-informed approach.

“The SANE is one of the first people [a patient sees],” said Beth White, president and CEO of the Indiana Coalition to End Sexual Assault. “It’s so important that it’s the right interaction. … They are the first advocate.”

SANEs also work within the legal system by collecting evidence from patients and testifying in court cases.

“They’ve had either a 40-hour or a 64-hour didactic training. They’ve done all this clinical training to become competent,” Friona said. “It’s easier for a prosecutor to qualify them as an expert than someone who says, ‘I got the kit off the shelf and went into the room.’”

A SANE sets the tone for a sexual assault patient’s experience from treatment to trial, according to Amy Blackett, domestic violence and sexual assault prosecutor with the Indiana Prosecuting Attorneys Council.

“It’s a first-responder situation,” she said. “[Prosecutors] come in a little late, and we’re hopeful that those interactions with police and medical personnel have been positive to get the survivor started on the right path.”

Several factors contribute to the SANE shortage in Indiana, including vicarious trauma and burnout, on-call staffing issues and lack of institutional support. Although the HRSA grants cover the cost of SANE training, nurses have no guarantee of compensation from their employers while they’re taking the adult/adolescent course and/or pediatric instruction.

“We have seen many nurses who are like, ‘My hospital’s not going to pay for this, but I still want to do this.’ They will proceed out of the goodness of their hearts because it’s the right thing to do for the patients they serve,” said Morris.

When a SANE is not available, a sexual assault patient might not want to travel to the nearest provider and decline an exam altogether.

In Elkhart County, pediatric SANE services didn’t exist until last fall when a partnership between Child and Parent Services and Maple City Health Care Center made services possible. Before this initiative, the closest care for children was in South Bend.

“The moment a forensic exam is suggested, that parent and child have just gone through some of the worst moments of their lives. This is a really vulnerable moment,” said Rebecca Shetler-Fast, chief executive officer of the recently merged CAPS & Maple City. “And then to say, ‘We’d like you to travel 45 minutes, an hour.’ We regularly have parents decline.”

Medical personnel who haven’t completed SANE training may perform a sexual assault patient exam. However, because of their lack of instruction, these health care workers could miss steps in evidence and paperwork procedures.

“Our documentation is more intensive, it’s more thorough, it’s more complete. We have the ability to do photographs,” Morris said. “We’re trying to capture a true and accurate representation of that patient’s presentation.”

SANEs in the courtroom

On the witness stand, SANEs make better expert witnesses in sexual assault cases than other medical employees, Blackett said.

“As a prosecutor, I would much rather have a SANE as a witness than a generally trained nurse,” she said. “They’ve likely had way more training on the injuries and topics that are more specific to what we’re talking about in criminal court, and they likely have spent more time with the patient. They’ve even had some training on how to testify and what’s expected of them in court.”

Friona said extensive examinations conducted by SANEs can often be the key to convictions from an evidence perspective.

“Anecdotally, from lots of attorneys and prosecutors, people are much more likely to plead to something if there’s been an exam by a SANE or a forensic nurse than if there wasn’t, because there’s all of that documentation,” she said. “The case starts from a much stronger point.”

Although hearsay is generally not admissible in court, the medical hearsay exception enables SANEs to testify on behalf of their patients.

“[SANEs] will write down what the patient tells them. Then, as prosecutors, if we lay that foundation in the right way, if that is in fact what happened, that the survivor was telling the nurse that for purposes of medical diagnosis and treatment — which 99 times out of 100, the answer is yes — then we get that in through the nurse,” said Blackett.

At the end of April, the Indiana SANE Training Project is hosting the Empowering Medical Forensic Practice conference in Indianapolis, where national experts will explore topics shaping patient care and professional collaboration while providing current practice updates for nurses and multidisciplinary teams. Blackett believes the project is critical for training and supporting SANEs throughout the state.

“It would be my dream come true if there were full-time SANEs employed in every hospital in the state, which I understand is a pipe dream,” she said. “But the more nurses trained in this discipline, the better. It would be amazing if every nurse had some of this background. And it is different between pediatric patients and adult/adolescent patients.”

While SANEs fall under forensic nursing, Bachmeier said there’s more to the field than just sexual assault. Her facility actually sees more domestic violence patients, and her training allows her to assist in those cases, as well.

“I’ve testified in murder cases. I’ve testified in strangulation cases, physical assault cases where a patient was shot. Because we were involved in that care, I was able to testify and spare the surgeons from coming to court. [The victim] needed somebody to talk about their injuries,” she said.

Beyond the general nursing shortage, White believes the lack of SANEs in Indiana is not just a health care workforce problem; it’s a justice issue.

“If we don’t have enough [SANEs], or we can’t get them where they need to be to do this work, then we’re failing our victims,” she said.•