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Forensic Focus

Safety and community health go hand-in-hand for SANE nurses at Texas Health Presbyterian Hospital Dallas

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Loren D. Larkin, MA, BSN, RN, CEN, CPEN, CA-SANE, believes in serendipity and timing. The nurse educator in the Texas Health Presbyterian Hospital Dallas emergency department has spent his 32-year career in the ED, working with victims of trauma, accident and crime. He's seen first-hand how victims of sexual assault are re-victimized by a medical and legal system that, at times, is unable to bring attackers to justice. So, even as Texas Health Dallas rolled out a program in 2010 to help care for these voiceless victims by bringing in trained sexual assault nurse examiners (SANE), he was already looking forward to the day when these nurses would be trained in-house.

That day has arrived.

Program Development

For years, Dallas was the largest city in the U.S. without local SANE training. Nurses who wanted to be SANE-certified had to travel for the training. Larkin said the need for community training was a pressing concern for the Texas Health Dallas ED staff and local law enforcement. But as persistence often breeds success, Larkin and his colleagues found a way, and Texas Health Dallas rolled out on-site SANE training in November 2010. Larkin said a lot of things came together to bring SANE training to Texas Health Dallas.

"People from the district attorney's office to law enforcement who worked with crime victims expressed a great need for SANE staff and local training," he said. "Our hospital listened and it all came together in a great way."

Audio Interview

SANE Nursing at Texas Health Dallas

A chat with Cole Edmonson, DNP, RN, FACHE, NEA-BC, vice president of patient care services and chief nursing officer

Though a latecomer to the party when he joined the Texas Health Dallas staff 10 months ago, Cole Edmonson, DNP, RN, FACHE, NEA-BC, vice president of patient care services and chief nursing officer, quickly became a SANE training champion.

"The program was nursing led and nursing driven," Edmonson said. "The professional staff brought it to the table to meet a community need. It gives nurses a platform and evidence-based tools to be able to say, we have resources and we can help both individuals seeking care and our community."

Nursing Focus

Key for nurses was development of a sexual assault response team, which would design and implement medical/forensic care for both adults and adolescents in Dallas. Playing a key role was Mary Rowe, MSN, RN, CEN, NE-BC, ED nursing manager, who accepted the challenge and gained the support of Elizabeth Asturi, MSN, RN, ED director. Rowe pulled together a multidisciplinary team that included Larkin, ED physicians Mark Till, MD, and Brad Sellers, MD, and SANE nurses Tammy Prewitt, RN, CA-CP SANE, and Beth Adams, BSN, RN, CA-CP SANE. Community agencies also were represented, including Courtney Underwood and Jana Barker with Dallas Area Rape Crisis Center (DARCC), Victim's Outreach represented by Claudia Alexander, Dallas police represented by Sgt. Patrick Welsh and Pat Keaton, and Dallas County district attorney representative Erin Hendricks. Each of these important community members formed a dynamic team that would be known as the Texas Health Dallas Sexual Assault Response Team with the purpose of defining the future focus and direction. Rapid cycle testing during the pilot stage allowed the group to be nimble and improve the process as it moved forward. To date, 10 Texas Health Dallas ED nurses have become SANE-certified.

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PPROPER PROTOCOL: Renee Donald, BSN, RN, CEN, CA-CP SANE, prepares a swab for use during a SANE exam.

"We have been under-resourced in the community for sexual assault victims, so this program is truly an amazing gift," Edmonson said. "It is exciting to know that Texas Health Dallas nurses and leaders took this to heart and took action. This demonstrates how important it is to the community to be able to treat these patients with the care, compassion and respect they deserve, while being able to collect the forensic evidence necessary to get a conviction of the perpetrators. Actual conviction rates go up when a SANE nursing program is present in a community because of the care, treatment and education, and preparation of the evidence is so much better."

Training Day

Larkin worked to develop a comprehensive program that would maintain the high standards Texas Health Dallas has set. Along with 60 hours of didactic education, SANE candidates put in more than 90 hours of clinical training, observe 16 hours of criminal court proceedings and perform supervised patient forensic exams. It can be grueling, and Larkin makes sure nurses who are interested know that up front.

"The certification comes from the state of Texas through the office of the attorney general," he said. "It is a lengthy process. Candidates must be approved, must have been in nursing for at least 2 years, must be able to put in 2 weeks of classroom training and be prepared to put time in for clinical."

The facility has worked very closely with the office of the attorney general. An October class trained four Texas Health Dallas ED nurses, plus 23 other nurses from across the state.

"As we get fully flowing, we want to do more training here," Larkin said. "One of the next steps is to become a training site that allows nurses to come here from across Texas to do the clinical portion of their training if they've met the criteria and done the appropriate classroom training. In a way, it's like student nursing for SANE training. We want to help set the standard for the state and, at the same time, be a resource for other communities. We're building a good support team for the entire state."

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ATTENTIVE CARE: Renee Donald, BSN, RN, CEN, CA-CP SANE, talks with a patient at the Texas Health Dallas emergency department.

Those high standards are important for every case going forward, Larkin said. Nurses must learn how to treat and care for sexual assault victims from the moment they enter the ED, as well as to perform proper evidence collection and prepare to testify in court. As the program has grown, hospitals in outlying areas already are sending their sexual assault patients to Texas Health Dallas for expert treatment.

But, Larkin points out, the training is much more than creating "sexual assault phlebotomists."

"We are not training nurses to be kit collectors," he said. "We start a process of healing that's far more than evidence. If they came in without one ounce of evidence on them, we would still want to work with them in every way we could to start a healing process for them."

Patient Care

SANE training and the work of SANE nurses at Texas Health Dallas are making an impact, Larkin said. While Texas Health Dallas nurses drove the project, financial backing in the form of a generous $2 million grant came from the W.W. Caruth, Jr. Foundation of Communities Foundation of Texas. The grant supported not only the training program, but also funded DARCC, an independent rape crisis center that provides counseling and sexual assault education in local schools and universities.

Along with funding from Texas Health Dallas, the Caruth grant also has been used to construct the W.W. Caruth, Jr. Center for SAFE (Sexual Assault & Forensic Evidence) Healing at Texas Health Dallas, adjacent to the ED. Once completed, the 2,900-square-foot center with three self-contained suites will be used to provide comprehensive treatment for sexual assault victims, including sexual assault exams and collection of court-admissible forensic evidence. The suites are anticipated to be open in September 2011.

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STANDING WATCH: Loren D. Larkin, MA, BSN, RN, CEN, CPEN, CA-SANE, emergency department clinical educator and SANE program coordinator (center), discusses a case with the emergency department staff.

Each suite has a spacious, well-appointed lounge complete with a place for family members to wait. Once patients enter the suite, patients don't go back into the ED, but move from the lounge to a fully supplied exam room. Following the exam, they can go to the connected bathroom for a shower and to put on fresh clothes. Once they're discharged, they leave through a private exit, not through the ED.

"The suites provide privacy and a calm area, a place for healing," Larkin said. "We've tried to be very creative. No one even knows they're there."

Looking Forward

Calling the program a "pilot," Larkin said each participant is fully vested in its development.

"We're constantly trying to look at areas where we can improve," he said. Hopefully, nurses and other patient advocates will be able to make a difference in the lives of these sexual assault victims, so they see us as true allies. We're hopeful, from the field introduction to that victim through the whole process of healing, it can all start through what we're trying to do here in a seamless process. We're not just there for these patients for the several hours they're with us in the ED."

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PATIENT PROTECTORS: SANE nurses at Texas Health Dallas take pride in their work, including the core group of Yolanda Blaine, BSN, RN, CA-SANE (front row, left); Mary Rowe, MSN, RN, CEN, NE-BC; Tammy Prewitt, RN, CA-CP SANE; Hope Otto, RN, CA-SANE (back row, left); Renee Donald, BSN, RN, CEN, CA-CP SANE; Beth Adams, BSN, RN, CA-CP SANE; and Loren D. Larkin, MA, BSN, RN, CEN, CPEN, CA-SANE. photos courtesy Texas Health Presbyterian Hospital Dallas

That fits in with the Texas Health Dallas nursing mission, Edmonson said.

"This training speaks to how our nurses extend into the community and really explore their roles, embracing the health of the community in a much richer way," he said. "One of the key points of the Institutes of Medicine report is to reframe the future of nursing as not just a nursing issue, but also as a societal issue. This program really exemplifies that nursing is a societally impactful profession and that nurses really have an obligation and opportunity to improve the health and safety of the community, whether it's their own community or the one in which they work. Programs such as the SANE program demonstrate that beautifully in terms of making the community safer, improving health and also increasing the conviction rate among perpetrators."

It also changes the dynamic for nursing staff.

"Looking at it from an employer's standpoint, the program also empowers nurses to perform to their full scope of practice and feel they're making a difference," Edmonson said. "At Texas Health Dallas, we believe in full scope of practice for nurses, that they're using all of the education, training and skills, both from their academic programs and what they receive post-graduation. We really do want to be on the innovative cutting edge for full scope of practice for nurses, and the SANE program is a great exemplar of that." 

Candy Goulette is regional editor at ADVANCE.


Aha, I knew I'd find you if I just kept looking. Would sure like to hear from you.
Marilyn McCoun, old teacher and friend

Marilyn McCounOctober 10, 2011
St. Joseph, MO


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