Abstract
Nurses and medical advocates respond to sexual assault survivors seeking hospital services. Ideally, both providers work collaboratively. However, this does not always happen. Extant research on the nurse–advocate relationship focuses on Sexual Assault Nurse Examiners (SANEs). This study examines how ER nurses perceive their training and experience influence the working relationships between emergency room (ER) nurses (not exclusively SANEs) and medical advocates. Key findings indicate nurses perceive increased training improves (a) role understanding, (b) trust, (c) respect, (d) rapport, and (e) appreciation. Less training was associated with poorer role understanding and trust.
Keywords
Introduction
To curb harmful responses to sexual assault (SA) survivors in medical settings, two interventions emerged in the United States: Sexual Assault Nurse Examiner (SANE) programs and rape crisis medical advocacy. SANE programs train nurses to ensure survivor medical treatment is respectful, patient-focused, timely, and capable (Ahrens et al., 2000; Campbell et al., 2005; Ledray, 1996; Ledray & Simmelink, 1997). However, it is not guaranteed that survivors seeking medical treatment will be cared for by a SANE (e.g., Delgadillo, 2017; GAO, 2018; Thiede & Miyamoto, 2021). Rape crisis medical advocates accompany survivors throughout their time at the hospital, seek to prevent negative treatment of survivors by the medical system, and attempt to ensure the medical system meets survivors’ needs (Campbell, 2006; Martin, 2005; Payne, 2007). Advocates and healthcare professionals need a functional working relationship to provide optimal care for survivors (Payne, 2007). However, tensions and conflict may occur between nurses and medical advocates and interfere with service delivery (Cole & Logan, 2008), which can negatively impact survivors (Payne, 2007). Therefore, more research is needed on factors that promote positive advocate–nurse relationships and ultimately contribute to better care for survivors. As most studies have focused on SANE–medical advocate working relationships, to date, there have been no studies that have examined how varied nurse training and nurse experience relate to the quality of nurses’ relationships with medical advocates. The purpose of this study was to use qualitative methodology to examine how nurse training and experience relate to nurses’ perceptions of their working relationships with medical advocates.
Problems With Medical Response to Survivors
Emergency department (ED) nurses are the primary medical providers that survivors interact with for the duration of their visits (Campbell, 2005). Nurses provide medical care and conduct medical/forensic exams. Medical care includes toxicology testing, treatment for injury, sexually transmitted infection testing and treatment, pregnancy tests, and emergency contraception (Tiry et al., 2020). The medical/forensic exam is used to collect and document forensic evidence (e.g., blood, saliva, and semen) and injuries via swabs and photographic evidence (Tiry et al., 2020). Evidence can be used to identify the assailant and/or corroborate the survivor's story in the criminal justice system (Office on Violence Against Women, 2013). EDs are typically fast-paced environments where nurses care for multiple patients at a time. This may lead to rushed and impersonal care for survivors or long waiting periods for those not deemed to have emergent or life-threatening injuries (Ahrens et al., 2000). Further, medical personnel may perpetrate “secondary victimization” (Campbell & Raja, 1999; Williams, 1984) by disbelieving the survivor, suggesting they were to blame for the assault, or denying services (e.g., emergency contraception, HIV prophylaxis, etc.) (Ahrens et al., 2000; Campbell & Martin, 2001; Campbell et al., 2005; Campbell & Raja, 1999; Mulla, 2016; Williams, 1984). Secondary victimization often leaves the survivor feeling anxious, further violated, and depressed (Campbell & Raja, 2005). This threat of further traumatization can prevent survivors from seeking help (Patterson et al., 2009) and additional services after the emergency room (ER) visit (Campbell, 2005). Moreover, untrained personnel may make mistakes in forensic evidence collection (e.g., breaking the chain of evidence), which may negatively impact prosecution rates (Campbell et al., 2005). As a result of these problems with medical response to survivors, two interventions emerged: SANE programs and rape crisis medical advocacy.
SANE Programs
SANE programs provide specialized training to nurses to ensure respectful, patient-centered, and timely medical treatment, as well as capable evidence collection practices (Ahrens et al., 2000; Campbell et al., 2005). SANEs are trained to care for SA patients in a trauma-informed manner and have extensive practice engaging in evidence collection (Campbell et al., 2005). SANEs often work as part of a Sexual Assault Response Team (SART). SARTs are formal, multidisciplinary, coordinated response teams that work to improve response to SA across social services, criminal justice, and medical systems (Cole, 2018; Greeson & Campbell, 2015; Maier, 2011a; Moylan & Lindhorst, 2015; Moylan et al., 2017; Patterson, 2014; Patterson & Pennefather, 2015). Ideally, survivors should have access to nurses with SANE training when seeking medical treatment postassault; however, in practice, this is not always the case (Delgadillo, 2017; GAO, 2018; Thiede & Miyamoto, 2021).
Rape Crisis Medical Advocacy
In addition to SANE programs, rape crisis medical advocacy services were created due to the problematic medical response to survivors. Rape crisis centers employ staff and trained volunteers to provide medical advocacy services (Maier, 2011b). These services are distinct from other victim advocacy, such as legal advocacy, in that medical advocacy is concerned with accessing medical and forensic services, whereas legal advocacy focuses on navigating the civil and criminal justice systems. Rape crisis medical advocates assist and accompany survivors who seek medical and forensic services to mitigate their potential negative experiences with the medical system (Moylan et al., 2017; Payne, 2007). In doing so, medical advocates provide emotional support to the survivor, advocate for the rights of the survivor, offer information and referrals, and attempt to certify that the survivor's medical needs are sufficiently met (Moylan et al., 2017; Payne, 2007; Wegrzyn et al., 2022). Survivors who work with advocates in medical settings report more comprehensive treatment, fewer negative interactions with ER staff, and less overall distress from their experiences with the medical system than survivors who do not receive the services of medical advocates (Campbell, 2006).
Research on Nurse–Advocate Relationships
While rape crisis medical advocates serve survivors, they also interact with medical professionals on the survivor's behalf (Campbell & Bybee, 1997; Greeson & Campbell, 2015; Macy et al., 2011; Payne, 2007). Ideally, the nurse and advocate work together collaboratively to provide the best care for the patient (Payne, 2007). Survivors have reported teamwork among medical advocates and nurses is comforting and can aid in healing (Campbell et al., 2008). Moreover, recent research highlights the importance of positive communication between the two providers, as nurses believe ineffective communication can have negative impacts on survivors (Hoffman et al., 2022). However, collaboration can be difficult because the advocate's role is to speak out when a medical provider is not meeting a survivor's needs (Payne, 2007; Wilt, 2019). Thus, relationships between nurses and advocates are strained at times (Maier, 2011a; Patterson, 2014; Patterson & Pennefeather, 2015). For example, research has shown SANEs and medical advocates may experience conflict around approaches to or perceptions of evidence collection (e.g., Maier, 2011a; 2011c; Patterson & Pennefather, 2015), survivor care (e.g., Maier, 2011a; Payne, 2007), and their respective roles (e.g., Patterson, 2014; Payne, 2007). One specific type of conflict discussed by Patterson and Pennefather (2015) related to survivor care included nurses’ feeling that advocates were providing instructions on how to perform their role, which they reported made them feel disrespected and judged. Such tensions between nurses and advocates pose significant challenges for both groups (e.g., Maier, 2011a; Patterson & Pennefather, 2015) and may negatively impact survivor care (Payne, 2007). Therefore, further research is needed to identify factors that promote collaborative relationships between nurses and advocates to facilitate more positive experiences and interactions between nurses and advocates, ultimately with the aim of improving patient care.
Current Study
Past research examining relationships between nurses and advocates while responding to SA cases has examined these relationships in the context of either SARTs or SANEs (Cole, 2018; Cole & Logan, 2008; Maier, 2011a; Moylan & Lindhorst, 2015; Moylan et al., 2017; Patterson, 2014; Patterson & Pennefather, 2015). Less is known about relationships between advocates and nurses who do not have SANE or other specialized SA training. Furthermore, there is no research to date on how nurse training and experience influence their work with advocates. These are important gaps, as advocates frequently work with nurses who have no specialized training to serve survivors (Delgadillo, 2017; GAO, 2018; Thiede & Miyamoto, 2021). However, the literature has yet to examine the differences in relationships with advocates between SANEs and non-SANEs. Additionally, advocates also act in an oversight capacity, ensuring that medical staff meet survivors’ needs (Campbell & Raja, 1999; Moylan et al., 2017). Thus, nurse training and experience may affect how advocates relate to nurses, with an advocate's oversight role changing depending on the nurse's skillset. Furthermore, SANE training includes teaching nurses about the role of medical advocates in responding to survivors. By helping nurses to understand advocates, training may also affect how nurses relate to advocates.
Therefore, the current study aims to understand how nurse training and experience influence their relationships with medical advocates within a sample of SANEs and non-SANEs. Data come from a larger study in partnership with a rape crisis center in a Midwestern city. We conducted qualitative interviews with nurses from a variety of hospitals the rape crisis center serves to understand nurses’ perceptions of their relationships with the advocates. Specifically, this study examines the following research questions:
How do nurses believe nurse training influences their relationships with rape crisis medical advocates? How do nurses believe nurse experience influences their relationships with rape crisis medical advocates?
Qualitative methodology was selected because it allows for in-depth, nuanced exploration of nurses’ perceptions of their relationships with advocates and can reveal mechanisms by which training and experience influence relationship quality. Understanding the role of training and experience in nurse–advocate relationships can help to inform future interventions to improve nurse–advocate relationships.
Method
Participants
The research team interviewed 22 nurses in a large Midwestern city from 11 different hospitals the focal rape crisis center serves. Participants in the study varied in age, gender, race, years of experience, training level, and experience with SA cases. For a full list of demographic characteristics of the study sample, see Table 1.
Nurse Demographic Characteristics.
Denotes participants of a different gender identity from female due to the small nature of the sample—revealing this identity may be identifying in nature.
Procedure
The study was approved by the university Institutional Review Board. Recruitment took place in two steps. The research team first contacted individuals at the hospitals such as SANE Coordinators, ED Directors, and Directors of Nursing who could connect the team to potential participants; these contacts were provided to the research team by the rape crisis center. Team members also called EDs directly. The team then asked hospital representatives to connect them with nurses who had worked with an advocate from the rape crisis center within the last year. Once contact information for individual nurses was provided, researchers contacted potential participants by phone and email to describe the study and invite them to participate. In addition, team members practiced in-person recruitment during staff meetings and distributed fliers within the ED. Nurses were eligible to participate in the study if they had worked with an advocate from the rape crisis center community partner within the past year and had worked with advocates on more than one occasion.
The team used purposive sampling (Suen et al., 2014). In qualitative methodology, purposive sampling is a best practice that allows researchers to ensure their sample captures diversity in areas that are theoretically meaningful based on preliminary patterns from earlier interviews (Suen et al., 2014). As interviews proceeded, it appeared that nurses believed SANE training was related to their relationships with advocates. However, early interviews were primarily conducted with SANEs. Therefore, the team began asking hospital contacts to connect them to nurses without SANE training. Interviewing continued until theoretical saturation was reached, meaning that new interviews reinforced preexisting themes and did not reveal new themes (Morrow, 2007).
Interviews were scheduled at a location convenient for the participant. Most interviews were completed in person. Two were completed via telephone, and three started in person and finished via telephone to accommodate participant schedules. Interviews were in-depth and semistructured. The interview began with the informed consent process. Interviews lasted an average of 2 h (SD = 0.44) but ranged from 1 h and 30 min to 3 h and 15 min. Participants were compensated with a $35 VISA gift card for their time. With participant permission, all interviews were audio-recorded and professionally transcribed. Research assistants checked the transcripts to verify accuracy.
Measures
The interview protocol was developed in collaboration with the focal rape crisis center. Questions examined nurses’ work with SA survivors, their overall experiences with and perceptions of advocates, their experiences with and perceptions of the advocate on their most recent case, nurse training, and demographic information. There was a list of interview questions and topics, but the interviewer was free to ask questions in a nonstandardized order. Interviewers also asked probing questions to elicit additional meaning and detail. Sample questions included the following: (a) “Have you completed SANE training? Didactic and clinical? Are you SANE certified?”; (b) “How would you describe the quality of your relationships with advocates?”; (c) “What do you see as your primary role or responsibility in responding to sexual assault patients?”; (d) “What do you see as a [medical] advocate's role in responding to victims?”; (e) “Do your perceptions of advocates vary at all from advocate to advocate?” (e.g., “Does working with an advocate you have worked with before influence your work?”); and (f) “How would you describe the relationships between doctors/nurses at your hospital and [name of rape crisis center] advocates more generally?” Weekly meetings with the principal investigator were held to monitor recruitment and interviewing, discuss preliminary themes, and assess saturation.
Analyses
Coding
Two coauthors (advanced doctoral students) engaged in an open coding process wherein each researcher read through all transcripts to identify meaningful concepts. The research team discussed patterns as a group and developed an initial codebook. The coders applied these codes to interviews, and the team revised the codebook based on code redundancy, ambiguity, or omissions of key patterns. Once a final codebook was developed, two team members independently coded all transcripts and met with the research team weekly to discuss discrepancies and reach consensus. This was done to ensure consistent application of the codebook. All data were coded in NVivo software, version 11. Additional analyses were conducted on the coded transcripts for the purpose of this study by the first and second authors (advanced doctoral students). These analyses focused on the influence of nurse training and experience on nurse–advocate relationships. An analyst supplemented the coding process by combing each participant's transcript for keywords and phrases (i.e., experience, relationship, training, etc.) until all relevant information for this study had been identified. Then, the analyst entered this into a table. For each participant (a row), the analyst sorted relevant data into two columns: effect of nurse training and effect of nurse experience. Common themes across participants were identified for effects of both training and experience and then attributed to participants. This analysis was then checked by a fellow researcher. Following data analysis, member checks were conducted with 18% of the original study participants (n = 4). Member checks are a strategy for ensuring the trustworthiness of qualitative findings (Kornbluh, 2015; Lincoln & Guba, 1985). Member checks verified accurate researcher understanding of participant training status at the time of the interview.
Results
Nurses discussed how training and experience affected their perceptions of their relationships with medical rape victim advocates. Specifically, participants described how nurse training and experience impacted collaboration (in this study, this included mutual trust, respect, and rapport), role understanding, perceptions of relative SA expertise, and nurses’ appreciation for advocates. Results on how nurse training related to perceptions of nurse–advocate relationships are presented first, followed by how nurse experience related to perceptions of nurse–advocate relationships.
Influence of Nurse Training on Nurse–Advocate Relationships
Nurse Training
Nurses in our study had a wide range of SA training. Participants were classified into four distinct groups based on their level of training: (a) SANE certified, (b) SANE trained, (c) some SANE/SA training, or (d) no SANE training (see Table 2).
Nurse Training.
SANE certified denoted the highest level of SANE training, indicating nurses had passed all SANE training requirements implemented by the state where the study was conducted and had also passed the forensic nurses’ certification exam. This exam recognizes the nurse as a nationally certified SANE. SANE-trained participants had completed all state SANE training requirements and were fully SANE trained but had not sat for the national certification exam. The some SANE/SA training group had the highest variability among participants, and nurses were categorized here if they had attended any formal SANE or SA workshops during their career but had not completed all SANE requirements in their state. Thus, participants ranged from attending one 8-h workshop to having submitted all requirements for being fully SANE trained and were waiting to hear back from the state SANE Coordinator. Nurses categorized as having no SANE training indicated they had never in their careers attended a SA or SANE training workshop. Their only experience working with SA cases was based on hands-on experience rather than formal SANE training.
The data included participants’ perceptions of their own relationships with medical advocates, as well as their perceptions of other nurses in their department's relationships with medical advocates. First, we demonstrate how nurses believed training affected collaborative relationships with advocates. Second, we explore how nurses believed training affected who was perceived as the “expert in sexual assault” in the nurse–advocate relationship. Lastly, we examine how nurses perceived experience working with SA cases (distinctive from training) affects the working relationship between nurses and medical advocates.
Perceived Impact of Training on Relationships
Overall, nurses in the sample believed greater SA training led to more collaborative and positive working relationships with medical advocates, whereas less training was associated with poorer relationships with medical advocates. This section reports nurses’ perceptions of relationships between medical advocates and highly trained nurses, followed by nurses’ perceptions of relationships between medical advocates and nurses with less training.
Relationships Between Medical Advocates and Highly Trained Nurses
The results are summarized in Table 3. Although nurses consistently felt that higher training was associated with better relationships between medical advocates and highly trained nurses (e.g., SANEs), there was variability across how they believed training affected relationships between medical advocates and highly trained nurses (e.g., whether they believed it affected role understanding, rapport, respect, and/or trust).
Nurses’ Perceptions of Reasons for Highly Trained Nurses’ Positive Relationships With Advocates.
Across groups, nurses felt that higher training was associated with better relationships. They most commonly discussed how training was beneficial because it led to a deeper mutual understanding of roles. This was discussed by nurses with advanced SANE training (i.e., SANE-certified and SANE-trained nurses), nurses with some SANE training, and nurses with no SANE training. One SANE-certified participant with 10 years of nursing experience attributed their generally positive working relationship with medical advocates to their training and the associated improvement in role understanding. When asked how training influenced their interactions with medical advocates, they shared: I feel like that made all the difference. For me, it was that training, and understanding their role 1,000 percent better, but then also a way to understand how they are like. I think … it was almost just I was very more reassured of myself, and my role, and what my job was, and how the advocate fits in as a piece of the puzzle in caring for this patient.
Similarly, nurses with some SANE training and no SANE training also felt that training was associated with better relationships and, more specifically, better role understanding. When queried about how to improve their relationship with medical advocates, one participant with 24 years of nursing experience and no SANE training responded: “Always education … that's always helpful … Because then you understand each other's role and in what fashion you’re supposed to be utilized.” Throughout their interview, the participants discussed how despite their experience, they felt they were not as familiar with medical advocates’ roles as they should be or would be if they had more training. When asked about what a medical advocate does or should do, this participant indicated they felt their lack of SANE training put them at a disadvantage for understanding the scope of medical advocates’ roles and reported: “from what I do see what they do is comprehensive and valuable. But again, there's something else, myself not having full knowledge of both SANE and advocacy basic training…” This participant repeatedly stated how increased training would improve their understanding of the medical advocate's role and indicated they thought SANEs typically worked well with medical advocates, whereas those with less training might have less positive relationships.
Most participants also connected nurse training to better rapport and trust between nurses and medical advocates. Specifically, nurses with some training and highly trained nurses (SANE trained and SANE certified) noted how training improved rapport and trust, but this was not a theme among participants with no SANE training. One participant with 2 years of experience with some SANE/SA training emphasized feeling that when medical advocates are unsure of nurse training, they tend to monitor nurses more. Comparatively, when nurses have higher training, medical advocates focus on the patient more holistically and trust the nurse. This nurse stated: I think once I say that, “Oh, I’m one of the nurses that's gone through the SANE training,” they’re like, “Oh, perfect.” I think they get that more … if it's like, “Oh, they’re a SANE nurse,” … [the advocate] could trust them [the nurse] to know … evidence collection and their aspect of things.
Finally, some participants also believed that nurse training improved mutual respect between medical advocates and highly trained nurses. This was a theme across the highly trained nurses (i.e., SANE-trained and SANE-certified nurses) but was less salient, or not mentioned at all, by participants with less or no training. One SANE, who had been a nurse for 22 years, reported medical advocates attended the same SANE didactic training as they did, which the nurse felt was important to their mutual role understanding. This nurse considered their relationship with medical advocates a “partnership,” and when sharing their impression of positive nurse–advocate interactions, reported: “It just makes it—if the nurse knows what they’re doing, the advocate knows what they’re doing, the patient is just well taken care of … It [nurse and advocate relationship] works well together if there's always that mutual respect.” This highlights the way in which this SANE believed understanding between the nurse and the advocate is key for supporting patients and fosters better trust and mutual respect.
In summary, across groups, nurses felt the relationship between medical advocates and nurses was better for nurses with more training and suggested training led to better role understanding. However, nurses with some SANE training also tended to discuss improved rapport and trust; and highly trained nurses (i.e., SANE-trained and SANE-certified nurses) emphasized rapport, trust, and increased mutual respect between highly trained nurses and medical advocates. This suggests those with more training noted more nuanced aspects of the nurse–advocate working relationship than those with less training.
Relationships Between Advocates and Nurses With Lower Levels of Training
Most nurses who discussed relationships between nurses with lower levels of training and medical advocates tended to report these nurses had poorer working relationships with advocates than those with more training. This spanned participants across all four training categories; thus, results are reported according to theme rather than nurse training level. While most nurses in the sample deemed the relationship between lesser trained nurses and medical advocates as more negative, there was a small subset of participants that viewed this relationship as generally positive. These two seemingly contradictory themes are further explored below.
Generally, most nurses perceived the relationship between medical advocates and nurses with no or less SA training as currently poorer than the relationship between medical advocates and highly trained nurses. Nurses with this viewpoint shared that the relationship between less or untrained nurses and medical advocates suffered primarily due to nurses having limited understanding of medical advocates’ roles. One nurse with 7 years of experience and some SANE/SA training indicated role understanding might negatively affect the relationship of other nurses, stating: I think it … would be like interesting … to interview a bunch of ER nurses that aren’t SANE trained, and like see what their experiences are with [medical advocates], ‘cause I think it would be … different. Because I have like a respect, and I like know their role. And I like, you know I’m a little bit more nuanced in the process … versus somebody who like just isn’t nuanced in the process, and they’re just like, “I don’t know … This person shows up, and I don’t really know what they have to do.” I think they’re [medical advocates] unsure of the training and how much education—just like a normal staff nurse would have. I could see that—them [medical advocates] not really knowing … how much they [nurses] know. How much trust that they know that they’re doing…
This nurse felt medical advocates were not as trusting of less trained ED nurses, as opposed to SANEs, who the participant felt medical advocates were more able to trust with evidence collection. Other less salient reasons cited by nurses for worse nurse–advocate working relationships among less trained nurses and medical advocates were advocate criticism of nurses and advocate overstepping their roles. Several nurses who perceived the relationship between less trained nurses and medical advocates as poorer also noted they believed ED nurses with little training, but more years of experience, had a poorer relationship with medical advocates currently due to past negative experiences with medical advocates.
The second, less prevalent theme was that some nurses perceived the relationship between medical advocates and nurses with no or less SA training as currently positive. These nurses (n = 3) believed less experienced nurses found medical advocates helpful and supportive. The nurses who shared this perspective felt that newer nurses welcomed and were appreciative of the additional support and knowledge medical advocates provided when working with SA patients due to their significant experience. One nurse with 2 years of experience and some SANE/SA training shared that “newer nurses are more just happy to have them there and happy to have someone else to help the patient” to alleviate the burden working with survivors can place on nurses. Thus, there was variability in nurses’ perceptions of relationships between nurses with less training and medical advocates.
Perceptions of Expertise
In addition to affecting working relationships between nurses and medical advocates, nurses also felt that training should affect who is perceived as the expert in SA. Specifically, nurses in our study suggested medical advocates should have different attitudes toward nurses, and relationship dynamics between nurses and medical advocates should shift to reflect nurse training. This section focuses on nurses with advanced training (i.e., SANEs and non-SANEs with more training) compared to nurses with less training (i.e., nurses with little SANE training and nurses with no training). Nurses across both groups felt that nurses with lower levels of training should view the medical advocate as the expert regarding SA, and they should defer to advocates if disagreements or issues arose regarding general SA knowledge.
Nurses with advanced training expected medical advocates to respect and trust them more, with one SANE explicitly stating medical advocates should defer to their judgment. These nurses predominantly considered themselves the expert on medical/forensic issues but recognized medical advocates can also provide useful input during this process. As such, while nurses with advanced training felt their training should allow for advocates to trust them more, they nearly all noted they expected medical advocates to take the lead as the “expert” on working with SA patients with nurses who have not undergone extensive training. One participant with 2 years of experience as a nurse and who was almost fully SANE trained (completed clinical and didactic SANE training) found it irritating when medical advocates questioned them and believed medical advocates should trust nurses more due to their training. Simultaneously, this nurse asserted that less seasoned nurses may benefit from medical advocates’ knowledge, stating: “someone who's not trained and not confident in how they’re collecting, that could be helpful maybe. Because it's like, oh yeah, you deal with sexual assault patients all the time, maybe you do know how to collect this, and it could just be helpful.” This nurse indicated medical advocates can offer helpful insights during the forensic exam for nurses who do not typically work with SA patients due to lack of training or lack of experience. However, they felt that due to their training, medical advocates should defer to their expertise and abilities around evidence collection.
Nurses with less training seemed to indicate that lower levels of training corresponded with deferring to medical advocates as SA experts and relying on their judgment and assistance more. One nurse with no training and 24 years of nursing experience expressed how helpful medical advocates can be when working on SA cases, reflecting: “all the advocates … have been helpful, either taught me something, showed me some new information I was unaware of.” As highlighted by this participant, nurses with less training tended to welcome medical advocate support and viewed them as not only an emotional support person for the patient but also a guide during the forensic exam.
Role of Nurse Experience in Perceptions of Nurse–Advocate Relationships
In addition to discussing the role of training, nurses also described how gaining experience over time affected their relationships with medical advocates, generally with more experience relating to more positive relationships. This was linked to but distinct from training. Three salient subthemes emerged: (a) working with the same medical advocate is beneficial for relationship building; (b) nurses are more appreciative of medical advocates over time; and (c) medical advocates are more trusting of more experienced nurses and critical of newer nurses.
Many nurses in our study felt that working with the same medical advocate over time is beneficial for relationship building. Nurses indicated working with the same medical advocate on multiple occasions allowed them to establish rapport, while working with different medical advocates did not. Indeed, many nurses who had never worked with the same medical advocates indicated that they wished there were specific medical advocates assigned to their hospital or that they were able to know the medical advocate beforehand outside of working with a patient. One participant with 7 years of experience who had received some SANE training noted that working with the same medical advocate on multiple occasions would aid in relationship building, reflecting: I just don’t feel like I have enough time to really like make a relationship with them, you know … maybe, if the same [advocate] came all the time, then you just get to know them and like know their style … But [right now] it's like you just never know what you’re walking into in any—I don’t know what I’m walking into. They don’t know what they’re walking into. It's like hard to um make a relationship in that kinda environment. When you have an advocate that you know will be able to take care of that extra piece of care more thoroughly than I would be able to, it's just better, or makes it less stressful … When I’ve worked with an advocate before who is someone that I know that they’re experienced and I can trust, it makes it a little bit easier because you know that they’re helping the patient with any questions they might have when I’m not in the room.
This participant felt working with the same medical advocate on multiple occasions made the job easier, and they were able to trust the medical advocate to do their job and work well with the patient when the nurse could not be present. Another participant with 2.5 years of experience, some SANE training, and had worked with the same medical advocate more than once during their career indicated it was helpful to have the same medical advocate because: … they know how I’m gonna work. And they kinda know what my process is. So they can kinda direct the patient … because I’m sure every single person is different in their like way of approaching things. So for them, it's probably helpful, … and she can help prepare the patient … It could just be helpful ‘cause they know my routine, and, also, know my personality, too, and like know how I work as a nurse. ‘Cause all of us are so different.
This nurse shared how working with someone who is familiar with how you work can be helpful and remove a layer of complexity that exists with a new medical advocate. Additionally, an ED nurse with no SANE training and 13 years of experience reflected that in their experience, working with the same medical advocate more than once “brings a sense of comfort, because you know that this person has come out before … and if the experience was great … then you know it's gonna be great this time … you know the patient is getting the best care.” Participants in the study emphasized how working with the same medical advocates over time may be beneficial to the nurse–advocate relationship and patient care.
In addition to discussing the benefits of experience working with the same medical advocate, participants discussed becoming more appreciative of medical advocates over time. This was often attributed to an increase in role understanding. The more often nurses worked with medical advocates, the better they understood what medical advocates did, and the better they felt their working relationship was. For example, one SANE-trained participant with 10 years of experience stated: “It's really been better over the last few years … Maybe I changed. Because I appreciate them so much, because I know what they do.” In this way, the nurse showed how they came to understand and value medical advocates more over time. Another SANE-certified participant with 22 years of experience indicated: I used to think they were there for their emotional safety, you know being there for them in that status to say I’m here for you. I’m sorry this happened to you. Um I’m here to hold your hand if need be, you know. But [now I know] on the flipside, they also educate too.
Finally, nurses also suggested medical advocates are more trusting of more experienced nurses and critical of newer nurses. They shared instances where, earlier in their career, medical advocates were less trusting and more critical. One participant with 9 years of experience and no SANE or SA training reported: Um, I’ve only had like uh maybe two negative cases sort of with an [advocate]. And this was when I first started. I think it was like my, maybe my second sexual assault case and so I was, you know, inexperienced with it. And the [advocate] … pointed out something that I should be doing but it wasn’t in a constructive way … [they were] just very … critical of me … in front of the patient.
Discussion
Impact on Nurse–Advocate Relationships
Participants in this study connected nurse training and experience with their perceptions of the quality of their working relationships with medical advocates (i.e., advocates who assist survivors in obtaining medical and forensic services through the medical system) (Wegrzyn et al., 2022). Specifically, training and experience were associated with nurse–medical advocate collaboration (i.e., rapport, respect, trust, and appreciation), role understanding, and perceptions of SA expertise.
Collaboration
Our study's findings suggest both nurse training and nurse experience improve nurse–advocate collaboration, with more training and experience positively impacting multiple aspects of the working relationship. Specifically, nurses with the highest levels of training (SANE trained and SANE certified) felt they had better rapport with medical advocates and more mutual respect and trust than their fellow ED nurses who had not undergone similar training. Similarly, nurses with lower levels of training, who discussed the relationship between medical advocates and SANEs, indicated SANEs and medical advocates have a more collaborative relationship, citing higher levels of rapport and mutual trust. Additionally, more experienced nurses cited an increased level of appreciation for medical advocates. Further, nurses who worked with the same medical advocate on multiple occasions found they had increased rapport with these advocates. They also noted experience working with the same medical advocate increased nurses’ comfort, reduced pressure, and improved overall patient care. Prior research has shown trust and mutual respect are important components of effective interdisciplinary relationships (e.g., Foster-Fishman et al., 2001; Nowell, 2009; Zakocs & Edwards, 2006). However, this is the first study to link nurse training to improving nurse–advocate rapport, trust, and mutual respect. Improving collaboration through training is important because successful interprofessional collaboration can positively impact the quality of care for patients and survivors of SA in medical settings (Maier, 2011a; Molina-Mula et al., 2017; Zijlstra et al., 2018). Indeed, some participants in this study linked more training to better relationships and better care for survivors, a finding echoed in Campbell et al. (2008) when survivors noted positive relationships between SANEs and medical advocates helped them feel more comfortable and aided in their healing. In addition, this is the first study to show nurses prefer working with the same advocates over time, which nurses believed would also translate into better care for survivors.
While nurse training and experience were connected with a variety of aspects of collaboration (i.e., communication, rapport, respect, and trust), trust was particularly salient to our sample. In this study, participants felt nurses with more advanced training and/or more experience had more trusting relationships with medical advocates. Nurses reported that those with more training were generally more trusted by medical advocates, with some even noting advocates often visibly showed signs of relief once they found out they were working with a SANE or a nurse who had undergone some form of SANE training. Other nurses shared medical advocates tended to question or were more critical of them when they were newer nurses; however, as they gained experience, they felt more trusted and supported by medical advocates. This finding is partially supported by prior research on SANE–advocate relationships, which indicates trust between nurses and advocates exists, most notably between more experienced nurses and medical advocates (Patterson & Pennefather, 2015). However, the current study expands this to demonstrate there is less trust when nurses are not SANE trained. This is an important finding because previous literature has noted trust is a crucial component for conflict resolution between nurses and medical advocates (Patterson & Pennefather, 2015), as well as better collaboration for interdisciplinary professionals in healthcare settings (Zijlstra et al., 2018). Trust in collaboration makes it easier for professionals to focus on their own tasks because they know other important aspects of care are taken care of by other professionals (Zijlstra et al., 2018).
Role Understanding
Overwhelmingly, nurses in our study believed an increase in nurse training and/or experience correlated with better role understanding between nurses and medical advocates. This finding is partially supported by Patterson and Pennefather (2015), who found more experienced forensic nurses and medical advocates were better able to mitigate conflicts related to role understanding due to higher trust. However, this is the first study to show that more SANE training is associated with better role understanding between nurses and medical advocates and decreased perception of medical advocate criticism and/or overstepping. This is important because previous studies have found role understanding and role ambiguity are sources of tension between medical advocates and SANEs (Patterson & Pennefather, 2015; Payne, 2007). Further, when examining SANE–advocate relationships, Maier (2011a) found that participants felt role understanding between medical advocates and SANEs is necessary to foster a positive relationship between the two groups. When interdisciplinary care providers understand what their collaborators are supposed to be doing, they are better able to focus on their own tasks, thus improving overall care for survivors of sexual violence (Zijlstra et al., 2018). As such, training nurses on medical advocates’ roles may help to mitigate problems with role conflict; at the same time, it may benefit medical advocates to know these issues may be exacerbated when nurses have less training.
SA Expertise
Our data revealed nurses' perceptions of the “expert on sexual assault” (i.e., nurses versus advocates) shifted with nurse experience and training. Most notably, nurses across training levels (e.g., SANE, some SA or SANE, and no SANE training) felt nurses with less (or no) training or limited experience should defer to medical advocates’ judgment (e.g., during the forensic exam or regarding resources and helpful materials for patients) or look to them for guidance while working with survivors. However, nurses with more advanced training indicated medical advocates trust and respect their training, medical knowledge, and expertise more than nurses with less training. Typically, nurses with advanced training viewed themselves as the experts on medical/forensic issues but also felt medical advocates may have valuable input at times on these issues. One SANE, however, felt that as a trained SANE, they should be considered the SA expert in the relationship, and the medical advocate should defer to their expertise when interacting with patients. This finding sheds new light on prior findings, suggesting SANEs do not like it when advocates provide medical-related care or advice (Maier, 2011a). Our study examined nurses with varied training and suggests nurses believe medical advocates can offer input on medical issues when the nurse is not highly trained or is inexperienced. Additionally, this study found some nurses with advanced training still believe medical advocates can—at times—provide valuable input on medical/forensic issues, even if the nurse is the primary medical/forensic expert. This finding may also explain why medical advocates and SANEs sometimes experience tension regarding who knows what and what should be said by medical advocates to patients (Maier, 2011a). If medical advocates are expected to take the lead on walking patients and less trained nurses through the entire SA process, including the medical forensic exam, this may bleed over into and lead to tension when working with SANEs.
Limitations
This study has several limitations. All participants were interviewed about past experiences with advocates; therefore, the information gathered is subject to both retrospective and self-report biases. Additionally, because these data are qualitative and our sample examines relationships between nurses and advocates from a specific rape crisis center, these findings are limited in their generalizability to other settings. For example, this information may not apply to the relationships between nurses and medical advocates from crisis centers with different training practices for medical advocates or in states with different laws and regulations around medical care for SA patients. Further, because of the qualitative nature of the study, the participants discussed their training in a nonstandardized format and had varied experiences with different trainers. The researchers probed to understand factors such as whether they completed didactic versus clinical training, whether they were certified, etc., to create meaningful categorizations of more versus less training. However, future quantitative research is needed to examine variability in participants’ training and to examine how collaboration, role understanding, and perceived expertise change before and after standardized training. Finally, this study only examined nurses’ perceptions of the influence of nurse training and experience on relationships with medical advocates. Therefore, we are unable to capture how medical advocates believe nurse training and experience affect their working relationships.
Implications
Policy and Practice
Extant literature suggests interdisciplinary healthcare teams improve patient well-being (Krause et al., 2006; Sims et al., 2014). More specifically, medical advocates help ensure survivors receive proper care, are treated more positively, and do not suffer further victimization by healthcare providers (Campbell, 2006; Martin, 2005; Payne, 2007). Our study suggests nurses with more advanced training and experience have better working relationships with medical advocates. Further, less trained and less experienced nurses in our study were perceived to have poorer role understanding and more strained relationships with medical advocates. This suggests SANE training is necessary for improving care for survivors and important for ensuring role understanding and positive collaboration between medical advocates and nurses. While an increase in nurse training does not solve the conflict between nurses and advocates (e.g., Cole, 2018; Cole & Logan, 2008; Maier, 2011a; Patterson & Pennefather, 2015), our study further underscores the importance of states having policies that ensure SANEs provide care for SA survivors (Campbell et al., 2005). In many states, SANEs are not available or required to care for survivors, or there is a greater need for SANEs than available in the area (Delgadillo, 2017; GAO, 2018; Thiede & Miyamoto, 2021). Minimally, hospitals should implement policies to ensure all ED staff have undergone training on trauma-informed care. As ED nurses often interact with patients who have experienced severe trauma (e.g., SA) (Delgadillo, 2017), the more trauma-informed their practice is, the more patients are likely to benefit from their services (Schenkel et al., 2020; Sullivan et al., 2018).
Further, these findings also provide support for practitioner resources that recommend SA responders from different disciplines train one another on their respective roles to promote collaboration (e.g., National Sexual Violence Resource Center, 2018). Training disciplines on one another's roles is common in formal collaborative teams like SARTs (Greeson & Campbell, 2015). Therefore, state policies that support the formation of SARTs and provide funding to allow for such training are likely to be helpful. With that said, there continue to be jurisdictions where nurses who engage in survivor care may not have SANE training or training on advocates’ roles. Therefore, advocates may benefit from training that directly helps them think through how to approach SANE versus non-SANE nurses.
In addition to nurse training, our study suggests nurse experience matters. We found nurses’ appreciation for medical advocates tends to increase as they work with them over time. Sharing examples from experienced nurses about how they came to appreciate medical advocates and how they developed more effective collaboration with medical advocates over time may be particularly helpful when training new nurses. This study also found that when the same nurse–medical advocate pair works together over time, they develop more trust and better collaboration. Logistically, it is very difficult to intentionally pair medical advocates and nurses. Thus, we do not suggest policymakers attempt to determine how nurses and medical advocates are paired. However, some strategies could be considered to help make this happen more often. For example, when a rape crisis center serves multiple hospitals, they could consider whether having subpools of medical advocates cover specific hospitals would be feasible. In addition, research shows both medical advocates and SANEs experience burnout due to their vicarious exposure to survivors’ trauma (Long, 2020; Maier, 2011c). Thus, policies that help fund interventions to prevent burnout among medical advocates and SANEs may allow for medical advocates and SANEs to serve together for longer. Finally, other opportunities to help build trust prior to a call may be helpful. For example, hospitals or rape crisis centers could host events where medical advocates and nurses meet and establish positive relationships outside of their work with patients. Multiple nurses in this study expressed interest in meeting medical advocates prior to working together on a call. However, such interventions are unlikely to occur if they are not supported by funders.
Research
This study found distinct differences in perceptions of working relationships between SANEs versus non-SANE-trained nurses and medical advocates. Future research should explore medical advocates’ perspectives of nurse training and experience and how these influence their collaboration. Specifically, do medical advocates see benefits to working together over time or feel appreciated more by nurses with more experience (or appreciate experienced nurses more)? It would also be worthwhile to explore whether medical advocates approach their work with SANEs differently than non-SANEs, and if so, how. Further, it would be particularly interesting to examine whether medical advocates agree with nurses that they are more trusting of nurses with more training. To complement this work, scholars should also consider exploring survivor perceptions of how nurse–medical advocate relationships impact their care and whether these perceptions vary by level of SA training. There is also a need for more quantitative research on nurse training. This can help provide a complementary picture of how nurse training and advocacy are linked with nurses’ perceptions of their relationships with medical advocates. Furthermore, within-subjects longitudinal designs will be helpful for examining the impact of SANE training. Researchers should specifically examine whether improvements take place in role understanding, trust between medical advocates and nurses, respect, and rapport after training has occurred.
Finally, our findings regarding the relationships between less trained nurses and medical advocates were nuanced. Some nurses suggested nurses with no training had poorer relationships with medical advocates due to nurses’ lack of understanding of the medical advocate's role. Others suggested nurses with less training appreciated medical advocates because they have more expertise than the nurse and could help guide the nurse through the exam. Across the sample, participants suggested untrained nurses should view the medical advocate as the SA expert and acknowledged medical advocates tended to be more critical and less trusting of nurses with less training and experience. This suggests a great deal of complexity. It may be that inexperienced and less trained nurses both value medical advocates’ expertise on the exams and, at the same time, are frustrated with the medical advocate's oversight role. Further research is needed to unpack these complex relationships and understand how some nurses with less training are able to overcome this and manage to form positive working relationships with medical advocates when others do not.
Conclusion
The study suggests that nurse training and experience play an important role in relationships between nurses and medical advocates while serving SA survivors. Specifically, more training and experience of ED nurses are related to nurses experiencing an increase in advocate trust and respect, as well as better mutual role understanding, rapport, and communication. This made nurses with more training and experience feel their collaborative working relationships with advocates were more positive than those with less training. In addition, experience working together with the same advocate improves mutual trust, respect, and understanding between nurses and advocates. These findings are particularly important because medical advocates believe developing or maintaining positive relationships with nurses helps them to better serve survivors (Corrigan, 2013). The study further underscores the need for SANEs to provide care whenever possible, as well as the importance of helping medical advocates and nurses develop positive working relationships while considering nurse training and experience levels.
Footnotes
Acknowledgments
The authors would like to acknowledge Mary Takbajouah.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was partially supported by the DePaul University Steans Center Community-Based Research Faculty Fellowship.
