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HOW MULTIDISCIPLINARY COLLABORATION CAN IMPROVE PATIENT CARE SANEs and Victim Advocates.

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Presentation on theme: "HOW MULTIDISCIPLINARY COLLABORATION CAN IMPROVE PATIENT CARE SANEs and Victim Advocates."— Presentation transcript:

1 HOW MULTIDISCIPLINARY COLLABORATION CAN IMPROVE PATIENT CARE SANEs and Victim Advocates

2 OBJECTIVES Define the purpose of the medical forensic exam. Define the role of a community based confidential advocate in the medical forensic exam. Review patient case studies that were impacted by the care of a forensic nurse and community based confidential advocate.

3 Memorial Hospital University of Colorado Health 2 Hospitals plus a Children’s Hospital; 771 beds

4 Program initiated in 1995 Saw sexual assault patients of all ages Worked as “on call” In 2008 we expanded our services to care for more than sexual assault Memorial Hospital; University of Colorado Health Colorado Springs, CO Forensic Nurse Examiner Program

5 Forensic Nurse Examiner Program Today:  Team of 10 nurses  “In house” 24/7  Provide medical care to victims of violence  Sexual Assault  Intimate Partner Violence  Child Abuse  Elder Abuse  Human Trafficking  Any strangulation or hanging patients

6 TRAINING OBJECTIVES 1.Understand the dynamics of sexual assault, different types of cases, and how those factors may affect patient care. 2.Learn the role of the victim advocate (within the multi-disciplinary team) in delivering excellent survivor patient care for individuals who present to the ED for sexual assault evidence collection and follow-up medical care. 3.Differentiate between the systems-advocates and community-based advocates in Colorado. 1.Understand the dynamics of sexual assault, different types of cases, and how those factors may affect patient care. 2.Learn the role of the victim advocate (within the multi-disciplinary team) in delivering excellent survivor patient care for individuals who present to the ED for sexual assault evidence collection and follow-up medical care. 3.Differentiate between the systems-advocates and community-based advocates in Colorado.

7 PLEASE NOTE… Colorado is a very diverse state, and policies and practices vary considerably across the state. Your facility should be a part of all multi-disciplinary efforts, to ensure a consistent, mutually-agreed upon response system is in place.

8 LAW ENFORCEMENT REPORT MEDICAL REPORT Cases in which the survivor reports the assault to law enforcement either prior to or at the time of the medical forensic exam. The survivor seeks medical treatment services following a sexual assault, but elects not to participate in the Criminal Justice System at the time the Victim receives Medical Services. TYPES OF CASES RECEVING A MEDICAL FORENSIC EXAM

9 HOW UNDERSTANDING SEXUAL ASSAULT MAY ASSIST WITH PATIENT CARE SEXUAL ASSAULT DYNAMICS

10 A sexual act is nonconsensual if it is inflicted upon a person who is ▪ unable to grant consent or ▪ if it is unwanted and compelled through the use of Physical force Manipulation Coercion Threats Intimidation W HAT IS SEXUAL VIOLENCE ?

11 PREVALENCE OF SEXUAL VIOLENCE Nearly 1 in 5 women (1 in 4 in Colorado) and 1 in 71 men in the U.S. have been raped at some time in their lives. When other sexual crimes are added (unwanted sexual contact and other types of coercion), 1 in 2 women and 1 in 4 men in Colorado have experienced sexually violent crimes in their lifetime. National Intimate Partner and Sexual Violence Survey, NISVS: 2010 Summary Report. Centers for Disease Control and Prevention, released 2011

12 WHO ARE VICTIMS? Victims:  Can be anyone They are chosen because they are:  Vulnerable or can be made so  Accessible or can be made so And most often  Lacking in credibility or can be made to seem so **The most highly victimized people are those who are lacking in credibility**

13 WHO ARE THE MOST VULNERABLE, ACCESSIBLE, AND LACKING IN CREDIBILITY? Children Adolescents Women, especially women of color People with developmental & physical disabilities People with communication impairments People who have a mental illness ANY dependent, institutionalized or incarcerated person Non-English speaking people People who are undocumented People who are poor, especially the homeless People on the fringe of crime People who are drunk or on drugs People with non-dominant gender identity and/or expression Children Adolescents Women, especially women of color People with developmental & physical disabilities People with communication impairments People who have a mental illness ANY dependent, institutionalized or incarcerated person Non-English speaking people People who are undocumented People who are poor, especially the homeless People on the fringe of crime People who are drunk or on drugs People with non-dominant gender identity and/or expression

14 WHO ARE VICTIMS? Most sexual assault is first experienced in childhood and adolescence. Most female victims of completed rape experienced their first rape before the age of 25 and almost half experienced their first completed rape before age 18. Over one-quarter of male victims of completed rape experienced their first rape at or before the age of 10. NISVS, 2010

15 WHO ARE VICTIMS? Most victims of rape knew their perpetrators. More than half (51.1%) of female victims of rape reported being raped by an intimate partner and 40.8% by an acquaintance. For male victims, more than half (52.4%) reported being raped by an acquaintance and 15.1% by a stranger. NISVS, 2010

16 AGE & RELATIONSHIP The younger the victim, and the closer the relationship… the less likely they will report.

17 WHO ARE VICTIMS? Approximately 1 in 5 Black women and 1 in 7 Hispanic women in the United States have experienced rape at some point in their lives. More than one-quarter of women (26.9%) who identified as American Indian or as Alaska Native and 1 in 3 women (33.5%) who identified as multiracial non-Hispanic reported rape victimization in their lifetime. Nearly one-third of multiracial non-Hispanic men (31.6%) and over one-quarter of Hispanic men (26.2%) reported sexual violence other than rape in their lifetimes. Approximately 1 in 3 Hispanic (36.1%) and Asian or Pacific Islander (29.5%) women reported sexual violence other than rape. NISVS, 2010

18 WHO ARE VICTIMS? Over 50% of transgender individuals are survivors of sexual violence. (FORGE, 2005) Persons with a disability had an age-adjusted rate of rape or sexual assault that was more than twice the rate of persons without a disability. (US Bureau of Justice, 2009)

19 V ICTIM I MPACT What Causes Trauma? Trauma Penetration Severity Weapon Quantity

20 VICTIM IMPACT Primary causes of trauma: o Betrayal o Extreme Fear/Terror o Blitz/Surprise Attack o Self-Blame o Lack of support o Invalidation

21  Humiliation  Shame & self-blame  Guilt  Fear of people  Feeling a loss of control  Concern for the rapist  Grief  Depression  Denial/Anger and irritability  Belief in myths about sexual assault COMMON REACTIONS

22 IMPACT OF TRAUMA Trauma interferes with cognitive functioning  Thought processing  Concentration  Memory and specific recall  Realistic assessment of own situation  Decision making Therefore, the victim’s ability to cooperate and work seamlessly with forensic nurses, law enforcement and/or advocates can be impaired.

23 Victims/Survivors who experience a supportive and compassionate response, regardless of the criminal justice outcome, have lower rates of post traumatic stress. Campbell, et al. (1999). “Community Services for Rape Survivors: Enhancing Psychological Well-Being or Increasing Trauma.”

24 MAJOR NEEDS OF VICTIMS 1. The need to feel safe 2. The need to express emotion 3. The need for information about what will happen next 1 Letting victims make decisions for themselves at this stage is critical to gaining a sense of control over their lives Woods, T. O. (2000). First Response to Victims of Crime. Washington, DC: U.S. Department of Justice: Office for Victims of Crime. 2.The Office of Justice (2001). Victim empowerment: Bridging the systems mental health and victim service providers. Washington, DC: U. S Department of Justice.

25 ADAPT THE EXAM PROCESS TO ADDRESS THE UNIQUE NEEDS OF EACH PATIENT Patients’ experiences during the crime and the exam process, as well as their post-assault needs, may be affected by multiple factors: Age Gender and/or perceived gender identity/gender expression Physical health history and current status Mental health history and current status Disability Language needs for limited English proficient patients, Deaf and hard-of-hearing individuals, and those with sensory or communication disabilities Ethnic and cultural beliefs and practices Religious and spiritual beliefs and practices Economic status, including homelessness Immigration and refugee status Sexual orientation Military status History of previous victimization Past experience with the criminal justice system Whether the assault involved drugs and/or alcohol Prior relationship with the suspect, if any

26  If the assailant who was in an authority position  If the assault was part of a broader continuum of violence and/or oppression (e.g., intimate partner and family violence, gang violence, hate crimes, war crimes, commercial sexual exploitation, sex and/or labor trafficking)  Physical injuries from the assault and the severity of the injuries  Illegal activities at the time of the assault (e.g., voluntary use of illegal drugs or underage drinking) or have outstanding criminal charges  Involvement in activities prior to the assault that traditionally generate victim blaming or self-blaming (e.g., drinking alcohol prior to the assault or agreeing to go to the assailant’s home)  Whether birth control was used during the assault (e.g., victims may already have been on a form of birth control or the assailant may have used a condom)  Level of support available from families and friends  Whether they have dependents who require care during the exam, were traumatized by the assault, or who may be affected by decisions patients make during the exam process  Community/cultural attitudes about sexual assault, its victims, and offenders  Frequency of sexual assault and other violence in the community and historical responsiveness of the local justice system, health care systems, and community service agencies  If the assailant who was in an authority position  If the assault was part of a broader continuum of violence and/or oppression (e.g., intimate partner and family violence, gang violence, hate crimes, war crimes, commercial sexual exploitation, sex and/or labor trafficking)  Physical injuries from the assault and the severity of the injuries  Illegal activities at the time of the assault (e.g., voluntary use of illegal drugs or underage drinking) or have outstanding criminal charges  Involvement in activities prior to the assault that traditionally generate victim blaming or self-blaming (e.g., drinking alcohol prior to the assault or agreeing to go to the assailant’s home)  Whether birth control was used during the assault (e.g., victims may already have been on a form of birth control or the assailant may have used a condom)  Level of support available from families and friends  Whether they have dependents who require care during the exam, were traumatized by the assault, or who may be affected by decisions patients make during the exam process  Community/cultural attitudes about sexual assault, its victims, and offenders  Frequency of sexual assault and other violence in the community and historical responsiveness of the local justice system, health care systems, and community service agencies A DAPT THE EXAM PROCESS TO ADDRESS THE UNIQUE NEEDS OF EACH PATIENT Adapted from the National Sexual Assault Protocol, 2 nd Edition, 2013

27 UNDERSTANDING ROLES Law enforcement officials gather information and collect crime scene evidence to facilitate the investigation. Health care personnel assess medical needs, offer treatment, and collect evidence from victims. Advocates can offer a tangible and personal connection to a long-term source of support and advocacy.

28 BEST PRACTICES FOR EFFECTIVE MULTIDISCIPLINARY COLLABORATIONS BETWEEN THE SANE AND COMMUNITY- BASED & SYSTEM-BASED ADVOCATES WHAT IS ADVOCACY?

29 What is Advocacy? Broadly speaking, advocacy is supporting and assisting a victim/survivor to define needs, explore options, provide options, safety plan and ensure rights are respected within any systems with which the victim/survivor interacts. Colorado has 3 types of advocates– community-based, law-enforcement, and victim/witness coordinators in DA offices. Each type of advocate has specific roles/responsibilities.

30 What is an Advocate? Colorado Revised Statute (k)(II) This Colorado statute details the qualifications of a community-based sexual assault advocate, who can protect the victim’s privilege. In Colorado, there are different types of Victim Advocates. A “Victim’s Advocate” with privileged communications is defined in state statute that explains who may not testify without consent. According to the statute, a victim’s advocate is a person at a battered women’s shelter or rape crisis organization or a comparable community-based advocacy program for victims of domestic violence or sexual assault A) Whose primary function is to render advice, counsel, or assist victims of domestic or family violence or sexual assault; and B) Who has undergone not less than fifteen hours of training as a victim’s advocate or, with respect to an advocate who assists victims of sexual assault, not less than thirty hours of training as a sexual assault victim’s advocate; and C) Who supervises employees of the program, administers the program, or works under the direction of a supervisor of the program.

31 UNDERSTANDING ADVOCATES System-based Advocates are not covered under this statute-- C.R.S. § (k)(II). This means anything a victim says to or in front of a system-based advocate is not legally confidential. Community-based Advocates are covered under C.R.S. § (k)(II), therefore this type of advocate IS confidential.

32 UNDERSTANDING ADVOCATES Being an advocate is not the same as being a counselor or a therapist. Professional counselors and therapists typically have advanced degrees in counseling, social work, or therapy and have unique licensing requirements. This training will address a) community-based advocates, b) system-based victim advocates, c) advocates who provide both responsibilities, which may occur in some rural jurisdictions in Colorado.

33 Rape victims who have assistance from victim advocates were significantly more likely to report the crime to law enforcement and were less likely to be treated negatively by law enforcement. They also report less distress after contact with the legal system. Campbell, Rebecca. Rape Survivors Experiences with the Legal and Medical Systems: Do Rape Victim Advocates Make a Difference? Violence Against Women 12, 2006.

34 MANY COLORADO COMMUNITIES HAVE NON-PROFIT RAPE CRISIS CENTERS. SOME OF THESE PROGRAMS SOLELY ADDRESS SEXUAL VIOLENCE, WHILE OTHER PROGRAMS ARE DUAL AGENCIES, ADDRESSING SEXUAL VIOLENCE AND DOMESTIC VIOLENCE FOR A LISTING OF COLORADO’S COMMUNITY-BASED PROGRAMS, PLEASE VISIT THE STATE RESOURCES PAGE HAS AN INTERACTIVE MAP! COMMUNITY-BASED RAPE CRISIS ADVOCATES

35 RAPE CRISIS CENTER SERVICE PHILOSOPHY Generally, the rape crisis center service philosophy is based on social justice models. This work grew out of the anti-violence movement and holds the belief that clients are inherently well people, but it helps to get some support after a devastating event such as sexual violence.

36 VICTIM-CENTERED APPROACH Rape Crisis Centers typically espouse a Victim-Centered Approach in service provision. The Principles of a Victim-Centered Approach: Consider the needs and wants of the victim first Listen and promote victim self-advocacy Coordinate and collaborate in the victim’s interest Promote Victim Safety Hold self and other accountable Seek just solutions for all Rape Crisis Centers typically espouse a Victim-Centered Approach in service provision. The Principles of a Victim-Centered Approach: Consider the needs and wants of the victim first Listen and promote victim self-advocacy Coordinate and collaborate in the victim’s interest Promote Victim Safety Hold self and other accountable Seek just solutions for all

37 CORE RAPE CRISIS SERVICES 24-hour Crisis Intervention (oftentimes through a hotline) May include information about the effects of sexual violence and possible reactions, general information about medical and legal issues, offering advocacy and information about other services available in the community, active listening and empathic responding and exploring options. Legal Advocacy Provides support during the client’s interaction with law enforcement and the civil or criminal justice system. Support may be provided through information, referrals, and requested accompaniments to any investigations, interviews, court hearings, and other proceeding related to the sexual victimization. *In Colorado, the system-based advocates are more likely to provide advocacy through the Criminal Justice system. While an advocate can provide guidance through the legal system, it is not the same as having an attorney.

38 CORE RAPE CRISIS SERVICES General Advocacy Trauma Informed Care Case Management Counseling/Therapy Support Groups Information/Referrals Community Awareness Prevention Education System-based advocates may provide some of these services as well.

39 MEDICAL ADVOCACY Assistance and in-person support in making informed decisions about medical care and the preparations needed, including:  Coordination of victim transportation to and from the exam site  Referral for possible forensic exam  Information about medical care/concerns, including assistance with needed follow-up  Support at medical exams and appointments, to help cope with the trauma of the assault  Information and/or assistance with Crime Victim Compensation and other emergency assistance (SAVE Fund)

40 WAYS A COMMUNITY-BASED ADVOCATE MAY SUPPORT A SURVIVOR Promote the needs & choices of the victim Provide accurate information/referrals Increase access to services Work toward the delivery of consistent, quality services Crisis intervention Bear witness Believe the victim Help navigate the systems (medical, law enforcement, and criminal justice) Protect confidentiality of victim/survivor Increase informed decision making Intervene in victim-blaming/oppressive comments, actions and behaviors

41 Working with Community- Based Advocates with Cases Involving Minors A Victim’s Advocate of a community-based program (sexual assault crisis center or domestic violence shelter) is entitled to privileged communication (C.R.S. § ). Privileged communication applies to spoken and written communication—including notes, records, and reports. However, privilege does not “trump” mandatory reporting requirements outlined in C.R.S. § In cases involving a minor, it is not uncommon for a teen to want to have a parent/guardian/friend present when speaking with a Victim Advocate. It is a best practice for the Advocate to explain that having a third person in the room could potentially impact privacy. However, the Advocate can acknowledge that needing support is different than forgoing privileged communications. It is important for the third party in the room to understand that the conversation involves private information. There is Colorado case law which protects privileged conversations of minors when there is a third party in the room. For more information, please contact the Rocky Mountain Victim Law Center (www.rmvictimlaw.org).

42 IN SUMMARY…. Community-Based Advocates: Provide a range of services: hotlines, shelters, safety planning, counseling, referrals and communication with other agencies, etc. Can respond to hospital to provide patient support Can provide assistance and support regardless of law enforcement involvement Will continue services after the conclusion of the justice process Can protect victims’ privilege under Colorado law – this confidentiality can help establish trust and ensure safety of victim Exceptions are child abuse, victim consent

43 Work in conjunction with Law Enforcement. Provide a range of services: on scene response, interpreters, communication assistance with officers, safety planning, case updates, notification of case status, case management, referrals and support, etc. Cannot protect victim privilege due to status as law enforcement employees and rules of discovery. LAW ENFORCEMENT ADVOCATES

44 LAW ENFORCEMENT ADVOCATES & MEDICAL ADVOCACY Depending on the Jurisdiction, Law Enforcement Advocates May Provide Medical Advocacy as well. Law Enforcement Advocates and Medical Professionals need to be aware that having a LE Advocate in the room, during an exam:  Jeopardizes a victim’s legal privilege  Could be in conflict with Crawford vs. Washington and negatively impact medical hearsay at time of trial (talk to your local DA office for more information) This is why a mutually-agreed upon multidisciplinary protocol should follow national best practice, outlined in the National Sexual Assault Protocol. Assistance and in-person support in making informed decisions about medical care and the preparations needed, including:  Coordination of victim transportation to and from the exam site  Referral for possible forensic exam  Information about medical care/concerns, including assistance with needed follow-up  Support at medical exams and appointments, to help cope with the trauma of the assault  Information and/or assistance with Crime Victim Compensation and other emergency assistance (SAVE Fund)

45 Work in District Attorneys’ Offices Provide a range of services: case management and support for the victim after the defendant has been charged, court preparation and court support, assist with victim impact statements, case status updates, victims compensation, communication assistance between DAs and victims, etc. Cannot protect victim privilege due to status as law enforcement employees and rules of discovery. VICTIM/WITNESS COORDINATORS

46 SYSTEM-BASED ADVOCATES… Provide support during the client’s interaction with law enforcement and the criminal justice system. Support may be provided through information, referrals, and requested accompaniments to any investigations, interviews, court hearings, and other proceeding related to the sexual victimization. While an advocate can provide guidance through the legal system, it is not the same as having an attorney. Don’t forget~ System-Based Advocates cannot protect confidentiality. Provide support during the client’s interaction with law enforcement and the criminal justice system. Support may be provided through information, referrals, and requested accompaniments to any investigations, interviews, court hearings, and other proceeding related to the sexual victimization. While an advocate can provide guidance through the legal system, it is not the same as having an attorney. Don’t forget~ System-Based Advocates cannot protect confidentiality.

47 UNIQUE ARRANGEMENTS IN ADVOCACY… CAN AN ADVOCATE BE BOTH COMMUNITY-BASED & SYSTEM- BASED?!

48 Prior to 2008 TESSA Advocates responded to the hospital for any sexual assault patient 18 years or older In 2008, Manager Jen Pierce-Weeks and TESSA Advocate Nancy Duke met and discussed expanding TESSA’s role as well  Nancy had Jen and the forensic nurses call for any patient that had advocacy needs  This started the documentation process for the NEED Today, TESSA Advocates respond to the hospital for:  Sexual assault patients 15 years or older  Any intimate partner violence patient  In 2012 TESSA provided support to approximately 350 victims of sexual assault/domestic violence History of TESSA and Memorial Hospital Relationship:

49 HOW TO UTILIZE ADVOCATES  Utilize a system in which exam facility personnel, upon initial contact with a sexual assault patient, call the victim service/advocacy program and ask for an advocate to be sent to the exam site (unless an advocate has already been called).  Prior to introducing the advocate to a patient, exam facility personnel should explain briefly, in a language the patient understands, the victim services offered and ask whether the victim wishes to speak with the already onsite advocate.  If possible, victims should be allowed to meet with advocates in a private place prior to the exam. Adapted from the National Sexual Assault Protocol, 2 nd Edition, 2013

50 WORKING WITH ADVOCATES Advocates can provide practical help at the hospital; but are not involved in collecting evidence. They can: Prepare survivor for what to expect during an exam Support survivor during the exam (with survivor’s permission) Inform survivor s/he can stop the process at any time Inform victim about the Victim Rights Act, Victim Compensation, and other referrals Support friends and family Know that Advocates will be involved with this survivor from the time she or he reports and throughout the court process. Community-based advocates may be involved for much longer, if the survivor utilizes the program for ongoing services. When releasing evidence to law enforcement, an advocate is never involved in signing chain of custody.

51 Work to develop good relationships with advocates through a multi- disciplinary team approach Use multi-disciplinary team meetings to establish or explain hospital protocols, relevant laws, etc. Get to know one another Hospital practice examination rules (who can be in room) survivor decides who is in the room during the exam Consent forms and confidentiality: recognize that patients control the extent of personal information they share. Have defined roles and know the roles: advocates (community-based & system-based), law enforcement, medical personnel Advocates should inform you whether or not they can protect the patient’s privilege – if not, you should ask A TEAM APPROACH !

52 Multi-disciplinary agencies (and/or Sexual Assault Response Teams—SARTs) should develop policies and plans to meet the needs of specific patient populations (e.g., to obtain necessary interpreter services and translated documents for limited English proficient patients, qualified interpreters for Deaf and hard-of-hearing patients, and identify legal referrals for immigrant victims of sexual assault, domestic violence, dating violence, and stalking.)

53 Obtaining Patient Feedback Adapted from: A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents Second Edition April 2013 Responders can benefit from survivors’ feedback about response to the crime. After some time has passed, it can be useful to talk with victims about their experiences during the exam process, including the location of the exam, and explore how the process might be changed to better minimize trauma. Advocates can help design a victim feedback system that is confidential, sensitive, does not harm victims, and has mechanisms to quickly link victims with appropriate victim services if needed.

54 ADVOCATES & THE MEDICAL FORENSIC EXAM With survivor permission, the advocate can stay with the victim throughout the exam and evidence collection process. The priority of the community-based advocate is with the survivor, not the medical facility or the criminal investigation... It’s national best practice to have a community- based advocate respond to cases in which the survivor is sure s/he wants to be a Medical Report only.

55  Advocates should be able to provide patient support and advocacy during the medical history, if desired by the patient. The presence of an advocate may help patients feel more comfortable answering questions and advocates may also assist patients in voicing their concerns about questions being asked and clarifying their needs during this time. Advocates should be careful not to answer questions asked of patients or otherwise influence their statements.  While documenting photographic evidence and during the exam, patients may want an advocate and/or a personal support person to be present.  Best practice is for the advocate to sit facing the patient, so that the advocate and patient can engage in conversation (if desired by the patient). The advocate should not, under any circumstances, assist with the exam.  Advocates should be able to provide patient support and advocacy during the medical history, if desired by the patient. The presence of an advocate may help patients feel more comfortable answering questions and advocates may also assist patients in voicing their concerns about questions being asked and clarifying their needs during this time. Advocates should be careful not to answer questions asked of patients or otherwise influence their statements.  While documenting photographic evidence and during the exam, patients may want an advocate and/or a personal support person to be present.  Best practice is for the advocate to sit facing the patient, so that the advocate and patient can engage in conversation (if desired by the patient). The advocate should not, under any circumstances, assist with the exam. THE ADVOCATE ROLE DURING THE EXAM

56 Work to develop good relationships with advocates through a multi-disciplinary team approach Use multi-disciplinary team meetings to establish or explain hospital protocols Hospital practice examination rules (who can be in room) Patient rights and confidentiality Have defined roles and know the roles: advocates (community-based & system-based), law enforcement, medical personnel Advocates should inform you whether or not they can protect the patient’s privilege – if not, you should ask W HAT F ORENSIC N URSES N EED TO K NOW ABOUT W ORKING WITH A DVOCATES :

57 IAFN POSITION STATEMENT International Association of Forensic Nurses (IAFN) Position Statement :Collaboration With Victim Advocates Effective Date: November 19, 2008 Status: New Position Statement Originated by: IAFN Board of Directors Adopted by: IAFN Board of Directors IAFN Position Statement IAFN supports patient centered and evidence based care for the victimized patient. IAFN recognizes the benefits to victims of violence when there is timely interaction with Victim Advocates. Furthermore, IAFN recognizes and supports the role of the Victim Advocate as part of a patient centered team approach to providing services to victims. IAFN encourages the creation of strong collaborative relationships between forensic nurses, advocates and other team members in order to provide rapid, compassionate, comprehensive, patient centered and evidence-based care to victims.

58 N ATIONAL PROTOCOL FOR SEXUAL ASSAULT MEDICAL FORENSIC EXAMINATIONS The National Protocol for Sexual Assault Medical Forensic Examinations (2004), developed by the U.S. Department of Justice, states, “Advocates can offer a tangible and personal connection to a long-term source of support and advocacy.” The Protocol goes on to recommend that, in order for health care responders to facilitate a victim-centered approach they should ”understand the importance of victim (support) services within the exam process....(and) involve victim service providers/advocates in the exam process (including the actual exam) to offer support, crisis intervention, and advocacy to victims, their families, and friends. National Protocol for Sexual Assault Medical Forensic Examination, United States Department of Justice p. 34

59 Who is in the Room? In addition to the advocate, if possible, accommodate patients’ requests to have a relative, friend, or other personal support person (e.g., religious -and spiritual counselor/advisor/healer) present during the exam, unless considered harmful by responders. From: A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescen ts Second Edition April 2013

60 ADVOCATES ALWAYS INFORM THE VICTIM THAT THEY CAN PROVIDE FOLLOW-UP CALLS THEY ASK THE VICTIM IF IT IS OK FOR FOLLOW-UP ADVOCATES OBTAIN A SAFE CONTACT NUMBER FOR THE VICTIM AND ASK WHEN WOULD BE A GOOD TIME FOR CONTACT IF THE VICTIM DOESN’T WANT FOLLOW-UP, THE ADVOCATE WILL PROVIDE PHONE NUMBER OR CRISIS LINE NUMBER Advocate Follow-up

61 WHEN PROVIDING TRAUMA INFORMED CARE REMEMBER THAT A VICTIM WILL ONLY REMEMBER A VERY SMALL AMOUNT OF THE INFORMATION PROVIDED. REASSURE THE VICTIM THIS IS NORMAL AND S/HE ALWAYS HAS THE OPTION OF CALLING THE RESOURCES PROVIDED FOR ANSWERS TO ANY QUESTIONS. Trauma-Informed Care

62 T O C ONSIDER When a victim reports, s/he may have to turn over clothing (some or all) for evidence. Work with your collaborative team to provide clothing for the victim when s/he leaves the hospital. This includes underwear, bra, pants, tops, sock, shoes, for men and women. Also consider the need for toothbrushes, toothpaste, combs, brushes, shampoo, hair dryer, soap for the victim to be able to shower after the exam. When a victim reports, s/he may have to turn over clothing (some or all) for evidence. Work with your collaborative team to provide clothing for the victim when s/he leaves the hospital. This includes underwear, bra, pants, tops, sock, shoes, for men and women. Also consider the need for toothbrushes, toothpaste, combs, brushes, shampoo, hair dryer, soap for the victim to be able to shower after the exam.

63 WORKING COLLABORATIVELY WITH ADVOCATES TO ADDRESS CASES IN WHICH THE VICTIM DOES NOT WANT TO PARTICIPATE IN THE CRIMINAL JUSTICE SYSTEM VIOLENCE AGAINST WOMEN ACT (VAWA) FORENSIC COMPLIANCE

64 THE FORENSIC COMPLIANCE LAWS (28 C.F.R.§ 90.2(B)(1) & COLO. REV. STAT. § ) MANDATE THAT SEXUAL ASSAULT VICTIMS RECEIVE FREE MEDICAL FORENSIC EXAMS WITHOUT REQUIRED PARTICIPATION IN A LAW ENFORCEMENT INVESTIGATION. IN COLORADO, VICTIMS HAVE TWO REPORTING OPTIONS: MEDICAL REPORTING VICTIMS - VICTIMS WHO SEEK MEDICAL SERVICES FOLLOWING A SEXUAL ASSAULT BUT ELECT NOT TO PARTICIPATE IN THE CRIMINAL JUSTICE SYSTEM AT THE TIME OF RECEIVING MEDICAL SERVICES. LAW ENFORCEMENT REPORTING VICTIMS - VICTIMS WHO REPORT THE ASSAULT TO LAW ENFORCEMENT PRIOR TO, AT THE TIME OF, OR INDEPENDENT OF A MEDICAL FORENSIC EXAM. Understanding Forensic Compliance

65 A VICTIM HAS THE RIGHT NOT TO PARTICIPATE IN THE CRIMINAL JUSTICE SYSTEM AT THE TIME OF THE MFE, BUT CAN ALSO CHANGE HER/HIS MIND AT A LATER DATE. IT IS IMPORTANT FOR THE ADVOCATE TO EXPLAIN TO THE SURVIVOR THE TIME FRAMES OF HOW LONG EVIDENCE IS KEPT BY LAW ENFORCEMNT, HOW AN INDIVIDUAL COULD “CONVERT” A MEDICAL REPORT CASE TO A LAW ENFORCEMENT CASE, AND FOLLOW-UP SERVICES AVAILABLE. Victims’ Right Not To Participate

66 Sexual Assault Victim Emergency (SAVE) Payment Program To be eligible for the fund, the victim must have a sexual assault medical forensic examination in Colorado. The Division of Criminal Justice (DCJ), Office for Victims Programs administers the SAVE Payment Program (starting July 1, 2013). DCJ already administers the payment for forensic evidence collection and DFSA testing for sexual assault victims initially choosing to not participate in the criminal justice system. Financial assistance through the fund are limited to the medical procedures related directly to the sexual assault (emergency room fees, physician fees, lab testing, medications, etc.,) with a cap per victim.

67 A special thank you to Karen Moldovan from CCASA for her assistance with the development of this presentation!! Questions?


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