Health Professions Training Programs, Professional Standards and Guidelines

Little is known about who and how many health professionals have received training or education in the examination and treatment of victims of sexual assault or other forms of abuse, nor the content, duration and scientific basis for the training. However, as noted in the Background section, most States have mandatory reporting laws that require health professionals to report known or suspected child maltreatment and elder abuse, and a few require providers to report injuries from domestic violence. A much larger number of States (42) requires physicians to report injuries resulting from firearms, knives, and other weapons (Houry, et al., 2002).

Only a few States also have established mandatory educational requirements for health professionals, and the requirements principally focus on reporting requirements and mechanisms, rather than on development of clinical skills. California, Iowa and New York require health providers to receive training on identification and reporting of child abuse and neglect; Alaska, Florida, and Kentucky require training to familiarize providers with intimate partner violence and community resources; and Iowa mandates two hours of training every five years on identification and reporting of elder maltreatment (Stobo, 2003).

A recent review of the literature conducted by the IOM found no formal evaluations of the impact of mandated family violence education for providers (Stobo, 2002). They note that studies demonstrate that providers who have taken continuing education on child maltreatment are no more likely to report abuse; and that some samples indicate that continuing education courses make it less likely that providers will report. They recommend evaluation research on whether instruction—didactic or other—increases knowledge or changes behavior, whether changes are sustained, and whether there are positive outcomes in terms of such factors as costs of care, severity of presentation, and mortality.

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Academic Training Programs

There appear to be few university-based, academic training programs for health professionals that include curricula to develop clinical skills for performing forensic or medical evidentiary examinations. However, a handful of degree-granting programs in medicine and nursing are known to exist, and a small number of colleges and universities have recently added course work to existing programs in nursing and medicine.

The IOM Report, Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence, identified seven pediatric medicine fellowship programs affiliated with medical schools in the United States that include one to two years of training on child abuse and neglect or child forensics (Stobo, 2002). They also noted a few medical and nursing schools that offer one to four month elective courses or other clinical rotations related to child abuse or domestic violence. However, the degree to which the courses build clinical skills related to medical evidentiary examinations is unknown. Referring to curricula on family violence in general, the report concluded generally that the "content is incomplete, instruction time is generally minimal, the content and teaching methods vary, and the issue is not well integrated throughout the educational experience. Moreover, studies indicate that health professionals and students in the health professions often perceive curricula on family violence to be inadequate or ineffective" (Stobo, 2002).

The nursing profession is moving to develop new academic programs which train students to perform evidentiary examinations for victims of sexual assault, child abuse, elder abuse and domestic violence. In November 2002, the SANE/SART Internet site (www.sane-sart.com) listed some six colleges and universities that offer graduate, undergraduate and/or certificate programs in forensic nursing. The newest program was developed through the nursing and law schools at Duquesne University in Pittsburgh, PA, which offers both a Masters of Science in Nursing (Forensic Nursing) or a Post Masters Certificate in Forensic Nursing.

A few nursing schools have applied for federal funding to support development of programs, though only one program has been funded by HRSA's Division of Nursing. The College of Nursing at Seton Hall University in New Jersey received funds to strengthen the primary care component of their adult nurse practitioner program. The College will develop a new specialty in violence prevention that will educate students to become Sexual Assault Forensic Examiners. The Division of Nursing has also supported development of training materials for nurse-midwife program faculty and providers on caring for survivors of sexual assault, elder abuse or child abuse.

HRSA and others in HHS also have worked with schools of nursing to assist development of improved curriculum content related to violence against women. The curriculum is primarily focused on identifying and assisting victims of domestic violence, and only lightly touches on issues related to sexual assault. In addition, HRSA reports that some Area Health Education Center Program and Geriatric Education Center Program grantees are offering education programming related to sexual assault and elder abuse. In 1996, HRSA funded the first General Preventive Medicine residency program to teach physicians preventive strategies in correctional health, developed at the University of Texas Medical Branch (Galveston). The curriculum offered elective rotations in forensic psychiatry and medical management.

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Certification and Continuing Education Programs

Sexual Assault Nurse Examiner/Sexual Assault Response Team (SANE/SART)

A training program that is growing rapidly and bringing substantial change to the field is the Sexual Assault Nurse Examiner program. The growth of these programs across the country has established forensic nurses as the dominant provider of medical evidentiary examinations in many communities. SANE programs are often integrated into a Sexual Assault Response Team model for the delivery of emergency medical care to survivors of sexual assault. Within a local community, SARTs bring together providers, law enforcement, prosecution, and victim advocacy and public health organizations to promote more coordinated, comprehensive, effective, and efficient care. In addition to its multidisciplinary focus, the SART model features use of specially trained forensic nurses who conduct evidentiary exams, most often with the supervision of a physician medical director.

The basic SANE program is available to trained registered nurses (RNs), and offers certification as a nurse examiner on completion of classroom and clinical training. Typically, programs require 40 or more hours of classroom instruction, along with clinical training and subsequent continuing education.

There are a handful of programs with a long history, but most programs are less than five years old. The first programs were established in 1976 (Memphis, TN) and 1977 (Minneapolis, MN), and the initial development was slow until the mid-1990's. By 1998 the number had grown to 117, and by March of 2001 there were over 400 programs (Ledray, 2001).

The programs may be based at community locations or in hospitals. Hospitals have often been willing to donate space, supplies and equipment, though resources can vary considerably. Many programs operate on a fee-for-service basis receiving reimbursement from hospitals, police, or county prosecutors.

The development of an integrated community approach through the SANE/SART model offers the potential for reducing fragmentation and duplication, and improved efficiency in the delivery of services. The costs and other factors affecting programs have not yet been systematically assessed and compared, and will be difficult to evaluate as programs differ in how they are structured and in the cost of doing business. Reimbursement is available through funding from State victim compensation programs, supported partially through the Federal Victims of Crime Act, and varies according to State policies and resources.

The growth in the number of SANE programs is influenced by the fact that many physicians prefer to avoid seeing sexual assault victims because they don't feel they have the specialized expertise required for evidentiary examinations, and they are reluctant to get caught up in time-consuming legal proceedings. In addition, emergency physicians may be precluded from serving the immediate needs of sexual assault victims because of delays and interruptions due to more severely injured patients (Voelker, 1996).

The growth of these programs has also been facilitated by the support of the USDOJ Office for Victim Services, which has promoted development of programs by making materials and training available through the Web, and via regional workshops. Many States have vigorously adopted the program as well, including Texas, Wisconsin, Colorado, and Pennsylvania.

Other Professional Training Programs

Many programs offered on sexual assault or domestic violence provide the learner with an overview of issues related to violence and abuse, but few are intended to teach skills related to evidentiary examinations and therefore most lack technical content related to forensic evidence collection. The emphasis tends to be on screening, management, and referral of victims to social service organizations.

However, the programs vary in this regard. Programs that offer detailed clinical education on sexual assault and examination of victims include:

• The National Health Service Corps (NHSC), a program managed by BHP at HRSA, developed and provides a detailed clinical training module on Child Abuse, Neglect, and Domestic Violence (Jenny, 1996) as part of an ongoing educational program for students and providers practicing in rural and urban, inner-city areas.
• ACOG, AAP, AMA, and other professional groups offer training programs of various lengths that provide training related to medical-legal aspects of family violence and sexual assault.
• The Violence Against Women Act of 2000 amended the STOP Violence Against Women Formula Grants Program, administered by USDOJ, to add a purpose area for training of sexual assault forensic medical examiners in the collection and preservation of evidence, provision of expert testimony, treatment of trauma, and prevention related to sexual assault.

In general, however, the lack of detailed material on sexual assault and training on performing medical evidentiary examinations in programs on family violence is somewhat puzzling, given that rape is a common component of family violence. Most sexual assaults are perpetrated by husbands, boyfriends and other current or former intimate partners. Yet, a review of materials on family violence will reveal that rape, child molestation, or other sexual assault is seldom mentioned in screening or management of patients who are victims of family violence. Rather, course work tends to focus on physical assault—broken arms, bruises, concussions, strangulation, and the like, and future safety planning and community resources. Evidence collection skills tend to be limited to a mention of the usefulness of taking notes on victim statements and use of a body map or photograph to document injuries.

Aside from the issue of whether the content related to sexual assault and evidentiary examination is adequate, many of the programs offered do not appear to be solidly constructed. The IOM review of educational offerings concluded:

"There are few scientific underpinnings to support the content, instructional methodologies, or extent of education now being provided in these training programs ... Curricula content is incomplete, instruction time is generally minimal, the content and teaching methods vary and the issue is not well integrated throughout their educational experiences" (Stobo, 2002, p. 6).

The IOM report recommends that core competencies for health professional training on family violence be developed and tested, and concludes that the core competencies needed include the identification, assessment and documentation of abuse and neglect. They point to the limited evidence base in family violence generally. Additional barriers to development of improved academic training programs include a lack of interest among faculty, competing pressures for curriculum time, and the limited availability of developmental resources.

Clinical Practice Guidelines: A Tool for Practitioners

Clinical guidelines, professional standards and practice protocols are developed by professional organizations or quality improvement bodies to help guide practicing providers toward improved health outcomes. They are distinct from educational programs that are offered at a particular time and place as part of a formal academic training program. The development of guidelines and protocols has grown in recent years as evidence-based medicine has become a dominant force in the way medicine is practiced.

At the heart of evidence-based practice is the systematic review of a body of research which can evaluate what clinical practices work best, for whom, and at what cost. It is only possible, however, if there is a body of rigorous study to support conclusions. In the case of medical evidentiary examinations, the necessary evidence base is sparse.

In reality, most medical care is not solely based on evidence from carefully designed studies, and variations in practice are common. Much medicine derives from experience and common wisdom handed down; where clear evidence is not available, practitioners rely on experienced-based clinical judgment. However, in the last two decades or so, the movement to evidence-based practice has brought about further improvements in the outcomes of care provided, and works to conserve resources by eliminating unnecessary or ineffective health care services. In general, the lack of research on the outcomes and effectiveness of the components of the evidentiary examination process can be expected to hamper efforts to improve existing training programs and establish effective practice protocols.

A well-written guideline presents a synthesis of the available scientific evidence on a topic relevant to clinical practice. Ideally, the synthesis is presented in a structured format that facilitates the ability of providers and patients to make decisions about health care services to be provided. To be viewed as solid and reliable guidance, the guideline must be based on a systematic literature search and review of existing scientific evidence published in peer-reviewed journals.

Guidelines for Performing Medical Evidentiary Examinations. Although a number of States and locations have adopted protocols or clinical guidelines for conducting medical evidentiary or forensic examinations related to sexual assault and child abuse, few are based on systematic reviews of the literature, nor have they been compared or tested in terms of outcomes for patients and/or the purposes of criminal justice.

The largest national repository of clinical guidelines is the National Guideline Clearinghouse™ (www.guideline.gov). It is an Internet-based, collaborative public resource that is sponsored by AHRQ in partnership with the AMA and the American Association of Health Plans (AAHP). It accepts science-based clinical care guidelines developed under the auspices of medical specialty associations, professional societies, government agencies, public or private organizations, and integrated health care organizations and plans.

The science that undergirds those guidelines that are accepted varies according to the topic and the available research base, but each is evaluated by the NGC to assess whether development of the guideline was based on a rigorous scientific process.

As of August 2002, six guidelines in NGC referenced forensic or medical evidentiary examination. Two are specifically intended to guide practitioners/examiners in how to conduct such examinations:

• Practice Parameters for the Forensic Evaluation of Children and Adolescents Who May Have Been Physically or Sexually Abused (American Academy of Child and Adolescent Psychiatry).
• Practice Parameters for Child Custody Evaluation (American Academy of Child and Adolescent Psychiatry).

The other guidelines are less specific about procedures related to performing evidentiary examinations, but describe key elements in a general way:

• National Guideline for the Management of Adult Victims of Sexual Assault (Association for Genitourinary Medicine and Medical Society for the Study of Venereal Diseases).
• Care of the Adolescent Sexual Assault Victim (AAP, Committee on Adolescence).
• Practice Guideline for Psychiatric Evaluation of Adults (American Psychiatric Association).
• Domestic Violence (Institute for Clinical Systems Improvement; 2001 Nov. 39 p., June 1996, Revised 2001 Nov).

Professional Policies and Standards

In addition to guidelines, specialty-specific professional organizations and accrediting bodies often develop clinical protocols, training materials, professional standards and policy statements to assist their members. Many organizations have policies and protocols related to identification, treatment, and or reporting of family violence, but few are specific in terms of the mandate of this report: training of health professionals to perform medical evidentiary examinations. Among the organizations that appear to have developed materials or policies that are specifically related to sexual assault, child molestation and/or medical evidentiary examinations are:

American Academy of Pediatrics (AAP). The AAP's Committee on Child Abuse and Neglect (COCAN) has developed an excellent series of practice guidelines, policy statements and technical bulletins which focus on the physical, sexual, and mental abuse and neglect of children and adolescents. The journal Pediatrics published a guideline in 1999 outlining the basic skills needed when examining a child for possible abuse, including details on taking history, performing a physical examination, recording data, and treatment (AAP, 1999).

The AAP recommends that pediatric residency training programs and continuing medical education programs incorporate education on family violence and child abuse. Resources developed by AAP include guidelines and teaching materials related to care for the adolescent sexual assault victim, CD-ROM courses on child abuse and other self-teaching materials, and technical information on oral and dental aspects related to child abuse and neglect, a joint product of the AAP and the American Academy of Pediatric Dentistry.

American Association of Colleges of Nursing (AACN). AACN recommends that schools of nursing ensure there is a curriculum with content related to domestic violence across the lifespan. They also recommend that students be provided opportunities to practice in clinical settings to learn screening, assessment, and caring for victims of violence. It is unclear whether training related to caring for victims of sexual assault is encompassed by this policy statement.

American College of Emergency Physicians (ACEP). The ACEP has actively sought to develop policies and protocols related to sexual assault that will be helpful to front line providers. In 1997, the ACEP and more than a dozen partner organizations worked collaboratively to develop a handbook on the evaluation and management of sexually assaulted patients. The handbook addresses the medical and emotional needs of the patient, as well as the forensic requirements of the criminal justice system.

The effort was supported in part by MCH at HRSA, and involved more than a dozen public and private health and law enforcement organizations, including ACOG, the AMA (including the AAP), CDC, the FBI, the International Association of Chiefs of Police, the Emergency Nurses Association, IAFN, and the American Society of Crime Laboratory Directors. Advocacy organizations included the National Alliance of Sexual Assault Coalitions, the National Network of Children's Advocacy Center, and the STOP Violence Against Women Technical Assistance Project.

Although there were areas of disagreement among the participants, the resulting document, the Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient (ACEP, 1999), provides a basic protocol for conducting medical evidentiary examinations of adult and pediatric/adolescent patients. It also includes technical assistance tools such as information on how to develop a coordinated community response plan, a guide to development and operation of a SANE Program and a list of key organizations in the field.

The materials developed included a guide to Federal grant programs related to domestic violence, sexual assault, and stalking. Most of the Federal grant programs at the time were applicable to development of community sexual assault prevention programs, and training for law enforcement and social services personnel. Among the programs are grants to States to provide limited compensation for the medical expenses of sexual assault and other victims of crime. There was no Federal assistance for development of curricula, training, or forensic capabilities associated with evidentiary examinations.

The ACEP Board of Directors recommended in 1997 that emergency departments have written protocols on the recognition and treatment of elder abuse, which include appropriately educated staff and referral mechanisms. Notably, the ACEP opposes mandatory reporting of elder abuse and neglect, but encourages voluntary referrals. Other policy statements seek to educate providers about recognition of child abuse and family violence.

American College of Obstetricians and Gynecologists (ACOG). ACOG has mounted a sustained effort to educate their membership about the identification and management of Intimate Partner Violence (IPV) and sexual assault among patients. They publish materials designed to promote effective screening and management of patients, including a slide lecture presentation (ACOG, 2000), available in hard copy and CD-ROM, to be used in training residents, Fellows, medical students and other health care providers, and offer related continuing education sessions in conjunction with their annual meeting. The College also maintains updated information on their Web site. A technical bulletin for members provides practical direction related to the incidence of sexual assault, use of assessment kits, conduct of a medical evaluation, legal concerns, patient counseling and followup treatment.

American Dental Association (ADA). The ADA Recommends development of educational programs for training dental providers on how to recognize and report abuse and neglect of children, women, elders, people with developmental disabilities, physically challenged, and others who might be the object of abuse or neglect. Also seeks educational collaborations with other professional organizations, including the AMA and the American Psychological Association.

American Medical Association (AMA). The AMA publishes and offers for sale a series of diagnostic and treatment guidelines that address the basics of a patient interview and examination, as well as documentation, legal issues, testimony and trends in treatment and prevention. Specific guidelines are available on child physical abuse and neglect (AMA, 1992); child sexual abuse (AMA, 1992); domestic violence (AMA, 1992); and sexual assault (AMA, 1995). The guideline on elder abuse is less specific but also includes a discussion of ethical and legal issues around detection and reporting (AMA, 1992).

The organizational visibility of family violence was raised significantly in calendar 2000, when the AMA House of Delegates approved a resolution (419) calling for a committee of representatives from the National Advisory Council on Violence and Abuse and its Committee on Medical Education to identify the knowledge and skills needed by physicians to identify and respond to violence and abuse; to identify where in medical education these skills could be included; and to investigate continuing education needs. The resolution also called on the AMA to advocate for hospital and community support of violence survivor programs, as well as for equitable coverage and reimbursement for all health and mental health related to family violence.

American Professional Society on the Abuse of Children (APSAC). APSAC has five data-based guidelines on key areas of practice related to child maltreatment. The guidelines were developed by expert task forces, and then reviewed by other experts, legal counsel and APSAC leadership. The guidelines address:

• Psychological evaluation of suspected sexual abuse in children.
• Descriptive terminology in child sexual abuse in medical evaluations.
• Use of anatomical dolls in child sexual abuse assessments.
• Photographic documentation of child abuse.
• Psychological evaluation of suspected psychological maltreatment of children and adolescents.

APSAC also offers week-long forensic interview training clinics with both classroom and clinic-based sessions. Topics include forensic interviewing techniques, legal issues, and other practical skills needed for both investigative and therapeutic purposes. The training targets mental health professionals, as well as professionals in child protective services, law enforcement, social services, medicine, and law.

The guidelines have not been systematically tested or compared in terms of how well they support the dual purposes of a medical evidentiary examination: providing medical care and collecting evidence for use in prosecution.

American Psychological Association (APA). APA has developed a guide on the education and training of psychologists on issues of child abuse and neglect that is designed to facilitate development of semester-long courses. The association has developed educational materials for graduate-level programs as well.

American Society for Testing and Materials (ASTM). ASTM has a standard guide for sexual assault investigation, examination, and evidence collection which calls for using trained forensic examiners in the setting of a multi-disciplinary team. The ASTM guide requires facilities to have written procedures for providing information on the treatment plan, evidentiary and medical examinations, documentation and evidence collection, transmittal of evidence and the chain of custody and post-examination procedures. Agencies conducting child sexual assault investigations are required to develop special protocols appropriate for the examination of children.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). JCAHO is a non-profit entity which evaluates and accredits more than 17,000 hospitals, health care networks, home care and other health care organizations in the United States. Its guidelines require that hospital organizations have observable, objective criteria for identifying victims of physical assault, rape or other sexual assault, domestic abuse, and abuse of elders and children. In addition, the hospital is required to have a staff education plan and to maintain a list of organizations that provide or arrange for assessment and care of alleged or suspected victims of abuse and neglect, in order to aid in making appropriate referrals.

JCAHO specifies that medical assessment of victims of abuse must be conducted with the consent of the patient, meet legal responsibility for the collection, retention, assessment and safe keeping of evidentiary material, and include the notification and release of information to the proper authority when legally required.

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