'We desperately need some help here' - The experience of legal experts with sexual assault and evidence collection in rural communities

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Introduction

The purpose of this article is to examine the experiences of expert legal providers in rural areas with a specific look at their experience working with sexual assault nurse examiners (SANEs), with issues relevant to SANEs, and with the judicial process. The results presented here are from a larger study examining expert legal and advocate providers in rural areas. The rural setting was selected because virtually all research examining sexual assault over the past 20 years examined non-rural areas¹. While the larger study examined prosecuting attorneys, law enforcement, victim witness advocates, social workers and crisis center advocates, this article focuses only on the results of interviews with the attorneys, law enforcement and victim witness because the other providers generally did not discuss issues related to forensic nursing.

Overall, 17-18% of women and 3% of men experienced a completed or attempted rape in their lifetime^2-4. In the rural setting, rates of sexual assault as high as 30% have been documented¹. In Virginia, 27.6% of females and 12.9% of males experience a sexual assault within their lifetime⁴. Of these, more than half (78%) of women reporting lifetime sexual assault experienced child sexual assault^5,6. Most (94%) male sexual assaults, in comparison, occur prior to age 18⁷.

The medico-legal response to sexual assault has changed dramatically in the past 30 years in the USA. Before the first SANE programs began in the late 1970s^8,9, a healthcare provider with little or no specific forensic training performed post-sexual assault exams and victims experienced long waits for emergency room treatment¹⁰. Today, as part of a healthcare evaluation, a qualified SANE can provide expert evidence collection. The examination itself involves the collection of a physical evidence recovery kit (PERK) and a physical assessment including genital and anal examination. In addition to the collection of forensic evidence, the essential components of a SANE evidentiary exam include evaluation and preventative care of sexually transmitted infections, prevention of pregnancy, crisis intervention and evaluation of injuries¹¹. The SANE evidentiary exam varies slightly for adults and children and there is separate training for each.

SANE programs have wide support, improving the quality of care provided to sexual assault victims^12,13. The American College of Emergency Physicians supports sexual assault nurse examiners performing the evidentiary exams¹⁴. State and federal appellate courts have rejected defense challenges to expert testimony from sexual assault nurses¹⁵. Many areas have developed a sexual assault response team (SART) consisting of law enforcement, prosecuting attorneys, advocates and SANEs¹¹.

The medico-legal response to sexual assault varies in other countries. In Belgium, for example, forensic medicine is a new specialty (since 2002) and the collection of evidence is mostly performed by physician gynecologists¹⁶. A recent extensive literature review examining barriers to evidence collection worldwide found widespread incompetence, negative attitudes toward women, and corruption of the legal process¹⁷.

Along with the growth in numbers of SANE programs, the work of the SANE is increasingly important in the prosecution of the perpetrators of sexual assault. The judicial system relies on the forensic nurse examination and record to help determine the cause of the victim's injuries^18,19. The sexual assault nurse's examination, expert testimony and the PERK results are useful tools for prosecuting attorneys and law enforcement.

Methods

Sample

The sample of expert legal providers included seven commonwealth attorneys (the state prosecuting attorneys in Virginia), six sheriffs or police investigators, and five victim-witness advocates, all from rural areas of Virginia. These 18 legal experts were interviewed for 1 hour each on average. Participants' experience in working with the sexual assault population ranged from 1.5 years to 25 years. In this report, participant names are changed to maintain confidentiality.

Participating counties were selected using a system designed by the Economic Research Service (ERS) of the United States Department of Agriculture, which classifies counties on an urban-rural continuum²⁰. In Virginia, 21 counties were in the most rural ERS codes 8 and 9. These counties were designated as either completely rural or as having an urban population of fewer than 2500. For this study, participants were first solicited from those counties within a given radius and classified as codes 8 or 9. There were also 21 counties in Virginia that were in ERS codes 6 and 7. These counties were classified as non-metropolitan areas with an urban population between 2500 and 19 999. Because not enough participants for data saturation were obtained from the codes 8 and 9 counties, participants were also solicited from counties in codes 6 and 7. Each county had a limited number of legal providers who were experts in this area. In total, seven counties were selected that were in ERS codes 6-9.

Procedure

Letters were sent to potential participants (prosecuting attorneys, sheriffs and victim witness directors) describing the study, followed by phone calls. Potential participants were asked for the name of the person they believed to be the most experienced in sexual assault cases. Recruitment criteria included (1) currently working in designated rural counties of Virginia, (2) ability to speak and understand English, and (3) having recent experience (within the last year) assisting survivors of sexual assault.

Interview format

Qualitative data were collected by in-person interviews with a hermeneutic-phenomenological format as presented by Cohen et al²¹. This format was designed to help participants report their experiences in the form of a story. The study author asked participants to recount their experiences with victims of sexual assault. Because the expert participants were involved with a number of cases, they were asked to talk in detail (without using any information that might identify the people involved) about cases they thought were typical or usual and also cases they thought were unusually difficult or troublesome. They were asked to identify facilitators and inhibitors of reporting and following through the judiciary process, and finally they were asked if there are categories not mentioned. For specific questions and probes, see Appendix I.

All of the recorded interviews were conducted at the participant's office or a conference room. The opportunity for further dialogue at the end of the interview was provided.

Validity

Validity, sometimes called 'trustworthiness' in qualitative research, is judged by adherence to methods and methodology and the use of triangulation. Validity of the analysis is upheld when using analytic induction by a thorough search for disconfirming evidence. Triangulation is the use of multiple sources in obtaining data. Specifically, it involves the collection of observational data, interview data and paperwork data²².

Reviewing material culture

Many of the participants had brochures or advertisements on bulletin boards on ready display within or outside of their offices. No other relevant documents, such as blank reporting forms or relevant policies and procedures, were shared by participants for analysis.

Field notes

Either during or after each interview, field notes were taken. These included information about the setting of the interview and any other relevant thoughts about the interviews.

Data analysis procedures

Data were analyzed by the author using a hermeneutic-phenomenological approach. The data were transcribed by an independent, secure transcription service. After transcription was completed, the data from each participant were checked for accuracy, and then formal analysis began. The goal of the analysis was to determine the themes that characterized the experiences of the participants²¹ with a focus on the judicial process.

As described by Cohen et al²¹, the first step in analysis was data reduction. This was performed because the amount of data generated in the present study did not lend itself immediately to a line-by-line coding. The goal of the first step was to concentrate and make clear the major aspects of the data about a participant without losing the individuality of each interview.

After the field notes and transcripts of interviews were interpreted, they could then be subjected to line-by-line coding with a considerably reduced chance of being overly reductionistic and losing sight of the meaning of the whole experience. These resulting narratives were subjected to hermeneutic analysis.

In this method, data were analyzed by (a) reading transcripts to gain a sense of the overall experiences, (b) re-reading transcripts to identify and sort basic units of data called strips²³, (c) re-reading the completed texts as a validity check of the categories, (d) sorting strips into categories according to observed similarities and relationships to form larger themes, and (e) re-reading the texts that resulted from the first step of analysis to determine if the themes were representative of the data as a whole. NVivo software v2.0 (QSR International; http://www.qsrinternational.com/products_previous-products_nvivo2.aspx) compatible with hermeneutic phenomenology facilitated data management at later stages of analysis.

Ethics approval

This study complied with all requirements and received approval from the Human Subjects Investigation Committee at the University of Virginia Health Sciences Center. General federal human subjects protection guidelines applied to all participants.

Results

Following an in-depth analysis of the transcripts, two significant themes were identified that described the essence of the legal providers' experiences with the medico-legal process. These were prosecution difficulties, and accessibility and experience of SANEs.

Prosecution difficulties

Participants discussed the process of deciding whether to move forward with a sexual assault case, which influences whether an evidentiary (SANE) exam is performed. From the law enforcement perspective, officers described the work they do to aid in that decision-making process for the prosecutors. This involved interviews, evidence collection and research to corroborate the victim's story. (All participant names have been changed.) Lloyd, a law enforcement officer, stated about one case:

There have been 18 people I've interviewed, not including the suspect himself and I have probably close to 200 hours into it at this point ... typically what I do is I'll work on a case until we can get to a decision point as to whether or not the commonwealth attorney wants to prosecute it.

Gloria, another law enforcement official agreed: 'Where there would be no physical evidence and no confession, we would present that case to the Deputy Commonwealth Attorney and go under her guidance, whether or not to obtain criminal charges.'

Ultimately, the prosecutors made the judgement to prosecute a case. One prosecutor, Bruce, stated, 'Those decisions are always my decisions. Once this starts, [the victims and their families] can't drop charges. That's up to me.'

Prosecutors described weighing each case carefully and balancing their obligations to the victim with their obligations to the public. Paige stated:

I take into consideration what my victims want and sort of what their motivations are and all of that, but that is just one of many factors because the reality is sort of the harm has been done to that person and my job as a prosecutor is to punish the perpetrator.

Nina, another prosecutor, agreed, stating that victims and their families are 'not in charge of the case ... it's not them against him, it's us against him [the perpetrator].'

The presence, or lack thereof, of DNA evidence has become increasingly important in sexual assault trials, according to legal providers, and has an important influence in the prosecutor decision-making process. Participants described artificially elevated jury expectations for DNA evidence, believed to be due to the influence of popular media. James stated:

CSI and all these DNA discussions have made juries believe that there is this magic out there that can be worked in almost every case.

The legal providers stated that the media depictions of quick results, advanced technology, and ability to work on one case at a time created unrealistic expectations. Arthur, a prosecutor, stated, 'People on juries watch CSI and think that people can breathe into the telephone and you can get their DNA off of it, and in 15 minutes you get a match back.' The net effect, according to participants, is that media programs have raised the evidentiary standard for sexual assault cases. In particular, prosecutors felt that jurors were no longer willing to accept just testimonial evidence in sexual assault cases, and they felt that jurors wanted near certainty when the standard is actually proof beyond a reasonable doubt. Samuel, a prosecutor, described a representative case where the victim reported an assault and the alleged perpetrator denied it. After the perpetrator was acquitted, Samuel related:

A jury member came up to me afterwards and said, 'Without the DNA evidence, I just couldn't be convinced'... And I just kind of looked at him. Were you ever confused about who the identity of the defendant was during the trial? Did you ever think someone else did it that wasn't him? And he said, 'Oh no, the only question was whether it happened or not.' I said, 'Well, did you believe the girl?' He said, 'Oh yeah, but without the DNA, I mean, you were asking for him to go to jail for the rest of his life.'

Along with concerns about the effect of media on the prosecution of sexual assault, the legal providers also mentioned problems with a lack of any physical evidence, making successful prosecution more difficult. Many sexual assault cases are based mainly on one person's testimony against another's, and Alex, a law enforcement official, stated that defense attorneys use this to their advantage. He said:

These attorneys more and more are talking about no evidence, no crime. And in many of these child sexual assault cases, there really is no [physical] evidence ... It makes it hard for a jury to convict on some of these cases when you do bring them.

Having good forensic evidence appeared to be the exception rather than the rule. Two participants reported that they each experienced only one case with solid forensic evidence in more than 4 years.

This lack of physical evidence was attributed to several things. First, frequently victims delayed reporting. Jean, a victim-witness associate, stated, 'Those [delayed reporting] types are [difficult cases] because by that time you've lost a lot of your evidence, so it's he-said, she-said at that point, unless there is some bruising or something that's left behind.' Another officer stated:

So many of the cases that we get, if there has been penetration, if it's reported after three or four days, if we do elect at that point in time to send them for an exam, everything is healed up.

Second, some participants reported that many perpetrators were knowledgeable enough to leave no marks on the victim. Alex, a law enforcement official, stated, 'That's what's very discouraging about it because so many of the times it's just touching, fondling.' Third, many victims responded to an assault by destroying evidence. Fred, a law enforcement official, stated, 'A woman gets raped, the first thing she wants to do is to jump in the shower and clean herself up.' Delayed reporting, perpetrator knowledge and victim's efforts to clean up after an assault all contribute to inadequate physical evidence found in many sexual assault cases, according to legal providers. Samuel, a prosecutor, stated, 'A lot of times, you get these medical reports back that are non-specific, simply normal findings, and it's not completely consistent in the juror's mind with someone that has been a victim.'

Although lack of forensic evidence was a significant problem reported by legal providers, difficulties occurring during the judicial response were also discussed. Participants commonly discussed issues surrounding consent and victim testimony.

Even when the PERK results detect perpetrator DNA, the trial may still come down to the issue of consent. Consent is a core issue for many sexual assault cases because the alleged perpetrator often reports that the sex was consensual. Arthur, a prosecutor, stated, 'Even if you've got DNA, then it's always consent as the issue.' Participants stated that often juries do not believe victims and do not understand the reality of sexual assault. Fred, a law enforcement official, stated:

It's a situation where the woman's pointing her finger at this guy and saying that this guy forced me to have sex with him and the guy says, 'no, this was consensual.' You have to look for other things in order to get a conviction.

Participants also talked about the difficulties associated with victim testimony and its effects on prosecution. Arthur stated:

I would guess probably 15% don't go to court. And that's because the victim doesn't want to go to court. ... I know I'm supposed to prosecute everything there is, but if there is a case that just doesn't fit right ... I have discretion.

Memory issues often hampered successful testimony, especially with children. One prosecutor recalled that working with child victims is 'like handling dynamite'. The legal providers reported that child testimony was a particular problem because children often did not understand sex, their vocabulary was limited and they have short attention spans. Participants reported that testifying is very difficult, humiliating and intimidating for victims, especially child victims, which plays a part in the prosecutor's decision-making about pursuing a case.

Accessibility and experience of SANEs

According to the legal providers, there are not enough fully trained and experienced SANEs in rural settings. Legal providers mentioned 13 different hospitals they sent victims to for a forensic examination. Of the seven counties included in the study, only three had hospitals within the county. Therefore, victims often had to travel significant distances to more urban areas to obtain a forensic exam. Victim transport often resulted in police shortages and caused an increased burden on victims. Legal providers reported that police were often spread thin, especially at night when there were often only one or two officers on duty to cover an entire county. Sometimes victims had to wait for an officer to transport them to another county for a forensic exam. Paige, a prosecutor, stated, 'We have had instances of child sex assaults where there was nobody available immediately and so there was sort of a lag time ... and that's a problem.' The law enforcement officials described providing transportation assistance for forensic exams, but reported that the required travel to another county often led to police human resource shortages. Eric, a law enforcement official, stated:

The hospital calls and says, 'You've got a woman over here that says she's been raped.' ... Somebody's got to be there to take custody of that PERK kit once it's done three hours later. Leaving one or two men in the county by themselves. So we get stretched very thin quite often.

Participants also described a burden placed onto victims' families who travel for a sexual assault exam. Bruce, a prosecutor, stated:

You've got a mother who may be working and has got to take off from work. And instead of taking an hour or two hours, it takes you a day, by the time you drive there, wait and all that stuff. There's a problem then of time ... Of course, gas costs money ... the main thing would be nice if we had a hospital here in the county, or a clinic that did that.

In addition to the lack of local forensic nurses, and associated travel out of county, participants also reported that some SANEs were inexperienced with the forensic exam and, particularly, with testifying. Legal providers also discussed the problem of excessive SANE turnover. Legal providers reported they wanted sexual assault nurses with not only considerable training and experience in performing the exam itself, but also in giving effective testimony during a trial. Bruce, a prosecutor, stated:

I want that person who examines the child to have the experience of testifying in court so if I need them, I know I've got a good witness ... how many times has she testified in court, is she already qualified as an expert, and all that stuff. It's the comfort that comes with the known versus the unknown.

Local SANEs were working in only three of the seven counties and none performed child examinations. Participants reported few adult cases of sexual assault per year and that most victims went to a non-rural hospital for the forensic examination; thus, SANEs in rural settings are probably less experienced than SANEs in non-rural settings. Some legal providers were referring cases locally; however, most legal providers seemed to seek SANEs that were more experienced. Kathy, a victim witness associate, when asked about a SANE program at a local hospital, stated, 'We try to not send people [there].' Laurel, a prosecutor, stated, 'The one case that we had they had problems with was the one that went up there [to the local hospital].'

Participants also discussed rural issues including lack of a SART, a specific SANE program or trained, on-call nurses. Jean, a victim witness associate, talked about the lack of a SART: 'we have been working on, trying to get a sexual assault team, and it just hasn't happened yet.' In addition, participants often disagreed about whether exams were performed at a given facility and about what types of exams were performed there. For example, one legal provider erroneously reported that a local hospital did not perform pediatric exams.

Discussion

Many factors must go into the decision of whether to prosecute a sexual assault case. Legal providers considered many issues including DNA findings and the presence of other physical evidence. These issues may affect whether SANEs are asked to perform an evidentiary exam on victims. Research suggests that most sexual assault cases are not prosecuted. One in four forcible rapes led to an arrest²⁴. Only about one-third (30%) of reported sexual assault cases are prosecuted, one-fifth (20%) continued through the court process, and 12% resulted in some type of conviction²⁵. Reasons for not prosecuting include insufficient evidence, lack of victim cooperation, lack of victim credibility, inability to locate victim, and no probable cause²⁶.

As reported by the study participants, evidentiary problems compound the difficulty of prosecuting sexual assault cases in rural areas. Non-DNA evidence such as bite marks, blood grouping, and hair and fiber analysis have been important types of evidence for sexual assault cases for a long time, but since the application of DNA typing in 1984, forensic evidence has become even more important²⁷. Today, the lack of DNA and physical evidence can complicate the legal provider's work. Not having evidence to corroborate the victim's story makes presenting a case much more difficult. Forensic evidence is often seen as more important to jurors than the testimony of the victim^28,29; thus, prosecuting attorneys handling a case with little forensic evidence are less willing to move that case forward³⁰. Most child victims have normal or non-specific physical examinations during forensic evidence collection^31,32. In addition, many adult victims have no genital injuries^18,33,34 and no non-genital injuries^35,36. Legal experts working in the rural setting with less resources, less familiarity with SANEs and the evidentiary exam they perform, and limited exposure to victims of sexual assault, especially adult victims, may be more reticent to pursue a case.

Many of the evidentiary problems associated with these cases, such as delayed reporting, are not directly within the SANE's control. However, non-specific findings could be at least partially attributed to nurse error. Therefore, once the decision is made to perform an evidentiary examination, it is important that the SANE take the time to perform a thorough examination. While this may seem intuitive, correct processing of PERKs remains a problem. A study of evidence collected by physicians found that only 4% of exams had used a Wood's lamp, 59% collected blood samples, 35% collected clothing or linens, 34% collected saliva, and 2% collected foreign debris³⁷. These elements are required in the National Protocol³⁸. Physicians and non-SANEs were less likely to complete elements of the PERK correctly compared with SANEs^39,40. However, even among SANEs, 8% did not complete chain of custody appropriately, 9% did not appropriately seal specimen envelopes, 12% did not include the appropriate amount of pubic hair, and 12% did not include the correct amount of swabs in the kit⁴⁰. A less competent SANE may be more likely to leave steps out of the processing of the PERK. For example, a less competent SANE may leave a saliva sample out of the PERK if the patient does not have an oral assault. The competent SANE knows that the victim's saliva is used to distinguish patient DNA from perpetrator DNA³⁸. The competent SANE will know to systematically collect clothing, debris, foreign material, skin, hair, oral, and genital evidence as well as to methodically collect a medical forensic history, take photographs, and document findings appropriately, as per the National Protocol³⁸. In fact, the National Protocol calls for nurses to 'collect as much evidence from patients as possible' (p. 89) when performing a forensic examination³⁸.

SANEs working in rural settings may be particularly hampered in their role relative to non-rural SANEs. Given that legal providers are referring victims to non-rural settings for evidentiary SANE exams, the effect would be lowering the already small numbers of cases for rural SANEs. So, the rural SANE gets even less experience and a self-perpetuating cycle can exist, where the legal providers are less likely to refer cases locally because the local SANEs are not as experienced.

This study suggests that legal providers are generally appreciative of SANE programs, but that there is room for improvement. Both training and experience were important to legal providers seeking SANE services. Although access to forensic nurses was an issue, legal providers also had concerns about SANE turnover and experience. Further, confusion was apparent among legal providers surrounding the locations of SANE programs and the services they offered. According to legal providers, a formal SART was less likely to be in place and hospitals were less likely to have formal SANE programs in the rural setting.

Concerns about burnout and subsequent turnover, and about lack of experience, especially with testifying, are in accord with other research^41-43. SANE turnover is a problem likely due to stress associated with being on call, fulfilling the SANE role in addition to full-time work in another nursing role, the need for occasional testimony, and with working with a highly traumatized population^41,42. Since the majority of SANEs work in hospital settings³⁷, support from hospitals for the SANE program in general through on-call pay, appropriate resources, and continuing educational opportunities could help minimize this problem. Prosecutors should take the time to work with SANEs to prepare them for testifying with each case. In addition, new SANEs could partner with more experienced urban SANEs for a year or more in order to get more experience performing exams, and in observing SANE testimony. Training programs should review the judicial process, provide information about testifying, and hold mock trials⁴⁴. More importantly, these training recommendations should eliminate much of the variance found among some SANE training programs. The National Protocol for Training provides many details necessary for training, and would make it easier for any experienced SANE to develop a training session locally.

Another significant legal provider concern was local access to SANEs and burdensome travel. Other options may exist. Telemedicine is a technology that can assist with access to care and isolation of rural healthcare providers^45,46. First, with the rise of telemedicine, it seems feasible that nurses working in rural settings could receive their didactic SANE training online and via satellite. The use of videoconferencing in the rural setting has been successful in treating mental health issues in victims of sexual assault⁴⁶. Also, clinical simulation technology has been shown to be useful to successfully add clinical experiences to novice SANEs⁴⁷. Some of the clinical portion of the training could be performed in the local rural community, such as required police ride-along time and observing court. Moreover, this could foster SART development. Although travel is time-consuming and expensive, travel to an urban setting, with a large number of cases, would allow for completion of many exams in a short period of time under the supervision of an experienced SANE.

One of the biggest obstacles that SANEs in rural settings face is limited caseload. This makes it difficult to obtain and maintain competence. Nurses could maintain their forensic skills through monthly peer review of cases using telemedicine technology with urban SANE programs. All SANEs should participate in frequent review of cases¹¹. The peer review process, a systematic review of each case that team members have performed, provides the opportunity for SANEs to analyze photos, discuss findings and relevancy of findings, and critique documentation. Through this method, each team member is exposed to a greater number and variety of cases. The monthly peer review process could help examiners maintain competence without the cost of traveling outside of their community and would provide support to the rural SANE teams. This urban-rural peer review would require good working relationships between SANE programs within a region, with a network of rural SANE programs and an urban base. This association could even expand so that rural SANEs could access an on-call, more experienced SANEs from the central base to provide mentoring, field questions, and address issues that may arise. A regional network of this sort could also eliminate some confusion among the legal providers about who offers services.

Having more nurses with SANE training in rural communities could eliminate some of the traveling required of victims in rural communities. Alternatively, trained non-rural SANEs could travel to rural settings, as suggested by one legal provider in the study. A 1996 survey of SANE programs noted that 10 of 47 programs would send SANEs to other locations such as jails, health departments, women's clinics, and other hospitals¹⁹. One obstacle for this proposal is the need to transport equipment or to have each facility purchase the required equipment.

None of these suggestions is useful without a cohesive SART team in place in the rural setting. A SANE program is more likely to be successful with the interaction and support of law enforcement, prosecutors, victim witness associates, social workers, and crisis center advocates. Most of the counties involved in this study did not have SART teams, and the improved communication associated with this team would be a step in enhancing SANE services in rural communities.

Limitations

There were potential limitations to this research study. The first limitation is the assumption that participants spoke candidly and honestly about their experiences. People in rural areas may be more likely to be reticent to speak with outsiders, because of mistrust⁴⁸. The researcher attempted to interact with participants in a non-judgemental and courteous manner, emphasizing interest in their experiences (whether positive or negative). However, there is no way to tell how honest participants were in answering questions. At times, participants within the same community would answer inconsistently. For example, within one county, a prosecutor stated that they generally only share mandated information with the media, while the victim witness associate stated that the prosecutor often shared case information with the media.

Further, many participants sought reassurance at the end of the interview, asking if they had answered questions the way others had or had answered them appropriately.

A second limitation of this study was that although rural participants were interviewed about their experiences, some of these experiences may not be rural-specific. However, in interpretive research this is not a problem because the goal is to examine participants' meaning and world-construct, knowing that background and experiences influence that construction. In other words, participant experiences are what they are and are influenced by culture and setting. The providers interviewed were living and working in a rural setting and discussing their experiences with sexual assault victims in a rural setting. Participant experiences are the interest in this study, regardless of any generalizable non-rural focus of their experiences.

As with much qualitative research, limitations in generalizability may exist. However, interpretive research is interested in findings that apply to the particular situation, but generalizability as defined in positivist research was not expected.

Implications for clinical forensic nursing practice

Several clinical implications have resulted from this study. First, while many of the evidentiary problems reported by legal providers cannot be addressed by the SANE, the thoroughness of the forensic examination is critical. Both participant statements about non-specific evidentiary examinations and research studies suggest that not all SANEs are collecting evidence appropriately. SANEs in settings with low numbers of assaults, such as the rural community, may be especially challenged by this.

Second, nurses working in both rural and urban settings should explore collaborative efforts for SANE teams where experiences and expertise may be shared. SANE programs in rural settings should participate in urban-rural peer review of cases to maintain competence. The forensic nurse should keep a close collaborative connection to other legal, advocate, and healthcare providers in the region. Creation of SARTs in the rural setting should facilitate this process.

Lastly, forensic nurses should support policy and funding changes that would improve interactions among legal, advocate and healthcare providers, and between communities. These clinical changes should improve victim care and prosecution outcomes.

Future research should focus on the community context of rural assault and the motivations of both victims and providers. Specifically, the interactions and interconnections between victims and providers, collaboration between providers, and the effect of negative attitudes and acceptance of sexual assault in rural communities, should be examined.

These results suggest that successful interventions for rural communities may need to be different from non-rural communities. An intervention based upon an urban model may not be the most effective for less densely populated areas with different culture and history. Future research of this type will make the work of policymakers, health practitioners, service providers and advocates less demanding and more effective.

Conclusions

This study provides a context for understanding the rural medico-legal response to sexual assault and for the importance of the role of the sexual assault nurse examiner to rural populations. The experiences of the participants revealed many difficulties in working with sexual assault cases. Study participants described the need for many victims to travel long distances for health care and SANE evidence collection. Local rural SANEs were either inexperienced or not present in their communities. Telemedicine, peer review and rural-urban partnerships for rural SANEs may be helpful, although medical, legal and healthcare professionals need to also work to form cohesive SARTs in the rural community.

Acknowledgements

This research was supported by a Dissertation Award from the University of Virginia School of Nursing, Rural Health Care Research Center (NIH National Institute of Nursing Research #P20-NR009009).

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Appendix I: Participant questions and probes