Okay, I think we're going to go ahead and get started. Welcome, good morning or afternoon or whichever time of day it is, possibly midnight for you. My name is Karen Wickler and I am a member of the IFN Research Committee. And I wanted to welcome you to our Meet the Researchers 2022 presentation. We're looking forward today to hearing from five forensic nursing or forensic science and examination researchers today about their work. We're going to introduce them to you as we go. And each topic is going to be presented for about 15 minutes. And then there'll be some time for questions related to that topic or to the researcher's work or any questions you may have. There should be some time at the end as well for any additional questions. Before we get started, I do want to quickly thank Angie Ellis, who's on the call, who has helped me with getting this set up. Certainly want to thank all of our presenters and Sarah and Amy from the IFN for assisting us as well. So we will get started with our first presentation. Feel free to put questions in the chat or the Q&A, or as I said, when each presenter is done, we'll give a few minutes to just to go ahead and ask questions and have conversation and remember that nothing is off limits. And just a quick disclosure that there's no conflicts of interest for this presentation. Suzanne, if you want to go ahead and share your screen. And while you're doing that, I'll introduce you. Suzanne Polden is our first presenter today. She is a registered nurse who has worked as a sexual assault nurse examiner since 2015. She's worked in a variety of healthcare settings and she continues to work as a SANE in addition to her role as the clinical practice leader for student wellness services at Queens University. She completed her master's thesis in 2019 on the topic of how SANEs practice trauma-informed care. Really sorry, I'm actually having some issues. It's not letting me share for some reason. It's like saying my systems preferences aren't up to date. So I don't know, does the second presenter maybe want to go ahead and I can try to figure this out while, I know we're a little short on time. Oh, I'm sorry, Karen, I believe you're muted. Yeah, that would be fine unless Amy or Sarah, you have any other ideas, but we could do that. And then I could even advance the slides for you. So if you want to email that to me. Okay, that's good. Well, we'll introduce the next group then. So two presenters, the first is Dr. Stephanie Deutch who is a board certified in general pediatrics and child abuse pediatrics. And she currently serves as the medical director of the Nemours Care Program in Wilmington, Delaware. She completed residency at the Children's Hospital at Montefiore in the Bronx, New York and her fellowship at Children's Hospital of Philadelphia. She has a master's degree in physiology earned prior to medical school and is actively enrolled in a master's of clinical research program through the Medical University of South Carolina and is an associate professor of pediatrics at the Sidney Kimmel Medical College of Thomas Jefferson University. Dr. Deutch is clinical faculty for two advanced pediatric medicine fellowship training programs at Nemours including their academic pediatrics and pediatric hospital medicine programs. And she is co-presenting today with Shannon Lee Reese who has worked as a forensic nurse, sexual assault examiner since 2015. She has worked with Dr. Deutch as one of the forensic examiners at the Nemours A.I. DuPont Hospital for Children in Wilmington. And she works as part of the SART for the Salem and Cumberland County Prosecutor's Office and also works a full-time position with the Salem County Department of Health and Human Services as the mental health administrator and public health nurse. In her current role, she is working on implementing prevention and education programs in Salem County along with her coworkers within the division of mental health and addiction services. And she's working on her master's as a psychiatric mental health nurse hoping to bridge the gap in mental health care. All right, well, thank you so much, Karen. We're so thrilled to be here. I'm just going to attempt to share my screen here. Karen or Shannon, if you can just give me a thumbs up that you can see the full screen, excellent. Okay, so thanks for that lovely introduction. And again, Shannon and I are really excited to be presenting to this group. And it has been wonderful collaborating with Shannon and other forensic nurses throughout my several years here at Nemours. So we're going to be talking about sexual assault victimization among children and youth with developmental disabilities and responding with trauma-informed care. So just to let you guys know, the images that have been included in this presentation were accessed through Microsoft PowerPoint and they're stock images. And the Division of General Pediatric at Nemours does receive some remuneration for testimony provided by me in legal proceedings related to suspected abuse and neglect for select cases that are typically external to Delaware. So by way of background, all of you here on the call know that sexual assault victimization is really a traumatic experience for children and youth and that our response requires trauma-informed care approaches. So trauma-informed care approaches really prioritize the preferences and values of the survivor and their family, the medical and care decisions, and then strategies that really minimize any potential re-traumatization. And certainly this approach involves collaboration with our multidisciplinary team or MDT colleagues across the clinical, investigative, legal, social and victim services domains to really address the full spectrum of needs of the sexual assault survivor. Trauma-informed care approach is really about a culture of safety, of empowerment, of healing, that we should integrate trauma awareness into all of our policies and procedures across the medical setting to promote positive physical and emotional health outcomes among survivors and their families. And that without this commitment to a trauma-informed care delivery approach, there's the risk for re-traumatization or negative impacts on psychological outcomes specific to the survivor and their family. You all know also that sexual abuse affects everyone, but that there are certain subpopulations at greater risk. And that includes children and youth with one or more intellectual, emotional, visual, hearing, learning, developmental, behavioral, or physical disability. And that is a subset of the pediatric population that based on the medical literature and our clinical experience is at uniquely high risk for experiencing trauma, including trauma related to sexual abuse, compared to typically developing peers with 1.5 to even three times greater risk. This is important because this subpopulation of pediatric patients has a reliance on caregivers for personal care activities. For example, hygiene, intimate personal care. They may rely on caregiving adults for transportation, and they may have a lack of understanding of what constitutes or contributes to sexual abuse. The subpopulation may also have limited access to sexual education. And among the caregiving adults around them, there may be misperceptions about necessary psychoeducation related to body boundaries, sexual health, and relationships among children and youth with disabilities. Autism Spectrum Disorder, or ASD, is a specific developmental disorder that you all know is characterized by restricted interests and behaviors, frequently social and communication deficits, and very commonly co-occurring intellectual disability. And so this subgroup of children and youth with ASD in particular are at very high risk for traumatic sexual abuse victimization really related to social naivete, perhaps social inappropriateness, some degree of social isolation, and then their communication deficits, which represent a core feature of the disorder. Children with ASD may have difficulties expressing themselves after sexual abuse victimization, and that may then lead to barriers to a disclosure of sexual abuse victimization. And we know that independent of this risk, children and youth with ASD are at high risk for psychopathology, and that risk certainly heightens after an abuse experience. But regardless of the specific underlying developmental diagnosis, those children and youth with impaired communication abilities really have a universal issue then with a survivor's access to appropriate medical care, to mental health care, or to victim services. Within the victim services sector, there may be design features that may really fail to meet the needs of survivors with disabilities, and there may be programs that lack, for example, appropriate or tailored adaptations. There may be interview skill deficits among MDT members, that then impact or pose barriers to the disclosure, so how the questions are asked and what specific modifications may be made. And then among the MDT, there even may be a hesitancy to validate the experience of the survivor due to that survivor's disability or concerns about their credibility around the disclosure. So besides all of that, we know that there's also challenges to implementing and adapting trauma-informed care after sexual abuse victimization for children and youth with underlying disabilities. So we already talked about how trauma-informed care involves the identification and tailoring of services to the unique needs of the survivor, but really this means that a single best practice approach is elusive. There's a range of clinical presentations, including for those children and youth with disabilities who have varied vulnerabilities and needs, and there's widely disparate resources across communities, often with a poor recognition or understanding of the disability by the MDT and perhaps disparate uniform education or training. And there have been recommended adaptive techniques to consider when implementing trauma-informed care specifically for children and youth with underlying disabilities, and those include developmentally specific therapeutic medical play, like the use of games or books, toys, art, role-playing with real or pretend medical equipment that may aid children and youth in understanding medical procedures, anticipated treatments, or their illnesses. There may be other adaptations or modifications in the healthcare setting as well, like anticipating a prolonged examination in time or structuring your environment with reduced stimuli, creating a more sensory-friendly environment for those children and youth who may have AFT, for example. And then finally, the use of adaptive communication, assistive communication devices that may be preferential to the child or youth, depending on their underlying needs. So I'm really excited that we had the opportunity today to present a case of a youth with ASD who sought acute sexual assault care, but whose care was compromised because of multiple systems failures and gaps in communication regarding the youth's needs, inconsistency in knowledge among MDT members regarding necessary adaptations in trauma-informed care. And Shannon's gonna talk to you a little bit about the lessons learned and proposed solutions and approaches for MDT members to prevent unintended youth traumatization. And Shannon and I were very lucky to have our case report published in the January through March 2020 issue of the Journal of Forensic Nursing. And so I'll pass it over to Shannon. Okay, so we're gonna present the case on Eloise. Of course, all names were protected, so Eloise is just our case name for today. So Eloise presented to the emergency department 24 hours after the alleged sexual assault. She was accompanied by her maternal grandmother, who was identified as her legal guardian. She was also accompanied by a law enforcement officer who was not associated with the case. He was just bringing her to the hospital. She was triaged upon arrival. The protocol for sexual assault was followed. Forensic nurse and social workers were called regarding the concern for sexual assault. The social worker, forensic nurse, and the ED resident jointly obtained a history. We obtained them from the maternal grandmother and then from Eloise, both separately. Per Eloise's maternal grandmother, she left home to go trick-or-treating at approximately 1700, so 5 p.m., and returned home a couple hours later, disheveled, appeared very distressed, and was holding her costume in her hand. Eloise wouldn't give her grandmother many details, but she said that she was held at gunpoint by an unknown male and sexually assaulted. The maternal grandmother took Eloise the next day to see her therapist, where Eloise, again, disclosed the alleged sexual assault to her therapist, and law enforcement officers were contacted by the therapist. During the interview process, the maternal grandmother demonstrated a limited ability to convey the information needed regarding Eloise's sexual assault. She didn't provide much information on Eloise's medical history, and couldn't provide much history for the events preceding the ED visit. While we were there, Eloise appeared withdrawn, poor eye contact, and showed an inability to remain still during any type of forensic interview. When conversations were had with Eloise, again, she fidgeted with her clothes, she chewed on her sleeve, her head was down. She appeared overstimulated, anxious, and uncomfortable. She's exhibited significant difficulties with verbal communication. The FNEA medical team became concerned for any underlying or developmental mental health conditions. So we regrouped. During the interview too, we reorganized our interview approach due to the concerns of possible delays. Eloise had a very limited understanding on reproductive health or sex in general. She finally disclosed certain aspects of the alleged assault through utilization of detail-seeking strategies. Later, the forensic nurse called law enforcement officers, and then was informed that Eloise had already been interviewed by the law enforcement and Child Advocacy Center prior to being transported to the emergency room. And at that time, it was also disclosed that Eloise had a diagnosis and was on the autism spectrum and her preferred method of writing, of communication was writing, sorry. So one of the things we like, we saw with this, so caring for youth with underlying developmental disabilities who experienced sexual assault victimization is complex, and it warrants consideration and implementation of TIC practices, right? I feel trauma-informed care should be utilized in any sexual assault, but when you're dealing specifically with children with disabilities, there needs to be other considerations in place. So some of the system failures that we noted during this case were the lack of knowledge regarding communication preference, the underlying diagnosis and interviewing skills, need for enhanced multidisciplinary team education, and at the survivor level, unclear, unknown whether sexual knowledge or education impacted Eloise's ability to disclose. From this scenario, we learned that, you know, practices needed to change within the facility and global screening tool for sensory-emotional issues was developed and utilized within the ED. There was a warm handoff procedure and sign-outs created amongst the MDT. We implemented better engagement or improved engagement with the victim advocates and trauma-informed care training amongst the institutional providers. So our team went out and educated the providers, residents on trauma-informed care and disabilities. She was 15 years old. Great. So, you know, in this report, we presented a case of a youth with ASD who sought sexual assault care, but the care was really compromised by multiple systems failures, including gaps in communication regarding unique needs, and then inconsistent knowledge and strategies utilized by the MDT members that may have actually resulted in summary traumatization and really, you know, came to light that we needed to adapt and implement our trauma-informed care strategies at the institution appropriately. So we concluded that children with disabilities, such as ASD, are uniquely vulnerable to sexual assault victimization and to adverse psychological reactions from their trauma, traumatic experiences, and it's critical to really approach care with a trauma-informed lens, as Shannon mentioned, with every patient, but with special focus in this population, and that caring for sexual abuse survivors with developmental disabilities really necessitates an understanding of their underlying needs and capabilities for the most effective care delivery and then prevention of that unintentional re-traumatization. I'd also like to thank you, and here's our contact information, and we're happy to take any questions now. Feel free to put your questions in the chat or the Q&A section or share them. It looks like we got one question about age from Gina, which Shannon mentioned that she's 50. One question that I did have is, are there a decent amount of continuing education options that are provided for forensic interviewers or other people like that? I'm curious if you ladies know that. Related to these topics. For this population, I would say no, there's not. I mean, they like, for law enforcement officers who are going to be doing it, or ideally this patient should have been interviewed one time at the Child Advocacy Center where it could have been done once. But instead, because of the lack of communication amongst the MDT, she was interviewed by police, then Child Advocacy Center, then us, and nothing was shared within the team, right? So that child relived her trauma three times trying to do it and her preferred method of communication was writing. So we didn't know that either. But at the Child Advocacy Center, they have that ability to use the dolls and stuff. And if we would have known that and we had to interview her, we would have been able to use those tactics too. And like I said in the presentation, we did use different strategies to get information out of her and help guide our exam, but there aren't many educational opportunities towards this specific population for forensic nursing, no. Yeah, and I would just add to that, that at least resources like National Children's Alliance or our particular center here in Wilmington follows corner house protocol for their approach for forensic interviewing. We have, since this case occurred and the child was treated in our institution, we've made some adaptations and modifications for our practice as we described in the case report. But we, even when Shannon and I were writing this up as a case report, we found relatively little in the published literature that specifically focuses on education for skilled forensic interviewers. And that's aside from any approach for medical or mental health professionals that might be interfacing with this child acutely. And I think what we, you know, while we wanted to, while the community that was serving this child acutely after the sexual assault wanted to respond, you know, expeditiously and for the medical needs and everything was addressed, I think it also sort of came to light that we had to take a step back and really have the most information possible about the child to ensure that we're approaching the case in the best way for the best. Great, thank you both so much. I'm gonna hold off on any other questions right now. I don't see any, but we're gonna have another presentation related trauma-informed care so that might stimulate some questions here. So I'm gonna go ahead and share my screen for Suzanne. Um, can you all see this? Yes. Okay, great. So Suzanne, then if you just wanna tell me when to advance, I can happily do that for you. Sure, it's still on, it's not on the presentation yet. I'm not sure if you want it to be or not. Yes, I do. All right, perfect, that looks great. Yeah, so apologies again for the technical difficulties and thank you very much for the opportunity to present today. And thank you for the introduction, but just as a little refresher, my name is Suzanne Polden, I'm a registered nurse. I think I'm the only Canadian here maybe of the presenters. I work in Kingston, Ontario and I'm a casual sexual assault nurse examiner. I have been since 2015 and this research was the basis of my thesis for my master's degree. So you can go to the next slide. I could probably skip over this one too. This is just the disclosure and that I have no conflicts of interest. And again, just an overview, we won't waste our time on that. I won't spend too much time on this slide because I think we're all familiar with most of these terms. And as well, the previous presentation did talk a little bit about trauma-informed care, which is great. But just to give you a bit of local context. So in the province where I work in Ontario, we have a network of 37 sexual assault, domestic violence treatment centers. They're scattered mostly in the South part of the province, but you can see also there's a few up in the North. And I work at the Kingston location. Every center is a little bit different in terms of staffing. My center in particular is all casual nurses, but I know in some of the larger centers, it's a full-time staff because obviously the demand would be greater. And then just speaking a little bit about trauma-informed care, the previous presenters did a great job of overviewing it, but just for my purposes, I really looked at the research of a group of researchers called Fallow and Harris, as well as an organization called SAMHSA. And I use their frameworks as sort of my framework for trauma-informed care for my research. So the overarching principles of trauma-informed care that underpin my research were safety, trust, choice, collaboration, strength and scale building and cultural competence. And you'll see how that ties into the rest of my research. I did just see one quick question, what's a casual nurse? It just means someone who doesn't work in a full-time role. For example, I sign up for on-call shifts when I can between my other roles. So I have another full-time job somewhere else and I do the sexual assault nurse examiner role on sort of a once in a while basis. You can go to the next slide. So like any research, I started with a literature view and just as a little bit of information as well, I didn't really know what I wanted to research when I started my master's, but I knew I had an interest in this population and this topic area. And in doing a literature view, I sort of learned about trauma-informed care and thought it might be an interesting area to look into. So my keywords were primarily trauma-informed and nurses and it yielded a small amount of research. And most of the literature that I reviewed was either sort of theoretical, meaning it was an overview of what trauma-informed care was or it was sort of low rigor, meaning it was a small sample size or it was qualitative. So not a lot of research. It was interesting though, that there was a variety of different settings we talked about in the research. For example, there was a lot of research that was done in the context of trauma-informed care that we talked about in the research. For example, psychiatry, pediatrics and adult medical trauma were all ones that stood out. And another gap in the research I saw was the very few Canadian research findings, which was another gap that I could fill. So ultimately my study's purpose was to explore sexual assault nurse examiners' experiences and perceptions of using a trauma-informed approach in the care of their patients. We can go to the next slide. So for my methodology and methods, so I did use a qualitative interpretive description as my methodology. This is a methodology suggested to me by my supervisor, Lenora Doon. She had used it in her previous research and it did seem to fit well. It's a methodology that's aligned with applied nursing research. And the purpose is to sort of make sense of the findings through a conceptualization. So you'll see my conceptualization in a little bit, as well as focusing on linking the results with what's already known about the topic. My sample were sexual assault nurse examiners in Ontario. I did recruit purposefully. So I initially recruited at 10 random centers through email recruitment. So sending out the recruitment materials and then individuals could contact me. I did obtain ethics approval through my own university as well as other centers as necessary. And at the end, I had eight participants who completed an interview. Go to the next slide. So my data collection method was semi-structured interviews. So I did have a interview guide, which I disseminated to the participants prior to their interview. And it was based on both the research, sorry, the literature of new findings, as well as the principles of trauma-informed care. And they were all completed online using Zoom meetings. So they were audio and video recorded. For data analysis, I did a thematic content analysis based on the work of Miles Huberman and Saldana. So first I did first cycle coding, which I coded every single line of the transcripts and assigned labels or codes. And then in my second cycle, I grouped those into themes, which led to the development of the themes and sub-themes. And you can go to the next slide. So these are just a couple of examples of some of the interview questions. So you can see the first one, tell me about a time where you were able to build a trusting relationship with a client that was getting at one of the principles of trauma-informed care. And the third one, do you feel safe working as a SANE? So I also was trying to get at some of the themes that were coming up in my literature review. For example, one such theme was the idea of vicarious trauma in this work. So I did want to understand the participants' experiences with these topics as well. And the next slide. I just briefly wanted to touch on trustworthiness. So this is the framework from Lincoln and Guba. I won't go over this slide in detail because I know we're a little short on time, but you can see the various ways that I seek to improve trustworthiness in my research study. And the next slide. So in the end, I came up with six main themes and 16 sub-themes, which you'll see the main themes in the next slide. And then I also came up with a conceptualization, which I'll show shortly as well. Go to the next slide. So, as I mentioned, these were the main themes. I'm not gonna dwell too much on this because you'll also see them in my conceptualization slide, but these were further broken up into many sub-themes. I actually, I did have this, my research published in the Journal of Forensic Nursing. It was volume 17, number four. So if you're interested in seeing more, then you can find that online, but I will just show you the conceptualization on the next slide. So in mulling over my themes, I ended up coming up with the visual conceptualization of climbing a mountain. So the interaction with the victim or survivor was kind of like climbing a mountain as described by the nurses who I interviewed. So at the very bottom is the importance of understanding the patient's experience. So that was really foundational to being able to provide trauma-informed care to these nurses. And then at the very bottom is the importance of being able to provide trauma-informed care to these nurses. So that's understanding trauma itself, as well as being able to integrate cultural competence into the role. On the left side, you'll see the ascent, which is personalized connection, developing safe nurse-patient relationships. So this is obviously foundational as well to making that person feel safe. At the top is choice, the framework of how we do things. Choice really came out loud and clear as one of the most important things in these types of interactions. And you'll see that in my findings as well, that it was definitely highlighted. And then on the descent on the right side is rebuilding strength and skills to support healing and post-traumatic growth. So the participants described that this didn't always happen in the interaction, the initial interaction, but often this was in follow-up interactions or it was sort of touched on, but as a way to help the person move through or move on from this event. And then you also see the little icons in the mountains. So the tent and the snowflake and the tiger and the food. So these were sort of meant to be things that were more affected by the nurse themselves. So there was the facilitators to trauma-informed practice, which were described as the fact that it was a wonderful way to practice and they knew their patients benefited from it. And then there was the challenges. So challenges described were things like vicarious trauma, as I mentioned earlier. You can go to the next slide. So ultimately my findings were that nurses really valued trauma-informed care. They saw it as a really great way to practice. They saw it to benefit their patients and themselves. As I mentioned, choice was really a paramount priority in establishing a good interaction with the patients. There was a big need that was highlighted for education and continuing competence in this role. And that was also highlighted in the other research that I looked at, that there needs to be more done to prepare people to have these types of interactions. And then finally, the realities of vicarious trauma, that's just so inherent to this work. So it's important that in developing training that that's considered. And the next slide. So just to go over a few strengths and limitations of my study. So one strength is that it adjusts a gap in the population. As I mentioned, there previously hadn't been any published literature about this topic in the same population. The trustworthiness supports the findings. So I really tried my hardest as a research student to establish good trustworthiness. And then also the feasibility of the methods. So the Zoom interviews worked fantastically. The technology worked really well. I actually used a transcription software as well, which really sped up my data analysis process. I didn't have to type everything up. The computer did a lot of the work for me. And then some of the limitations. Obviously, it was a small sample size and it lacked diversity. There's the risk of social desirability bias as with most qualitative research. And then my experience as a SANE in this role may also present some bias. So that's all I have. I kind of whizzed right through that, but there's lots of time for questions if anyone has any questions. Don't see any yet. This was really great. And I think that it was great for everybody who's in attendance and who watched this later to see two different ways that you all have approached looking at trauma-informed care in our populations. And when we look at things from a research committee perspective, getting more people engaged. And so one approach is certainly this more conceptualization or quality or research project, but case studies are so important as well and can tell us so much information and really share those practice nuances. And so I think it's really great to see how both of these methodologies have been utilized to share your information. Don't see any questions. Does anybody have any questions yet? You reached out. Oh, go ahead. Suzanne, you reached out to your, what's the word? Your subjects of research via email and they were willing to do it. Yeah, so basically I sent the recruitment materials to whoever was deemed to be the most responsible person at the program in that city. So some programs have a manager, some programs have a nurse lead. So whoever's name was basically on the website. I sent that to them and then they would disseminate it to their whole team. So that's how I got it. With the research, one of the hardest things I think is to actually be able to get subjects in this matter. Yeah, I was hoping for more participants, but that's what I got, so. So Suzanne, my question is along the same lines. Do you feel like using the inceptive description kind of limited your participation? Do you feel like if maybe you used another tool or model that that might have gained more participation? Do you feel like that was a deterrent? That's a good question. I mean, there's obviously lots of different types of qualitative research. This was a really hard group to target. I think partly as I kind of talked to at the beginning, a lot of programs here in Ontario, nurses work on a casual basis. So I honestly think that was more of a barrier because people just don't have the time. Like, and I did hear that from some participants that they were really interested in participating, but they were very, very short on time. So yeah, there's definitely some research methodologies that are a bit more engaging. Hard to say in retrospect, but it would be interesting to see someone do something similar with a different methodology for sure. All right, I'm going to turn it over to Angie, who's going to introduce our next speaker, and we're going to shift gears a little bit. All right, good afternoon, morning. So Dr. Stacey Drake is our next presenter, and Dr. Drake is an associate faculty member at Texas A&M University College of Nursing. Her program of research focuses on impacting populations through the reduction of preventable causes of death. Her past work as an emergency medical service provider, firefighter, trauma nurse, and death investigator has challenged her in focusing on ways to reduce such deaths. As an active forensic nurse researcher, she serves as a member of the elder fatality review team, and as an expert forensic nurse consultant for the Harris County Institute of Forensic Science. Her employment interest focuses on establishing and working within an interdisciplinary team to address gaps within the delivery of healthcare systems via means of understanding the social detriments of health anchored among populations who die sudden and unexpected deaths for purposes of prevention. And her research that she's presenting today looks at such preventive measures. Hi. Dr. Drake. Thank you, Angie, and thank you for inviting me to present the research that we did surrounding stranded motorists. I'm going to share my screen quickly. And so it's shifting gears to talk about mortality data. Oh, I probably have to do the preview here. Sorry. All right. Very good. And to start, I have no disclosures to disclose, no financial or otherwise. And so why I'm here, it was sort of captured with Angie nicely. My background in death investigation brought me to full circle in attempting to understand more about what was going on with these deaths for purposes of upstream prevention so we didn't have to see them in the death investigation world. And the topic of stranded motorists actually occurred because one day in our morning meeting, there was a case that a person's vehicle had stalled and it became a basically disabled vehicle. The driver who was a dad got out to push the vehicle while the mom and the small child remained inside a vehicle. And then the process of him basically pushing that vehicle off the roadway, he was struck by another vehicle who failed to stop and render aid and then subsequently died. And the room at that point in hearing that story were just, it was traumatic to hear the fact that this was witnessed by the surviving mom or wife and the child. So the question, I started having questions about how often does this occur and how could this be prevented, et cetera. And as we dove into the topic, we realized that defining and characterizing the problem was much more difficult than what it sounds because most people recognize the stranded motorist as either a presenting auto pedestrian that arrives to your hospital or a motor vehicle collision patient that arrives to your hospital, but not necessarily the fact that the circumstances that got them to that point was the fact that they were a stranded motorist. And when I'm talking about a stranded motorist, I'm specifically referring to the occupant of a vehicle, whether inside or outside of a vehicle that stopped on the side of, stopped or on the side of a road versus a disabled vehicle or stalled vehicle. Those are specific for the vehicle. The stranded motorist is, again, the occupants within those vehicles, and that's who we are concerned about for their safety. So that's essentially how that happened. So after defining the problem and really trying to identify it, we also identified that you can't find that variable very easily within any databases, meaning death investigation databases or even trauma databases, because, again, it's captured under auto, pedestrian, or motor vehicle. And what are the laws surrounding the safety of those occupants who become essentially stranded? Most of us have heard over the move-over law. There are signs in a lot of states of move over or slow down, but those are typically all for people that have blue, red, white, or construction workers, blue, red, white lights, right? So in other words, law enforcement, EMS, tow truck drivers, and or construction workers to move over or slow down. However, it doesn't capture civilians. So in most states, if a civilian, a person that is not working essentially on a roadway would become struck, so they're either injured or killed, there's really no consequence. There's very little consequences that can occur for that driver and or to try to assist families. If you fail to respond and render aid, obviously that becomes a felony. That's a whole nother story. But for the stranded motorists, by and large, there's no law to protect us as we drive. So, the tracking of it became quite challenging and trying to identify the problem. So, what we did initially is we could only look at the deaths because we reviewed every single death report to try to identify which was a stranded motorist. And then linking law enforcement reports to the death investigation report or even hospital reports was yet another challenge because there's very few key indicators of being able to link that person. And you typically don't want to go on name or age or date of birth because of the challenges with misrepresentation or not linking correctly. And oftentimes the addresses for even law enforcement were different than what EMS had or the hospitals had. So, that became a challenge as well. So, we only start with deaths. And then after we did that, we implemented a tracking mechanism for stranded motorists within this local jurisdiction and then also within the two level one trauma centers in order to identify the problem. And after one year of doing that there were 20 deaths. So, we do know that the issue of the move over law surrounding law enforcement and then also construction workers and now tow truck drivers is a problem. And then 24 deaths within less than 10 years for law enforcement officers and then 26 firefighters within three years. So, those would all be essentially captured as stranded motorists, in addition to being on the at work type of deaths. We weren't able to identify anything within any trauma basis. So, if those of you who work in a trauma center know that the American College of Surgeons requires injury capturing, and they also have a requirement for injury prevention. However, with this specific population, it was very difficult to drill down into sort of the circumstances in which they became either a motor vehicle crash or an auto pedestrian. So, we put that into place. And then within a short time again a year, a year later we identified 35 patients quickly within these two trauma level one trauma centers, and where I'm located there are over there are close to 50 hospitals within the medical location and there's probably more. I believe there are 14 trauma centers so it's it's a large number of facilities so we know that the numbers that we captured were just really the tip of the iceberg. The other thing that we did. And I'm going to ask all of you this question because this is what we essentially we're asking people. If you come stranded on a highway, what would you do. If you want to either shout out or put that in the chat box that would be great. So get out, call your friends stay in a vehicle, get out and try to fix the problem. There's a couple people chatting I'm not gonna. If somebody could tell me what people are responding that would be great. I don't want to minimize my screen. So, stay in the vehicle stay in the vehicle stay in the vehicle. A few people are saying get out and try to fix the problem. Okay. I mean you are asking what would you do. Yeah, yeah. It's hard to, to know right what is the best answer. So, here's yet again another one. If you drove upon a stranded motor and I'll get to the answer in a minute. But if you drove upon a stranded motorist. What would your response be, then slow down, move over a lane, slow down and move over a lane, I don't know, continue in your lane of traffic or call 911. Most people are saying slow down and move over a lane and a few people are adding the call 911 to that piece so both of those things. Okay. All right. Very good. So, what we identified in and look in aggregating all the data is that the majority of people who exited their vehicle. And remember these were only deaths were outside of their vehicle so they truly were the auto pedestrian. And the vast majority of them became stranded or had a disabled vehicle because of mechanical problems. And as a result of that we created a couple public service announcements I'm not going to play them here for you. I do have some links that we can put in the chat that you can go look at some of the information that has subsequently been done. But the bottom line is, you should stay. You're right. The ones, stay inside the vehicle buckled up. Pull off the road if possible, even if it's a flat tire and you're driving on a flat tire, trying to, you know, save your rim and that cost, it's better to get off that road, no matter what further away from moving traffic than anything. But if you must stay in your vehicle and remain buckled up, turn on your hazard lights and resist the temptation to render aid for stranded motors. We've seen this repeatedly where people would stop and try to render aid themselves, and then they subsequently became injured and or died. And we typically refer to those as secondary incidents or secondary accidents that actually becomes worse than the initial incident of becoming a stranded motorist. And don't necessarily, you don't necessarily have to call 911, call for roadside assistance. Most, if you flip your driver's license, there's a phone number on the back that will direct you to a state law enforcement agency, you'll give your location, and they will then direct you to that local area, who will then send a response accordingly, versus tying So it's a non-emergency call, essentially, to make people aware of this occurring. And I can tell you I've done this three times at least that I readily know, and the response was always very positive and within less than a minute. The other big preventive measure that you can do is maintain your vehicle. So the oil changes, the tire rotations, those two things in and of themselves would make a huge difference in terms of vehicles becoming disabled and then stalling, creating a stranded motorist. This was in another video we created. This was actually, this is a police officer who himself became a stranded motorist. He was rendering aid to somebody that was a stranded motorist, and as he was putting out markers, he was struck and injured and essentially forced to retire. So if you're coming across a, encountering a stranded motorist, pay attention, decrease your distraction, slow down and move over. If you observe traffic, and I have a habit of doing that, but 18-wheel truck drivers are consistently very, very good about slowing down and moving over every time they see any stranded motorist, whether it's an 18-wheeler or other vehicle on the road. It's just because they're, in their mind and in their training, this is the right thing to do because they know the consequences, but because the move over law is so haphazard and only applies to a certain number of the population, as civilians out on the roadway, we become confused on what we can and cannot follow. The other issue is obviously enforcement, enforcement regarding the law. There's not a lot of law enforcement, enough of them to enforce actually making sure people do move over and slow down. So some of the things that we have been working on is transportation codes to capture all stranded motorists, not just those with a blue light, a red light, or a white light, or the construction workers, but all motorists, and then slowing down. This just talks about the background. Obviously, ensuring that there's a way to actually capture the information within death investigation databases, as well as traffic crashes and hospital reports to better identify the problem. And with that, I have my contact information here, and I'll share with you those videos, but I'll take any questions right now if there are any. If not, that's great. I think I went over, so sorry. It was really great information. I thought it was really interesting. Yeah, really good. I think you're good on time. One question I have, Stacey, you know, in reading that in your ER background, and I also have an ER background, as well as flight nursing and my forensic nursing, but do you see in doing this research where there would be a opportunity for more collaboration with law enforcement and ER to look at some of these things and the injuries versus what's going on, you know, in the field, as it were? Actually, Angie, I'm so glad you brought that up. I think that that would be great because one of the questions that I, you know, my gut instinct and my thought was about some of these stranded motorists and auto pedestrians in general, is that there may be a component of human trafficking going on. Because most people recognize, well, maybe not most, but I at least recognize that it's very easy to, quote unquote, dispose of somebody in a motor vehicle or an auto pedestrian incident, and it be deemed an accident and not worked up as a homicide versus, you know, just eliminating somebody knowingly through blunt force trauma or other, right? But the fact that we have so little information about where did some of these auto pedestrians come from, how did they get here and why, where were they coming from and where are they going? Why are they crossing a, you know, eight lane highway? It should raise questions about the circumstances behind that and often that doesn't occur. But I've often thought of looking at what is the law enforcement data regarding human trafficking in that area, incidents of, you know, those kinds of sites, prostitution, et cetera, or other. And if there is some sort of relationship with these, some of these auto pedestrians being trafficked or getting rid of, because we see a high number of immigrants, homelessness, people that are auto pedestrians. And I think that's pretty common across the country. So I'm glad that you brought that up. I definitely think that it's a research opportunity worth exploring to any of you. It, you know, it's a hypothesis at this point. You know, I have nothing to validate it, but it's definitely crossed my mind as I've read and reviewed these cases. All right. Great. Thank you, Stacey. So next we're going to move to Dr. Tilley. So Dr. Donna Scott Tilley has been an educator for over 20 years. Throughout her career, she has focused her practice and research on the problem of gender-based violence. The content she is presenting today comes from a three-year project funded by the U.S. Department of Health and Human Services Office of Violence Against Women. The project joined 10 universities in Texas to create new or strengthen existing university policies related to campus sexual assault, to enhance bystander intervention, and to create sexual assault response teams at each university. And Dr. Tilley looked at the risk, the increased risk, especially for our LGBTQ plus community. So without further ado, Dr. Tilley. Thank you so much. Angie, I wonder if you wouldn't mind watching the chat and let me know if there's something I need to respond to on the chat. Not a problem. I can do that. So everybody else has been so great to have this in writing, but I'll tell you, this work is described in a lot more detail in the article in JFN 2020, 16 and 2, pages 63 to 72. The title of the article is Correlates of Increased Risk of Sexual Assault and Sexual Harassment Among LGBTQ Plus University Students. So I'm just going to give a kind of a quick summary. This was really one part of a larger study that, you know, as Angie described, we had a lot of things that we wanted to look at. But we had about 6,973 of these completed ARC-3 surveys. I love this instrument. If anybody is interested in doing research on sexual assault in college students, this instrument is great. It was designed by researchers and administrators, and it's got a little bit of a teaching component piece to it, which makes me like it. And it also gets at both victimization and perpetration. So there's a lot to learn about the ARC-3. It's a good instrument, though. So I hope that you'd consider it. We know that sexual assault is a huge public health problem in general, but in college students, it really does cause problems with dropout. Kids tend to go home and not come back, and it's an expensive problem. I think the most recent estimation was $8.3 billion per year is what it costs for us to take care of victims of sexual assault. Once we count in the medical health comorbidities and the mental health comorbidities, it's just really a devastating problem. We know that these kids can have symptoms of post-traumatic stress disorder, substance misuse, all of these long-term problems. But again, I think you all probably know the literature on this, and I don't want to kind of overspend my time talking about consequences. But really, the mental health consequences tend to be a little bit more severe in victims of sexual assault than with other forms of trauma. That's really the takeaway that I would want you to have. Here's what we know about prevalence. I thought it was a more profound difference in the LGBTQ community, but we know that about one in four students during university is going to be a victim of sexual assault or sexual violence. But look at this, 44% of lesbians and 61% of bisexual females are victims. 26% of gay men and 37% bisexual men are victims of sexual assault. And then the most vulnerable group of all, as you all probably knew, was 47% of transgender people are victims of sexual assault and sexual violence. One of the other things that we know from the literature is that the violence tends to be more severe during a sexual assault with members of the LGBTQ community. There's a term called corrective rape that kind of describes this idea of the increased violence that goes along with sexual assault in this population. So it's a serious problem. And really, we were trying to get at what were the correlates to sexual assault and other forms of sexual misconduct for these students. So I just want to describe a couple of terms that are going to come up in the results. This idea of risky sexual behavior is clearly defined in that instrument, the ARC-3, and they describe it as having many sexual partners, telling stories about sexual experiences, getting someone drunk or high to have sex with them, lying to someone in order to have sex with them, forcing someone to have sex, using physical force to resolve conflict with dates, and insulting or swearing at dates. And one of the things that we know is that negative peer norms or agreement with that statement up there, negative peer norms have been cited as possible factors in sexual assault. And that was a really lovely study by Brown and colleagues in 2014. So if you have friends who believe that those things up there in that statement are okay, you are at higher risk for sexual assault. All right, and then peer norms, again, that's the extent to which the participants' friends approve of these things. Okay, so consent. I love how the ARC-3 treats consent because it really does help the person taking the instrument kind of reframe what consent means. But on the ARC-3, the person taking the survey agrees or disagrees to some extent with these statements that consent must be given at each step during a sexual encounter. If a person initiates sex, but during fourth place says they no longer want to, the person has not given consent. If a person doesn't physically resist sex, they have given consent. That one was important for the LGBTQ community. Consent for sex one time is consent for future sex. If both you and your sexual partner are drunk, you don't have to worry about consent. Mixed signals can sometimes mean consent. And if someone invites you to their place, they're giving consent for sex. That is how the ARC-3 measures understanding of consent. Okay. And so here's what we found with our LGBTQ participants. They had significantly higher mean scores for those negative peer norms. That's what sets them up for increased risk. Peer responses, and they had a consistently higher score in that idea of if someone doesn't physically resist sex, they've given consent. They seem to understand that better than their non-LGBTQ counterparts. They also seem to be a lot more willing to or have already engaged in bystander intervention. Okay, so then they're non-LGBTQ counterparts. I'm sorry, I'm a little distracted trying to find my notes. Conversely, those students had significantly lower mean scores for student well-being, perceptions of campus climate regarding sexual misconduct scores, and campus safety scores than their heterosexual students. That indicated to us that LGBTQ students experienced worse sense of general well-being, a lower perception that the campus climate in general around sexual misconduct was safe, and they in general felt a lower sense of safety than their heterosexual counterparts. Okay, and on the one consent item, that was if a person doesn't physically resist sex, they've given consent. The LGBTQ students really significantly differently disagreed with that statement as compared with heterosexual students. There were not any other differences on the other consent items between the groups of students. Okay, so we know that LGBTQ students were more likely than their heterosexual peers to have friends who approved of risky sexual behaviors. They understood that absence of physical resistance. They were more likely to engage in bystander intervention. And I like this, they were more likely to expect a supportive response from their peers. This to me was really important. This idea of victim blaming that can happen when somebody tells their peers they were sexually assaulted, and the peers may come back with something like, well, I told you not to go to that club, it's dangerous, or I told you you've been drinking too much, those kinds of things. LGBTQ students really were able to expect a more supportive response from their peers, which I thought was very important. We controlled for episodic drinking on these and still found that the peer norm scores were the same. The single highest predictor of sexual assault for any college student is binge drinking. And to me, that's the most important message, period. There's no mystery that binge drinking is a real risk factor for sexual assault. But even when we took that out, we still found that this friends who approve of risky sexual behavior was significantly more for the LGBTQ students. So we need to pay attention to that piece. I don't know what the intervention is there. And we don't really even know. We know it's a correlation. We don't have a causal statement related to that yet. So that is an important piece of research for me, I think, to learn what that relationship is. So the thing that I would point out on this slide is, I mean, I feel like I've said it five or six times. We do know that the more a student has peers who agrees with those risky sexual behaviors, the more likely they are to experience victimization. But there was no relationship to perpetration. And I think that's interesting, too. I really would like to know why that is. And that relationship occurred regardless of where they are in their studies, whether they're a first year student or a fourth year student. That didn't seem to matter. That relationship was still there. These findings that they feel a little bit less safe and they feel an overall sense of well-being at a rate that's lower than their heterosexual peers paints a sad story for me, for the LGBTQ student who's in college. We could be doing a lot more to help them feel safe and to help them understand that we will do something when they're sexually assaulted, if indeed we will. OK, there were no differences between LGBTQ students and heterosexual students in terms of perpetrating any sexual misconduct. I think that is a very, very important finding for us. And there was no difference in stalking victimization. OK, and they seem to understand consent about the same, except for the one thing about the physical resistance. And so in addition to not feeling safe, we do know that regardless of that heavy episodic drinking, which is the number one predictor. But even when we take that out, LGBTQ students were more likely to experience sexual harassment by faculty and staff, sexual harassment by students, dating violence and sexual violence. So college is a scary place for these kids. And there's a lot we could be doing to make it not such a scary and dangerous place. Again, no difference between the two groups and perpetration and stalking victimization. So, you know, the bottom line is that LGBTQ students are more vulnerable to campus sexual assault, sexual violence for a number of reasons. They probably need a little more encouragement to trust administration to take care of them. But also, I would say we need to do a better job as administrators of actually taking care of them. For me, that underscores the value of ally programs. I love ally programs. I think they're important and that all universities should have them. And I'm hoping that there's some way that this group can teach us a little bit more about how to understand consent and bystander intervention. I would really like to get at why did they feel a little bit more confident in their ability to to do bystander intervention. And so I would be happy to take some questions now if anybody has any questions. I'm going to go ahead and close this so I can look at you. All right. So no questions in the chat so far and I don't see anything in the Q&A. As a mother who has sent three out of her four children to college, all girls, I will say this is a big concern. I did sit through one college freshman parent introduction where it was a retired police officer talking about the safety and sexual assault on campus. And he was portraying that we as parents need to make sure our children, our daughters are responsible and stay in groups. And as a forensic nurse, it was very hard for me to sit there, my daughter sitting next to me going, please don't say anything, please don't say anything. And I had to say we need to teach our children about consent and everything else because he put it on the students that if don't leave your friends alone, like your responsibility to watch them. So I definitely feel there's more education and I appreciate your research. I do think, did he say anything about binge drinking? It was just drinking. No binge drinking or anything like that. It was just being under the influence of alcohol. I think the binge drinking piece is important because that does make somebody more likely to leave their group or more likely to leave their friends behind. It's linked to perpetration and victimization because all of what we understand about consent is gone when intoxication happens. Well, and it affects our inhibitions as well. I mean, it has its effects on the brain and we don't think as well as we could. Not to mention a lot of the students, the college age students, their frontal lobes aren't fully developed yet to begin with. And so we add drinking on top of that. Then I think that is a formula for disaster. Dr. Tilley, I am interested. You had quite a bit of participation in this. I know you had 10 different universities that you used, but like almost 7,000 participants. That is amazing. And how did you do it? Well, what's the secret? Do you know what? It's funny that you ask that because we had two schools that had very, very low participation. And we had to take them out of our analysis because their response rates were so low. The schools that did the best had some kind of reward associated with taking it. So at the end of the survey period, you were eligible for one school did a parking spot at the front of the parking garage. So they offered some incentives for taking the survey. But we had a couple of huge schools. I mean, they were probably for very, very large schools. And so that really helped the response rates. But I'm telling you, at the private faith based universities, it was almost impossible to get students to fill this out. It's almost and it was very difficult to get administrators to even agree to give the instrument because it's very pointed language. It doesn't talk about inappropriate contact. It talks about penises and vaginas. And it's very pointed language that those faith based administrators worried about. They worried that their students wouldn't would be offended by those words. And that to me was the scariest part, that we're scared to talk with college students about vaginas. I mean, or or the fact that they I had a case where they were protecting the alleged perpetrator who was on a baseball team. And the victim didn't get services. They sent her to within the school systems team. I don't know what they call them. But then by the time she she was started recalling the events of the incident, it was too late for any prophylaxis treatment, for any medications or anything or evidence collection. And she was drugged with a report of multiple perpetrators brought to a hotel room from a party and remembered like points of the interactions, but couldn't recall things. Right. And they rushed it under a rug, unfortunately. Yeah. So we do have something in the chat. Did you see that, Dr. I did. And Gina, I am so grateful that you asked this question. Her question is college drinking is definitely an issue, but I wonder how to provide binge drinking risks without, again, making the victim at fault. And I completely appreciate that question. And I I don't think I emphasize this enough when I said it, that binge drinking was associated with higher perpetration as well as victimization. And so that's why I feel OK talking about the risks of binge drinking. But Gina, I'll tell you this. My daughter has gotten a whole big lecture about no binge drinking. You know, just if you can drink, just do not get that blind, stupid drunk. So I think we we still have to to talk to him about how to be safe. And I don't I don't want them to be at fault. But if we can give them a little bit of leverage to be safe, I think we should. But I agree with you. I would rather we could just say to people who want to perpetrate. You don't get to do that. All right. So we have about 10 minutes left and I just want to open it up. If there are any questions for any of our presenters, please feel free to put it in the chat and I'll give you just a minute to do that. And then we're going to wrap up. I've got just a few questions to ask each of the presenters, not necessarily about their topic, but just about research and how they got involved. So I give just a minute to see if we have anything in the chat. Got a thank you from Gina. And I don't see anything popping up. So I would like to start with, let's see, is Suzanne still on or did she pop off? I don't see her on. So maybe she had to go. So then Shannon, Shannon Lee, let's start with you. And then the rest of you can formulate. So one of the questions we have is how did you get started in research? Because a lot of us on here are part of the research committee and we're thinking about doing research. So, and especially Shannon Lee, with you being a nurse, what got you started in the research field and how did you get started with your research? So I was pushed by Dr. Deutsch to do research. I am not really into the research field. I am into making, correcting systems that need to be corrected for our patients and client and patient care. I am a true believer on in trauma informed care and that it needs to be utilized in every aspect. So when this subject came about and the incident happened, we, you know, touch base. We reorganized everything, made the recommendations that we need to be made, made an education system to provide to the residents and everything. And then Dr. Deutsch was like, let's do more research and publish it. So that's what we did. It was really all Dr. Deutsch who pushed me to do it. Dr. Deutsch, can you just speak to how did you get started in research? What advice do you have for those of us that may be thinking about doing some research? Sure. Yeah. So I'm very interested in data and making sure that the decisions we make at the clinical level are informed by good evidence and informed by the data. So I'm always trying to figure out how to make what we do better and informed by hard science. And I think what Shannon just touched on is, you know, how does research start? It's by an observation. You see a trend, you see an issue, you see a clinical gap. And that's what really sparks your ideas and then your hypothesis and kind of how to make it happen. So I work a lot with our forensic nursing team here at the institution and I'm trying to always figure out ways to collaborate based on what, you know, their frontline experiences may be with the children and teens that we're all serving and try to figure out how we can improve the systems of care. So we're always trying to collaborate on projects and figure out how to push each other to professionally grow. So I'm obviously very grateful for the collaboration with Shannon. And, you know, there we took an actual clinical circumstance that she's describing. It had all sorts of ricochet effects with our MDT partners, with institutional practices. So I think just try to look at the experiences around you and what can what can you change or what can you take away from those experiences to kind of study further. Great, thank you. Dr. Dre. Yes. The same question, I'm assuming. How did I get into research? Oh, I can't hear you. Yeah. What what advice would you have for those of us who are who are thinking about wanting to how did you get started and what should we how how can we do that? Well, if you're interested, I think that's great. Obviously, we need more nurse researchers, nurse scientists, whether it's in generating new knowledge or improving processes, procedures, etc. So I highly, highly, highly encourage that for nurses in general. For me, it was all about, you know, attempting to identify how to prevent these premature and preventable deaths, really how to better understand and go further upstream to prevent. Although I've done a lot of system improvement type of work within death investigation, so it sort of overlaps, but I just want to encourage everybody that has an interest, even an incline to to involve yourself with fellow collaborators in your institution or research or improvement processes for for nursing specifically. Dr. Tilley. Okay. So, as we were kind of waiting for the webinar to start Sarah Jennings came in and made a comment about something she was reading that was outside her practice area. And I remarked that that is the kind of curiosity that really makes life interesting and I think the first thing you have to do is really just be curious and ask a lot of questions about things. I, I love this panel that you all put together because there's such a good mix of practice and research and I think for me anyway. I think you have to have your hand in practice, at least a little bit. In order to really know what the research questions are, you know, what is going on that we need answers to. And so, like the first presenter, I am a casual practitioner, I take call two days a month, but it's enough to really help me stay tuned into what is going on out there. The other thing that I would say is, you know, you look at Stephanie and Shannon Lee and that's a perfect example, it is very hard to do research by yourself. So, I think you have to surround yourself with very smart people who have complimentary expertise, I am in the most fun partnership I've ever been in right now with a nurse who doesn't know a thing about sexual assault, but she knows a boatload about mindfulness, and we are having so much fun collaborating on that. So, I think you have to surround yourself with very smart people, keep your hand in practice and stay curious. Thank you all. I don't have anything else in the chat. I want to thank all of our presenters for taking time out of I know what is busy schedules for you to do our webinar today and to educate us on research. I'm going to just give a few minutes. I don't know Amy or Sarah, do you have anything you would like to say or add before we sign off? I know Amy is putting something in about make sure that you fill out your evaluation so you can get credit. I would just like to thank everyone. Thank you to all of our presenters. This webinar is put on by the IFN Research Committee. So, if you do have any interest in research or if you'd like to further explore that or if you're an experienced researcher, please reach out to us. You can email research at forensicnurses.org for more information. We'd love to have you as part of our committee. And again, thank you to all of our presenters today. Please make sure to complete your evaluation so you can receive your CE. And again, thank you. Have a wonderful week.

preventable causes of death

stranded motorists

extreme temperatures

lack of resources

targeted interventions

education

vehicle maintenance

emergency call boxes

forensic interviews

sexual assault

LGBTQ+ university students

bystander intervention programs

trauma-informed care

sudden unexpected deaths

patient experiences

trust building

multidisciplinary teams

sexual assault nurse examiners

preventive measures

education resources

interdisciplinary collaboration

data-driven decision-making