Welcome, everybody. My name is Sarah Jimenez-Valdez. I am a project manager with the International Association of Forensic Nurses. Today's webinar is titled SANE Testimony Part 1, Building the Foundation for Successful Testimony. This is the first of a two-part series which is made possible with grant funds awarded by the Office of Victims of Crime for the SANE Program TTA project. I'm going to ask that you bear with me for a few minutes so I can cover a few items before we get started, which includes a few brief disclaimers. This presentation was produced by the International Association of Forensic Nurses under the grant number you see listed on the screen. The grant was awarded by the Office for Victims of Crime, Office of Justice Programs, and the U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this presentation are those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice. Another disclaimer here, since there are 1.5 continuing education units being offered for today's presentation, we would also like to note that the authors, presenter, and planning committee for this webinar have no relevant financial relationship with ineligible companies to disclose. Upon verifying attendance, attending the course in its entirety due to the critical nature of the content or nature of the content, we will be also, and I'm sorry, and after you all complete the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is an accredited provider of continuing nursing professional development by the American Nurses Credentialing Center's Commission on Accreditation. For those that are live attendees, I will send an evaluation within a week of this presentation. All that said, we do encourage you to use the Q&A feature to ask any questions that may come up throughout the presentation, and the chat is also available for use, and I will be available throughout the presentation. If you have any technical needs, I'll go ahead and drop my information in the chat, and then also the other thing that I will be dropping is a registration for this second part to this series. I would like to welcome our presenter, Valerie Poulier, who has been working in this specialty since 1998, has been nationally certified as a SANE-A since 2002. She has worked as a sexual assault nurse examiner consultant, educator, and led a full-service forensic nursing program for victims of acute sexual assault, intimate partner violence, and elder mistreatment. She has served as an expert consultant with the Ohio State Attorney General's Office in training initiatives for law enforcement, prosecutors, health care providers, social workers, and professional advocates. Valerie has worked as a forensic consultant, expert witness, and educational consultant with the United States Department of Justice and Armed Services. She has also co-authored several articles on health care aspects of sexual assault, domestic violence, and strangulation, as well as contributed to several textbooks on forensic nursing. She has served on community, philanthropic, and professional organizations from the community to a national level. Valerie maintains a clinical forensic practice with the Crisis Center of Tampa Bay in Tampa, Florida. We thank you, Valerie, for joining us today. Thank you so much, Sarah. I hope you guys can hear me okay. And I do want to just start this off by expressing my thanks for your flexibility in understanding my recent bout with COVID, and as you will come to see during this presentation, the ongoing lingering upper respiratory issues I'm having with it. So I'm going to apologize in advance for all the coughing and hacking that I may do, and I hope that's not too distracting for you. I'm going to do the best I can, but sometimes you just can't hold it in like that. All right. I also want to introduce a colleague of mine who's going to join us today and be my partner and lead attorney in not just this session, but in our next session, which we'll talk about a little closer to the end of this session. I'd like to introduce you to Brian McDonough. He is a friend and colleague of mine from back in the day in Ohio, when we worked together on the Ohio Attorney General's Sexual Assault Response Training Team. He is also a former assistant Cuyahoga County prosecutor, which is the county where Cleveland, Ohio is located, and is also the former co-chair of the Cuyahoga County Sexual Assault Response Team. So welcome, Brian. I am so glad you're here with us today. Same here. Welcome, Val, and thank you all for attending. All right. So let's get into it a little bit. And Brian has an open invitation to chime in as we go here. This presentation today is really focused on the foundation for being able to provide effective testimony. So we're going to be talking from the ground up, parts of the criminal justice system. We're going to talk about our role within the judicial process as SANEs. We're going to talk about a very key aspect of our practice, which is defensible practice in our role as a sexual assault nurse examiner. And then we'll have a few minutes to talk about some key aspects of SANE testimony with the tease that more to come in session two about that. Okay. So let's just start at the basic understanding of the criminal justice system and how judicial proceedings just kind of work from an outsider kind of looking in. The diagram you see here is a typical setup or hierarchy of a court system within any given state. At that low part of the hierarchy, you see justice of the peace, small claims court. You may see at that next level courts that deal with family issues, whether it be divorces, adoptions, things like that, juvenile court, municipal court, probate court. Oh, what did I do? I didn't mean to move that. And criminal court on the far end there. Brian, would you give a brief explanation about the differences between say muni probate and criminal court? Sure. Most of those courts under state law are going to differentiate by either two things, the subject matter or by a monetary amount. So family court obviously deals domestic relations, adoptions. That would be the subject matter there. Juvenile court, anything juveniles under the age of 18, or perhaps parents who are not married that have a child for custody issues or visitation issues there. Municipal courts predominantly are, it's based on a dollar amount. You could have a $10,000 or $15,000 as the amount in controversy for a municipal court. And then also the type of offenses in a municipal court can also include criminal offenses, but these would be misdemeanors, which are typically any crime punishable by six months or less in jail. So you think of a DUI or operating a vehicle while intoxicated, theft, shoplifting, domestic violence, things like that. For probate court, that subject matter would be obviously involving decedents. So you have estates. You also have the potential for adoptions there and under state law, guardianships, conservative ships, things like that. And then also criminal courts. And depending on the state, you can have courts that are either defined by geographic boundaries. So it could be a particular city, it could be a group of cities, or it could simply be a county level. And for those, those typically again are misdemeanors. In some districts, you've got felony courts. The difference between a misdemeanor and a felony, felony is anything punishable by greater than six months in jail. And we like to go ahead and call those prisons. And then your trial court is where all the trials would go ahead and take place. Predominantly, you're going to see it in criminal trials, but you can't have them in civil, but by far more so in the criminal context for trial courts. And then would you like me to go on through the hierarchy there, Val? Sure. So for trial courts, every litigant in a trial court has the right to appeal the decision. So in a criminal case, if a defendant is convicted, that defendant has a right to appeal. And that appeal goes to an appellate court, which is comprised of a court of approximately three judges or so on a panel. And that court will review the record, the testimony, the evidence presented to see if there were any errors, to see if there were any mistakes made by the trial court judge. And in the adversarial system with one party suing another party, whether it's a criminal case, where it's the state versus the individual, the accused, the defendant, or even in civil cases where it's plaintiff versus defendant, the appellate court will go ahead and decide whether there was an error. And those are automatic rights. Every trial court, you automatically have a right to appeal. But then after that, the next level, state Supreme Court, that's really more discretionary. It's whether that state Supreme Court is willing to accept the case. There are normally some parameters in place. It's narrowly drawn. So it has to be an issue that that court is willing to go ahead and accept. So if someone says, hey, I'm taking this case to the Supreme Court, well, you could try. But all that you're guaranteed is one level of appellate review. Excellent. Thank you so much. All right. And then we have, beyond the state structure, we have federal courts. And I know, Brian, you know a little bit about that. So maybe a brief explanation about the federal court structure. Yes. So while we have 50 states and 50 different state laws, for federal law, we just have one law. We have federal law under the United States Code. And we have 93 U.S. district courts. And so, for example, in the state of Florida, for example, you've got three different sections. You've got three different courts, trial court levels there. You have the Southern District, the Middle District, and the Northern District. So throughout the country, some states are divided into two, three, four, or sometimes just one trial court district across the country. And then what's indicated on here is that the same thing, if there's an appeal, for example, if there's an appeal from a decision of the federal trial court, that would go to a court of appeals. And for Florida and for Georgia and Alabama, those are all part of the 11th Circuit Court of Appeals. And that's where those courts of appeals are heard. For federal court, obviously, any violation of federal criminal law would appear in federal court. And then in civil courts, there's a dollar threshold, $75,000 or more, for civil cases or cases in which the United States is a party. Okay. Thank you so much. There's so, so much that we don't recognize as SANEs. Primarily, we're going to be living as SANEs in those state court systems, in the criminal courts, sometimes depending on if we're seeing intimate partner violence that may involve even child custody hearings and things like that. But for the most part, as a SANE watching this, you can expect your practice to be within that criminal court system within your community, county, however that's set up. All right. So I wanted to just share a little bit, and this is more for nurses, MFE, Medical Forensic Exam. I get a little trigger happy, my apologies. And while we have kind of the judicial process system set up there from the arrest of a suspect all the way, potentially through sentencing, be aware that the Medical Forensic Exam takes place outside of the criminal justice system. And our focus as SANEs providing that medical legal care, focusing on those emergent medical needs of the patient, we're not really part of this process. And as we all know, none of our patients' cases may ever end up in the criminal justice system. So it's so important that we keep our focus in that patient care arena. This is just a little fun fact. So when you get a subpoena, just so you're aware, there is a reason and a method for all of the crazy coding that you see coming in on a subpoena. So for example, this actually kind of talks out or shows how the court division number that we just saw on previous slides, the year the case was filed, the type of case it is, whether it's civil or CR for criminal. And this may vary from state to state. The order of the case in the year, in this example, this is the 23rd civil case in 2021. The district judge initials would be involved there or the magistrate initials. So nothing you're going to be tested on. I just thought it was kind of an interesting thing I always wondered about. So I wanted to include it in there for you. Okay. When our colleagues, our SANEs go to testify, the process for that, and we're going to focus much more in depth later on, but I just want you to be aware of the process. So the SANE would be called to the stand. Typically that witness is not in the courtroom until their testimony is called on by the attorney that is subpoenaing you. But the SANE will take an oath, swearing to tell the truth, that whole right hand up kind of a thing. Basically we're saying, we promise we're not going to make stuff up. We're going to tell the truth here. Direct testimony will be provided or directed by the attorney that summons you to court through that subpoena. Those questions that the attorney will ask, and I know Brian will have lots to say about this as we go through, will be more open-ended, giving you the opportunity to describe what you saw, what the patient related to you, more open-ended questions. Remember that your purpose in testimony is to educate the jury or the judge or both, but education is the goal there. After the direct testimony is completed, then the opposing side, the opposing attorney will have the opportunity to cross-examine the witness, you as the SANE. Those questions may be much more direct yes-no questions. The purpose of cross-examination may be a couple of things, and feel free to chime in here, Brian. But typically with SANEs, the purpose of cross-examination would be to, number one, discredit the clinician, discredit their testimony, or the testimony of another witness like the victim. While direct testimony is trying to educate the jury about what happened, what that exam was, what the findings were, cross-examination often focuses, dependent on the attorney's approach, to discrediting something or someone in their testimony. Is that a fair assumption? Yes, yes. On direct testimony, I like to think of it as the SANE is the star of the show. Jury's looking at you, and you are the star, and that the prosecutor who's asking questions is really kind of fading into the woodwork, but you are the star. For cross-examination, and that's the one that a lot of folks get anxious about, that can take two forms. In both forms, it's the cross-examiner or the attorney who's the star. And the one form is they're going to try to do a destructive cross, which is exactly as Val said. They're going to try to discredit the testimony, find mistakes, find flaws, find what's not believable. Or there can be a constructive cross, where they're going to take the facts that are in the chart that may be helpful to them and simply have you, as the SANE, corroborate and explain that. So their story is being told, but they're picking out the good points for that. So it can go either way, depending on the facts of the case. Great. Thank you so much. Cross-examination finishes. And now that direct attorney, in many cases, it would be the prosecutor, the state attorney, will have the opportunity to redirect the testimony and address any issues that perhaps arose on cross. We're going to talk about how important preparation for trial is between the attorney and the SANE. This is where you have to have a little bit of, you have to have trust that the attorney that has called you to testify is going to pick up on some of those things and be able to readdress any concerns that came up during your cross-examination testimony. In some cases, in some states and jurisdictions, then the opposition, the opposing counsel, may be given the opportunity to recross. I've actually been in a trial where we've gone through recross, re-redirect, re-recross, and then a re-re-redirect before testimony ended. And that is not consistent across all courtrooms. Is that your experience, Brian? Correct. Normally, each following the redirect, there might be a recross or there may not. It gets very limited at that point. Some judges do allow jurors to ask questions, and it's up to each individual judge whether they will allow them to do that. And if they do that, which questions would be asked, and then if so, both attorneys for both sides, if they can do some follow-up questions. Okay. All right. So that's the general process of witness testimony. The next slide will transition us into our, that's an odd thing there, transfer us into our role within the courtroom. And this is a tried and true slide. It was actually the first PowerPoint slide, I think, that I ever did a diagram on. But it really, I think, visually speaks to the relationship between our interdisciplinary partners and the role that SANEs have within the larger context of a community response to violence, okay? You can see here that at the center of this Venn diagram is our patient, okay? Client, survivor, victim, whatever professional is, is terming that individual, that person is at the center of all of our care. And our roles sometimes overlap, just as you can see these circles overlap. What I would like to point out though, is let's focus on the SANEs since we're SANEs talking today. We have a role in the response to this patient that nobody else can replace. If that yellow bubble that is the SANE moves too far over into another lane, too far over into the investigative law enforcement role, too far over into the advocacy role, that space then that we filled and that we are responsible and accountable to meet patient needs there is abdicated. And that becomes an empty space that no one else can fill. So for us as SANEs to really provide the best possible care that we can for our patients, it's good for us to understand each other's roles, but to really stay in our professional lane, okay? And that will come into play with some aspects of testimony as well. What I would like every SANE going forward from now and forever to realize is that this is nursing practice, that we are nurses first and foremost, we don't lose our nursiness by taking care of a patient who has experienced violence. Doesn't matter what happens in the criminal justice system, okay? May never, patient's assault experience may never end up in the criminal justice system, or there may not be an arrest, a trial, a conviction, a sentencing. Regardless of what happens in the criminal justice system, our patients can have long lasting, if not lifelong emotional and health related sequelae to related directly to their assault. So for us to really provide optimal care, we want our forensic nursing practice to be consistent with other healthcare practices. And by that, I mean being non-judgmental, being objective, okay? I'm not the victim advocate, I'm advocating for excellent care, right? I'm addressing patient issues in the same way I would another diagnosis. One of the things that I will commonly do is document the patient's chief complaint. Patient presents with a complaint of sexual assault. Doesn't mean objectively that I believe everything the patient says, but that's what I would document. Patient presents with a complaint of chest pain. I'm keeping things consistent. That consistency between your mainstream practice and your forensic practice will serve you well when it comes to testifying as to your role as the forensic nursing caring for this patient. We go through the same process, nursing process. I think sometimes it gives people hives thinking back to undergraduate school and nursing process and care plans and all of those client care maps. But we do, we assess our patients, we identify issues, we plan care, we evaluate care. We're going through that same process. Our documentation should remain consistent. The specialty care that we're providing is unique, but within the larger healthcare arena. And we are responsible for HIPAA with the exceptions that we talk to our patients about, but really respectful and maintaining HIPAA just like every other healthcare practice does. This slide is kind of what I've called over the years, it's our cocktail talk. It's our 30 second elevator conversation when somebody says, well, what do you do? And what do you mean, what do you do? If we can describe our role when the attorney asks us, well, tell me what your role is. Well, tell me what your role is. This is the crux of it right here. We are basically meeting two primary goals. We're meeting the acute healthcare needs of our patients. We're meeting the emergent legal needs of our patients because of the knowledge and education that we have that allows us to kind of meet that patient in that unique space that kind of intersects healthcare and the law, okay? We meet healthcare needs through injury identification, through identifying any other kinds of medical issues that the patient may have. Oh, they're hypoxic when you're seeing them, their pulse ox is only 90%. We're identifying other needs that need addressed as well. We are the primary providers here of preventive care related to infection prevention and reproduction. And again, safety and discharge planning, just as we would with any other patient that we see anywhere else. I think this is one area that is often, often left to the advocates because they have such vast knowledge of community resources but please remember that part of your nursing role is to safely discharge your patient, okay? When you can talk about that, you can talk about meeting those healthcare needs of your patient. We're also going to meet the emergent legal needs that our victims of acute violence have by collecting samples. And there's an example of consistency in practice. I collect samples if I'm taking care of a patient in the ER or in ICU or in my forensic practice, okay? I collect samples. Criminal justice system may turn it into evidence. I'm also documenting injuries and that may involve possible photography, okay? I'm able to maintain chain of custody and potentially if the case goes to trial, I'm later able to testify. So, you know, you think, okay, let's compact our practice into one slide. That's it right here, okay? All right, our expectations. Sometimes we need to take a deep breath about our expectations. What are the expectations for the SANE going to court, okay? We're just gonna deal with the elephant in the room first thing, okay? It is not your job to win a conviction or an acquittal, okay? It is not our job. And Brian was kind to say in his direct testimony, the SANE is the star during her testimony, during that direct testimony. But in the big course of a trial, it is not the SANE's job. It is the attorney's job to win or a conviction or an acquittal. We are only one piece of that puzzle. But here's things that we can do, okay? We can apply knowledge and expertise to provide education to those who are listening to our testimony, okay? That will be whether that testimony has been requested by the prosecuting side or the defense side. And we'll talk a little bit about testifying for both here as we go along a little bit. There is no guarantee that we're going to only be a prosecution witness, okay? And we shouldn't want to be because as a private citizen, I am all about convicting criminals. And I could get into maybe creatively thinking about out of the box ways to punish criminals, okay? Just in my private home. As a SANE, as that professional in this community response to violence, I do not have a dog in that fight at all, at all. My goal is to provide really good patient care. But whether a criminal or a person is charged with a crime, whether they're taken to trial, whether they're convicted or sentenced in some crazy way is not part of how I define my practice, define my success within my practice. And I would just kind of encourage everybody to really remain that objective healthcare provider, okay? Ground your testimony in things like evidence-based practice, in practice standards, keeping your care and your testimony within the scope of your practice. Those are ways that you will remain objective and that you won't be that biased witness on one side or the other. We wanna make sure that any opinions that are rendered are based on the best possible evidence-based science that's available, not just the practice standards, but our own relevant experiences in the field of forensic nursing, okay? Patient care is based on widely accepted scientific principles, widely accepted healthcare practices. Our testimony should also be built upon those fundamentals, okay? We wanna make sure that our testimony are not crafted with the purpose of achieving a conviction or an acquittal, but that we kind of stick to that role of educator within our presence in the courtroom, okay? We need to stay within our scope of practice when we do that. We need to be clear about what our boundaries are. So that may vary from state to state, according to your nurse practice act. But being comfortable in our skin, in our scope of practice, in our role within the process, allows us to remain comfortable and objective during testimony. All right. If you guys happen to have questions, please put them in the chat box. I know we're gonna be monitoring that, and it's not something that I can respond to in the moment as those questions are coming in, but we will look at the chat and all the Q&As as these things come in. All right. We're gonna change our conversation here a little bit, and I wanna credit my friend and colleague, Jennifer Markowitz, with the basic content that comes in this section, because she is probably the strongest advocate for defensible practice that I know. And she was kind enough to let me use some of her slides here, and I'm gonna share them with you. I'm gonna share some of her slides here for this section. So I just wanna give her credit for that. And if you have the opportunity to listen or learn from her in any venue, please take that opportunity, because she's just amazing. All right. So what is defensible practice? All right. Defensible practice, reading it right here on the slide, it's a practice that is supported by clinical experience, by current research, and by accepted practice standards. And that's what we're gonna talk about for a few minutes. This is like so foundational for testimony. It's not quite maybe the practice questions that you were maybe expecting for testimony practice, but we're building that foundation right now. And basically what we're looking at is these two questions that we should be asking ourselves before we get into a courtroom. How do we know what we know? Okay. How do we know what we know? Okay. From trainings, maybe from things that we've read, from our own experiences, from research. Okay. And why do we do what we do? Okay. Do I collect moist swabs, samples of maybe the neck if there's strangulation, because, I don't know, because somebody did that and I'm just following somebody else's pattern. And that may be part of how we learn, but digging a little deeper and understanding Locard's principle and touch DNA transfer of DNA, would then give us deeper knowledge as to why we're collecting any particular swab that we would be sampling. Okay. So these are questions, kind of self-reflective questions. And if we were in a small group, we'd have some conversation about that right now. To develop a defensible practice. I'm sorry. To develop a defensible practice, we need to know what the standards of care are. Okay. We find those standards, we learn those standards by looking at a number of different things. We learn them from the protocols, you know, and in the chat box, feel free to add some of those comments about where these standards come from. Okay. The, you know, protocol for adolescent, adult, or pediatric sexual assault exams, best practices document that came out, our own policies and procedures and protocols, any guidelines that we may have that, you know, would be in alignment with those things in our own program that would help to frame our practice. Within your state, being familiar with your Nurse Practice Act and how your practice falls within, falls within those state guidelines. Okay. And this is something, if we're working in different states, if we're moving from location to location, you need to be familiar with the Nurse Practice Act in that location, in that state where you're working, because they will not be the same as the standards that are overarching. Okay. Keep in mind that we need to own this episode of care. Okay. Our care as a SANE begins with the triage of our patient and ends with the discharge of the patient. Okay. We cannot just pick and choose the pieces parts of the exam that we want to be involved with. That can leave us vulnerable when we're talking about testimony. So just one thing to keep in mind. Competency and evaluation and evaluations. I want to talk about this because some programs, while it's the goal, I think for all programs, this may be an opportunity for growth for some programs. So a quality assurance program is going to involve another, a colleague or another trained individual reviewing your documentation, your photographs, and making sure that benchmarks are being, being met for that threshold level of care. There may be programs, many programs across the country that really don't have, you know, a robust staff of SANEs. Here's the opportunity maybe where collaboration between multiple programs can take place that you get together and maybe do some of that quality improvement, quality assurance process, you know, in a coordinated way to support each other's programs. Heck, there's enough violence for everybody. We don't need to compete with other programs, right? We've got enough violence for all of us. So how can we strengthen that practice? If we're not part of this process, as a new SANE, I'm not getting that feedback to help me grow my practice and to develop a depth of knowledge and competency within the role. When we talk about annual evaluations, we're used to that in mainstream healthcare, but in the role of a SANE, that evaluation may never come. If you're working with an on-call program that you have a regular job in the ER and you're taking some call as the SANE, you may never ever get that annual evaluation. So I think that's another area that we can bolster looking at what are the expectations? What are the benchmarks of the program? And are we meeting that with opportunities for growth for that SANE to grow within the role? Keep in mind the ANA, American Nurses Association, that professional nurse practice model does include evaluation. The other thing that would be important there would be to belong to your professional organizations. Okay. Think about which organizations really meet your needs, setting the standards and the guidelines for education within your field. This right here where we're sitting today having this conversation is an example of that. But this is often that professional organization involvement, membership, participation is where you get the biggest bang for your buck. For your investment dollars in your own professional development and career. I apologize. Every time I cough, I'll quit saying I apologize, but I do in my mind. Let's talk about research for a minute, okay? And this is an area that I think many of us struggle a little bit with. Not all of us are inherent researchers and totally jazzed up when we have the opportunity to read a peer-reviewed article. What I would suggest that we do is kind of have some self-reflection about what is your comfort level in reading a research article? How comfortable are you as a SANE determining how applicable an article is to a specific case? How comfortable are you looking at an interpretation of the overall research underlying how we form our opinions, okay? This is an article or an opportunity as well for program leaders to maybe do some growth and development within their team. maybe have some conversations at staff meetings or a journal club about peer-reviewed articles and have conversations led maybe by people that are a little more comfortable to increase our own comfort level with that. A research article, and I feel like I maybe I should have said this up front or maybe I didn't need to say it at all, but a research article is a paper. It's written by individuals who have either collected and analyzed their own data, that would be called primary data analysis, or analyzed data that's been collected by someone else, that secondary data analysis, okay? There is a great resource on how to read research articles put out by Cornell, and that's a dot that we can connect for you afterwards if that's something that you're interested in. You don't need to know absolutely everything about an article or a book written in the field, but you should be familiar before you testify with well-known articles that are the foundation of your trainings and your opinions. Please don't think you need to memorize statistics. That is not the key to effective use of research and will lead you down all kinds of unwanted paths potentially in testimony. So just memorizing the data is not going to really give you that inherent understanding that you need of a research article. You need to be able to identify what's probable versus what is likely or possible. Sometimes it will lead us to, that research will lead us to the conclusions that there's just some things we can't say for sure, so I can't really offer an opinion on something. But it really, research should provide those parenthetic boundaries around our knowledge and our clinical expertise. So it's kind of like the bookends on, you know, all ends of that continuum. If you are asked to testify to research, and I will tell you to this day, that's probably where I kind of go, okay, you know, I've got game face, but in my mind I'm thinking, oh, I really don't want to do this. But if you're asked to testify about research, we need to think about what happens if you're confronted on the stand with research. Maybe it's from an article you read, maybe it's from an unfamiliar article, and what do we do in that case, okay? My suggestion would be to really be honest. You cannot really respond to something you haven't read, so you would need time to actually read and review and process that information. And that may be something that we can have some conversation about, Brian, when we get into some of those certain instances as we go through these next two sessions, because that's something that I think often strikes fear into people, is having to testify to the research. Okay, all right, I'm gonna take a deep breath and we're gonna move on here to testimony. Testimony, this is when defensible practice is put to the test. For program leaders, one of the things we need to understand are when programs are being developed is when that subpoena comes in, what's being released in the record? What is the expectation? What is the understanding for what will be released? Or does there need to be specific requests? Does it include the consent? Does it include the medical or the HIPAA protected portion of a chart? Does it include the assault portion? And how are the photographs? Are they subpoenaed separately or are they included as well? I'll give you one very, very brief example. When I first testified, when I moved down here to Florida, I was given a chart to review. And the state attorney asked me if this was the complete record I had created for the patient. Well, it was not. It did not include the consent. It didn't include the medical portion. It did include the assault portion of the document and it included the body maps. But it really didn't have everything. And that was the practice where I was working at the time that that's what was released with a subpoena. But I couldn't testify that this was the complete record. So just have clarification so we all know we're on the same page, program to attorney, okay? So that is a conversation within your own program and jurisdiction because that is going to vary from place to place. I like to think of the medical portion and the assault portion of the charts as a two chapter book. And that's just my easiest way to explain it when I'm talking about it. The medical, the HIPAA protected chapter is this type of information. The assault portion, that assault chapter has the history of the assault, the exam findings, the body maps, the samples that I collect, all of those things related to the incident that brought the patient into our care. All right. You as the individual nurse will probably get a subpoena after the record has been subpoenaed by the attorney. That records request will come first, but now you're getting the subpoena, okay? Holy crap, what do I do now, okay? So a couple of things to think about, okay? Number one is to continue to breathe. We don't need to panic about getting a subpoena, but you do need to respond to that attorney of record. One of the tidbits of advice that I would like you to kind of keep in the backs of your brains at all times is never assume you are off the record when you speak to an attorney. And I see Brian shaking his head yes. Do you want to add anything to that, Brian? Yes, once you receive the subpoena, assume everything, every conversation, there's nothing off the record on it. The attorney can use anything you say, anything you do, outside the courtroom, in the hallway, on the way to court, all those things, it's all fair game. Okay, so there's your warning, game face from the get-go. You should be reviewing the record with the attorney who subpoenaed you. You want to know your limits, okay? But I want you to make sure, and I want the attorney to understand, and I guess this question is for the attorney. Do you know what you think you know when you look at my chart, okay? Quick example, back from our days, back in the day, Brian, when the band was together, I had a patient who gave me a history of, the assailant's hand sliding between the labia. No digital penetration of the vagina occurred. No penetration of the vagina occurred with anything, okay? No finger, no foreign object or anything. But the hand had passed through the labia, okay? The attorney, legally, was looking at that as penetration, because we have gone between the lips of the labia, okay? Legally, that is the definition, correct, Brian, of penetration, typically? Yes, it's going to depend on the state. It's going to depend on the state definition, but yes, any penetration, however slight, typically qualifies, yes. Okay, I had documented in my chart that vaginal penetration had not occurred, because in fact, vaginal penetration had not occurred. We were not speaking the same language, and while I could definitely testify that the assailant's hands were touching her external genitals on the inside of the labia, that was not penetration of an orifice from a medical perspective. So make sure that you're both speaking the same language when you prep, okay? Back in the day, that was called credit carding. I don't know if that term is still used, but it was swiping the hand through the labia, which was apparently a thing. Who knew? All right, are the remarkable findings are what they seem to be, okay? Is the petechiae that you see on the body consistent with strangulation, or is it maybe also on the arms and legs and maybe consistent with some kind of a disease process? So make sure that the remarkable findings are indeed remarkable when you're having this conversation. Excuse me. Another strategy or another thing to consider during prep with the attorney is to explore possible cross-examination strategies. Just as Brian explained, what the defense attorney or the opposing attorney may choose their method of addressing your testimony, your attorney will often have insight into the likelihood of that and help you prepare for some of that. Make sure you're talking about any time or work constraint issues that you have so that that's known upfront. You know, oh, my son's getting married October 15th. I'm not gonna be available to testify that week. And that's fair enough. You need to be upfront with what your constraints are. Let's talk about some self-defense strategies, okay? So talking about what's easy to, I don't wanna say give up, but to concede. If you're being cross-examined, keeping the same demeanor, being objective, polite, using the same tone of voice that you would, and I think this will get it. We'll talk a lot more about this in the next session. It should really be our go-to, but I don't need to argue every point if there's legitimate points that are reasonable on cross-examination. Acknowledge those, okay? If we're getting snippy with the counsel on cross, it's not gonna work very well for the case or for our credibility, okay? Get a lot of negativity from getting snippy in court. Not a lot of positive things happen. And although SANEs are very well-respected, nurses are, I mean, we're the most respected profession out there. Keep in mind that these attorneys have had potentially days to create a relationship with the jury. We're only there for a very short time, minutes, an hour, two hours. The attorneys are creating relationships over days, okay? And that counsel can characterize you and your testimony any way they want to during closing, and there's really nothing we can do to rebut that, okay? So just being professional and calm across the board is a great approach to testifying. Oh, okay, let's talk some cross-examination. And I wanna make sure we're staying, time is flying here. Okay. And Valerie, I just wanted to mention there is a question in the Q&A. Okay. The question is, what happens when you receive the subpoena from the prosecutor, but the defense attorney calls you and also plans to issue a subpoena in the event the DA doesn't call you? Okay, so you're getting a subpoena from both sides is my understanding of the question. How I handled that in my practice is to, actually, I call both of them, and I actually suggest, why don't we meet together? It's time-efficient for me, but if you're subpoenaed, you should respond to that attorney. Your comfort level within that judicial system and within your own practice, suggesting that you meet on neutral ground, everybody together may very well be an effective strategy. Okay, you have any other comments on that, Brian? Sure, and I think the question was, the prosecutor or state's attorney issues you a subpoena, you get a call from the defense attorney, hey, if the prosecution doesn't call you, I want you to go ahead and testify. I'm issuing you a subpoena. Yes, that you're wanted. There's something good in your chart for the defense, and obviously, there's something that may be good in your chart for the prosecution. I would agree with Val. You're the professional. I think it's nice to have those attorneys. Make them come to see you at a time that's convenient for you. Definitely, with the state's attorney or prosecutor, you wanna go ahead and prepare and have that. If it's possible to do that joint meeting for efficiency, yes, that's fine too, but just be mindful that, again, anything you say, anything off the cuff, anything on that, keep it all professional, keep it all as you would, because again, even that stuff in preparing for trial, especially with a defense attorney who obviously has an objective, is a fair, fair play for trial. Absolutely. Okay, hope we answered your question. Please add into the chat box if you need us to address any more on that, even after the fact. Let's take a minute and talk about cross-examination, okay? And I'm not really gonna spend a lot of time on that first point, because I think Brian did a great job talking about that two-pronged approach, but here's some common areas that an opposing counsel may, paths that they may go down to discredit, okay? So they may want to discredit your qualifications through your education, your clinical experience, potentially your ability to render any opinion at all, if this is a case where you'll be testifying as an expert and rendering an opinion. Please keep in mind, and I know I have it on a slide farther down, but I want you to remember, you may be a new sane and that's all well and good, but you have a wealth of nursing background. You may be an ER nurse who has seen years of trauma. You may be a labor and delivery nurse who has looked at more genitalia and women's pieces parts than many, many other people. So you have many qualifications even beyond your sane experience. The exam also becomes an issue sometimes, either the documentation, the methods that were used, the samples that were collected. So again, going back, if your practice is grounded in research and protocols and you know why you're doing what you're doing, that you're gonna be able to support that practice. The refusal to make concessions really goes back to that attitude and the confrontation aspect that we really want to avoid. And then you may attempt to be discredited based on your opinions, either making opinions without support or without research to support why you're developing or why you're stating an opinion. So, exception for medical hearsay is so foundational to sane practice. And this goes back to all of my suggestions for keeping your forensic practice as mainstream as you can to the rest of your, to the rest of your clinical care. Why are you getting information? Is it necessary for you to provide care to your patient? Quick example, patient will tell you they were assaulted in a car. I don't need to document the make, color, year of that car because it doesn't impact the healthcare that I provide. It's not information that I need, okay? That would be information then to encourage the patient to share with law enforcement, to write down so they remember, but I'm not including it in my documentation because it's not pertinent to my care, okay? These are some of the examples of the discrediting attempts with qualifications. And this is probably my number one pet peeve right here. Get called to the stand and be told, nurse Julier, nurse Jones. It's like, this is not my title. This is my job. This is my job description. This is my profession. In my mind, every time I hear that, I see a plumber going to testify about some kind of a housing issue and the attorney saying, plumber Jones. And I just, it's like nails on a chalkboard. Use the appropriate title. Many of our colleagues are doctorally prepared. Doctor is a correct title to use with that. Ms., Mr., Mrs., Miss, whatever it may be, okay? But using those, you know, knowing your witnesses' pet peeves, you know, I have had defense attorneys who have used that just to try and get a rise out of me. Then you may hear, isn't it true, nurse Julier? You're just a nurse. Yeah, by golly, I am, okay? I have a specialized knowledge and more skill in this specific area of medical legal care than I would say anybody I'm going to come in contact with in everyday life, okay? Certainly more than physicians and, you know, are provided in school and within their residency programs. I have the education and the qualifications and the certifications that demonstrate, you know, that support my expertise in this area. And I follow, I know my standards of practice related to my, you know, to my role. Isn't it true you're an arm of law enforcement? Okay. Medical statements, and this is where our medical exception comes in for hearsay. I'm going to document what I need to know to provide care to my patient, okay? I am not writing verbatim everything that the patient tells me about everything they did from 24 hours before to 24 hours after the assault, okay? I do take photographs with many of the exams that I complete, okay? Photography is an accepted standard of healthcare practice. Specialties such as plastic surgery, wound care, routinely use photographs to document what they're visually seeing with their patients. We do the same in our practice, okay? The identity of the assailant is not so much key for me to say, oh, it was Bill Jones, but the fact that Bill Jones is my mother's boyfriend or an ex-boyfriend or a coworker, I need to know the relationship for safety and discharge planning, which is part of my role as a nurse, okay? I collect samples, okay? I'm able to collect those samples because of the knowledge and education and training that I have. It's not medically necessary for me to swab your forearm or your hoo-ha or anything else, but it is respectful and convenient for the patient for a medical professional to do that. Keep in mind that a patient can decline any part of the exam, and I would still provide medical legal care within the consent and assent that the patient provides, okay? Sample collection is not the, you know, I'm not a swab monkey, okay? Val, thank you for not being a swab monkey. Thank you. There was a question of how do you prioritize the collection of different evidence? Oh, great question. So I prioritize sample collection based on the history that the patient gives me, based on the standards and protocols that we have, and that would be, for an example, the timeframes that we have to do the sample collection, and honestly, with the permission and partnership of the patient. I had a patient yesterday, I was actually telling Megan before the exam, I collected external body samples from a lot of different places, but the patient actually declined the anogenital portion of the exam. So I wasn't able to visualize or collect any samples from that part of the body. So, you know, if you, you know, if we know touch can transfer DNA, if we know there was saliva there, if we know there was penetration or ejaculation, I'm definitely going to prioritize those areas, but I'm using the history and the protocols to do that, okay? And then imagine that defense attorney keeps questioning and keeps referring to you as How do you respectfully respond if you want to address being called that? What technique that you would use to say, yes, nurse is my occupation, I am Ms., Mrs., how would you respond? I actually, I could say that once. I might say it once at the beginning, and knowing that, I mean, I can probably name a few defense attorneys in Ohio that would literally continue to do that. I would then ignore it. And that's just part of keeping my cool and not rising to the bait that I know they're trying to throw my way. Yeah, little gamesmanship of testimony there. All right. The states do pay us to do rape kits. We are not being paid by law enforcement. Clinics all over the country are paid to do these, reimbursed to do these kits, okay? Bias is another key issue. When I hear someone say, you believe all your patients, well, I am not the professional advocate that is there to support that patient for that reason. I believe something happened to my patient and brought them into my episode of care. Just like when a patient comes into the emergency department and says, I'm having a heart attack, I believe they're there because something's happening that brought them here. But I don't necessarily, I remain objective. I document the history that the patient tells me. I do my physical assessment. My assessment findings may be consistent with the history that the patient gives. Sometimes it's not consistent with the history that the patient gives. If a patient tells me that they were, and I mean, you don't have to make this stuff up because it's real history. I was penetrated by a pitchfork and there are no remarkable visual findings, that would be Medina County, then those findings would be inconsistent. And I would be objective about that. I am an advocate for the standard of care, for excellent care for my patient. And that's what my priority would be as far as advocacy goes. I want to be clear about documenting past abuse as part of a noted medical history, not related to the assault history that I'm documenting. So if it's remarkable patient history that they tell me, I'm going to document it, even if it includes abuse. I'm not cherry picking medical history to include or disclude. That's not a word, but from the chart. You're just a prosecution witness. In our work, we may as a program or individually do defense work. And that may include being subpoenaed, being asked to review cases, being asked to testify. That's not a bad thing. That actually bolsters your objectivity and is something that actually can help, like I said, on the stand, bolster your objectivity. After the trial, get feedback. Don't get feedback from the attorney during the trial, but maybe after the trial. What's always helpful, though, is if you can have a colleague with you, a knowledgeable colleague in court who can observe your testimony and give you the good, bad, and ugly feedback in a way that is, you know, sane to sane relevant. What I would encourage you to not do is to have a bad experience on the stand and then get off the stand and change your practice because, oh my gosh, that was horrible. I don't want to go through that again, okay? And I don't want anybody to ever quit because they've had a bad testimony experience. I will tell you, I am easy to find. You're going to have my contact information. If that's your experience, call me and I will walk you back off the ledge and support you, okay? All right. We have about, what, 15 minutes left? I want to put a little commercial out for our part two, and then we can open it up to any questions that there may still be. And if not, Brian and I can do some conversational testimony or address a few topics. But part two of this session, now that we've laid that foundation, on March 28th at 3.30 in the afternoon, because blessed, I'm not going to get COVID again and get sick, we are going to have part two of this webinar, another 90-minute session. And look at the title of this. Brian gets total credit for this, but the Biology of Testimony. And Brian, I'm going to let you kind of draw people in here. What's Biology of Testimony? Just why should people want to hear about that? Sure. One of the things about Biology of Testimony is that a lot of sayings, there's nervousness, there's anxiety, there's stress while testifying. And if you go back to biology, what is really happening when you get the subpoena, you're called into court, you're sworn in, you're on the stand, your heart rate's going up, you got butterflies in your stomach, your mouth goes dry. How can you consider the biology and how to best use your brain, your body, and your voice to deliver effective testimony? And the program is really going to talk about some tools that are going to allow you to develop, explore, and expand a distinctly individual style. You have to be you, you have to be personal, you have to be authentic. You cannot simply mimic or copy someone else's testimony. You have to be you on it. But by understanding some of that biology in terms of what's going on, I found that that could make that a much more effective way to testify if you know, hey, this is what's going on. If my knees are knocking or if I'm naturally soft-spoken and boy, the microphone and I'm in a big courtroom and that's concerning, those are all the things to go ahead and consider regarding that. And I'm going to put an extra application on there. For those of us that have to talk to hospital administrators and organizational leadership, this is good public speaking preparation as well to help kind of get ready to be in front of people talking. And it is the 27th, I apologize. That was my mistake on the slide there. So it is March 27th from 3.30 to 5, okay? As preparation for that, anyone who would be willing to participate in part of that session by providing testimony to a chart that is already created, if you might like to get some of that hands-on practice, please reach out. I know, I think Sarah already put the link in the chat. Is that correct, Sarah? That's right. It's in the chat. So you can click on that link and we will make sure that you get that chart to review. Pretty generic. It's pretty tight. So nothing to be scared of. And we would love to have some people testify next time. Okay. You guys have been very patient with me. Do we have any other questions that we need to address right now? We do. The question is, do you have a process that you use with every case, such as review the ER record first or review the SANE report first, like a systematic process? That sounds like that's directed toward the attorney. I think it is. I think it is. Well, here's what's really interesting. As the attorney, when we get the medical records in the case, we normally receive them in a different format than what you may actually have at the hospital or on site. And so what I like to do is when I do get the medical records is to go through them. But what's critical is to set up the meeting with the SANE. No one's getting called to the stand cold. There will always be a prep session. And on average, it takes about three hours outside of the courtroom for one hour of testimony inside the courtroom. And again, as a SANE, as you're testifying, you want to have your comfort level. You want to be able to testify accurately and to make sure it's within the bounds of your practice and your comfortability on that. But my practice was to go ahead and have the entire record. And then actually, just as Val said, do I know what I know? I want to be able to go through and go line by line, page by page. And sometimes we don't have all the forms. Perhaps the medical records department did not assemble everything. Perhaps there's another sheet that may not be in there. So that's essential to a complete, systematic pretrial process. OK. I do see a question in the chat. On an early slide, there was a bullet point about the SANE providing care from triage to discharge. Can you talk more about that? Should the SANE be the primary nurse as well, not just a consult? Well, there's a loaded question. And if you're working in an ER and you're the primary nurse and you get a SANE case and you get pulled out of staffing, that is just, it's frustrating for the staff. It's frustrating for the SANE because you feel pulled in directions. Not all programs are set up that the nurse in the ER, staffing the ER, will become the forensic specialist in that case. And as many programs in ERs as there are across the country, we can see a variety. What I mean by own the episode of care from triage to discharge is that when you triage that patient, OK, that may not be the initial triage at the front door of the ER. But when you triage that patient and you're identifying issues and you're coming in, and it may be a consult role, you're not just coming in, filling out your forms, collecting your samples, and leaving, OK? And good luck to the ER staff for dealing with medication prophylaxis, you know, for STIs, for emergency contraception, potentially for NPEP, for strangulation, all of those kinds of needs, I'm going to guarantee you are probably more knowledgeable than the inpatient or the ER staff about any of those things. So maybe it involves sitting down with the provider in the ER to talk about why, you know, why you have concerns for this patient with a history of strangulation and recommendations potentially for imaging or, you know, observations and things like that. So it's not just coming in in isolation, doing our, you know, doing our kit and then leaving, but really being accountable for the relevant care associated with that patient. That would also go to discharge planning. I may, as part of my episode of care, I may have conversation with that patient just chatting about home environment and feeling physically and emotionally safe and what concerns do they have, and you know darn well those ERs are going to come in with pre-printed instructions for discharge and out the door good luck with that. So it really is kind of owning the entirety of that patient's situation. Does that make sense? Okay, good. I'm glad. I'm glad. Any other questions right now? I haven't looked back through the whole chat, so I'm kind of relying on my colleagues here to see if there was anything else. I think most of the questions were addressed, at least the ones in the Q&A, and I know that there was some information shared in the chat, but I think those were addressed as well. There is a question whether the PowerPoint will be made available. We certainly can. I'm happy to do that. Okay, what difference between testifying as a fact witness versus an expert witness and who determines this? Ryan, do you want to take the legal? Sure, sure, absolutely. So in court, two types of witnesses, a fact witness and an expert witness. So the fact witness is able to testify as to what they heard, what they saw, what they did. The expert witness, and there's a special instruction that goes, is allowed to give a testimony in the form of an opinion, and that opinion is based on their education, their training, their experience. One does not have to have necessarily advanced degrees. Someone could be an expert in some area, for example, apple pies. If they had baked apple pies all their lives, you could be an expert in different apples and different pies. But in court, what's powerful is the ability to be able to be an expert and to give an opinion. At the end of the day, the jury or the judge will decide how much weight to give to that opinion. We could have an expert say, I went to the Atlantic Ocean and there's water in the ocean. Or the expert could say, I went to the moon and the moon is made of green cheese. You could go from the obvious to the absurd and anything in between. Who makes the threshold determination if someone can be an expert? That's actually the judge. The judge, the state court judge, would be able to make that threshold determination that what the person is testifying to is expert testimony that essentially that is based on good science and that would be able to permit that. A lot of times, you're just going to have fact witness testimony, fact witness testimony as to what's in the chart, what was seen, what's observed. Okay. Thank you. Sarah, I know we're running up on the hour. And there's a couple of questions here. How about if we capture these questions and then I can respond, we can maybe address it in the next session? That works. We'll include those. Okay. So I'm going to, I know you need a couple of minutes, Sarah. So thank you all very much. It was a pleasure to talk and cough with you and I'm looking forward to the next session. Thank you, Brian. Thank you. And thank you, Valerie and Brian, for being with us today and all that you've shared as a non-nurse myself. I know that I've learned so much from the basic structure of the court to that fine balance of the convergence of that managing those healthcare needs and the emergent legal needs that you mentioned. I know that I'm looking forward to part two, as many of the folks are in the chat have mentioned as well. I do want to do a special thanks to Megan Crone and Diane Baber, who are IAF and forensic nurse specialists for their assistance in the development of this presentation.

SANE Testimony

sexual assault nurse examiners

court testimony

research articles

testifying in court

professionalism

cross-examination

opposing arguments

challenging nurse's qualifications

comprehensive care

triage to discharge

legal system challenges