Welcome, everybody. Thank you so much for being here today for the webinar, Teamwork Makes the Dream Work, How Advocacy Benefits the Patient and the Forensic Nurse. I would like to thank all of you for joining us today, and please know that this webinar is being put on through IAFN Safety, a technical assistance project. We are so grateful today to have representation from the National Sexual Violence Resource Center, as well as the National Network to End Domestic Violence. So today, you're going to have me as your host. I'm Angelita Olowu. I'm with the International Association of Forensic Nurses. I'm one of the forensic nursing directors here. But more importantly, we have our presenters that we'll be introducing in just a few minutes. But before we get into that, I just want to let you guys know that this presentation is being made possible by funding through the Office on Violence Against Women. The planners, presenters, and the content reviewers have no conflict of interest to disclose. At the completion of this webinar, you guys will receive a course evaluation. You'll get a certificate after you complete the evaluation. If you're an IAFN member, you have access to continuing education nursing credit, and that IAFN is an accredited provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. So today, our presenters, as I said, come from the National Network to End Domestic Violence, Andrea Wilson, and from the National Sexual Violence Resource Center, we have Sarah Walters and Carla Bierthaler. I will pass this over, and they'll do a little bit of a self-introduction. Thank you so much. We appreciate that, Angelita. Welcome, everyone. I'm really excited to be here with this team and to speak with you all. My name is Andrea Wilson. I'm a Deputy Director for the Capacity Technical Assistance Team at the National Network to End Domestic Violence. I started working in direct services with IPV survivors in the mid-90s, and then I also worked at the Illinois State Coalition Against Domestic Violence. But I've landed here at the National Network to End Domestic Violence, and I've been here for about nine months. And our organization provides training and technical assistance to state, territorial, and tribal coalitions against domestic violence, along with policy and advocacy work across the country and the territories. Again, I'm happy to be here. Can't wait to speak with you all and learn from you all. Thanks. Hi, everybody. My name is Sarah Walters. I work for the National Sexual Violence Resource Center. I'm a Project Coordinator, which just means that I work on a handful of projects that we have over at NSVRC, and working with IAFN is one of them. Prior to coming to NSVRC, I worked with a county-based Victim Services Assistance Center that was a dual center, so we served both survivors of sexual assault and domestic violence. I provide the direct service, primarily medical advocacy, to victims and survivors of SADV and human trafficking. I also, as part of my role there, provided education and training programs to different community groups. One that I did most often was I trained local physicians and healthcare providers in how to screen patients for domestic violence and how to respond to DV in those settings. I have my doctorate from the University of Tennessee in education, so I love talking about things and learning with people, and alongside people, so happy to be here. I'll round us out. Hi, everyone. My name is Karla Veerteller, and I work for the National Sexual Violence Resource Center. We are a project of the Pennsylvania Coalition Against Rape. I worked there for many years, and prior to that work, I also worked at my local rape crisis center in college, so I've been doing this work for many years and really excited to be here today. The National Sexual Violence Resource Center was founded in 2000 with funding from the Centers for Disease Control and Prevention to provide training and technical assistance to rape prevention education grantees, but we've grown since then and expanded our work. Now we do a range of sexual violence intervention and prevention work. Things that might interest you, we run a national sexual assault awareness month campaign, which is in April. We have a large library where you can request journal articles, books, any other resources having to do with sexual violence. We have over 55,000 individual titles right now, expanding our access of resources in different languages, so that is a resource for you all. I also wanted to share, we have a podcast that has been pretty popular, and that's on our website. I'll drop the link into the chat for you, but a big piece of what we do is also to support state sexual assault coalitions, those also in territories and tribal coalitions, and then in turn supporting their member rape crisis programs. So we're happy to be here and happy to provide conversation and thought for you today. So our learning outcomes today, first we hope to talk about the role of the victim advocate, and we know that can be a confusing title. It can mean many different things. That could be a community-based advocate from a community-based rape crisis program or domestic violence program. It could be a systems-based advocate, which is someone who works perhaps for the police department, the district attorney's office, the hospital. There are a range of system-based advocates. When we talk about all of those groups, we want to talk about the importance of understanding confidentiality among those advocates because the privilege is different there. We also want to talk about relationship building. That's why our kind of tongue-in-cheek teamwork makes the dream work. Relationship building is imperative to making sure that the, excuse me, patient's needs are met in the best way possible. So we're hoping to offer some strategies and ways to build those relationships. Then finally, we want to talk about some guidance that is out there, both nationally and other tools that are available to you, thinking about creating these relationships with your local advocacy program. So we just want to start with a quick icebreaker. We can use the chat to respond to this. You're welcome to participate, ask whatever question you'd like, but we'd like to know if there is one question that you have about the role of the advocate when it comes to being in a medical advocacy space, working alongside forensic nurses, or if you just have a general question about the role of an advocate. If you want to put that in the chat, hopefully we will address some of those questions as we go along today. And then if at the end there are some lingering that we have not answered, we will revisit them and talk about them. I just want to offer a moment or two for folks to put those questions in the chat, and then we can get going. Does the advocate document any events or conversations? As Carla mentioned, one of the primary things we will talk about today is confidentiality and what that looks like. We can talk a little bit about what documentation can look like for advocates in a forensic space. Should the advocate be called first or should they be called at the same time as the same? I'm glad to say we will also address that, thinking about what does that process look like and how do you build from there. So I want to invite folks to continue putting questions, and if you have questions that come up along the way, you're also welcome to put them in there. We will hopefully get to them either already in our presentation, and if we don't, we will revisit them when we get to the end. So what is the advocate's role? What does an advocate do when they are called during a forensic exam? I think that's the best place to start. What does it look like when an advocate comes into that space? An advocate is there to provide support and advocacy. I know advocacy is the vague word in a lot of ways, but what they're there to do is provide that support in a lot of different ways throughout the exam process, and this includes things like legal advocacy, advising the survivor or patient of their rights and options. When I say rights and options, a lot of different things. Legal rights and options, guiding them through their options around law enforcement and legal processes, as well as their rights as a patient during the exam and what to expect. So when I was training as an advocate, a big part of our training was actually taking apart a forensic exam kit and going through every step so that we as advocates understood what each thing was so that we could help guide that patient or survivors through that process. They're also there to just provide general support. They are trained in trauma-informed care and approaches, and oftentimes they provide a great comfort and emotional support beam through the process, especially if a patient comes in and they don't have a support person of their own. So having that advocate there can sometimes be just a source of safety and comfort to know that somebody in the room was there with only their best interests in mind and nothing else. And I will let Andrea talk a little bit about the last thing. I appreciate what you said, Sarah, about breaking down the forensic exam and the different pieces of it, because that really gets to the heart of trauma-informed care in terms of transparency so that a survivor and a patient is aware of what the steps are and can understand what the purposes are and has the opportunity to buy in or buy out of that. That's really critical. So I appreciate always anything that is focused or steeped in trauma-informed care. So the last dot point on the slide is about the advocate's role as providing safety planning, which is huge. It's, as you all know, a huge topic. It has a lot of components to it, but it is really about that support that Sarah just mentioned, knowing that advocate is there solely for the patient survivor and that advocate has connections in the community and not just knows the places that offer various services a survivor might need, can provide a warm handoff that knows that these are accessible, trauma-informed, positive places for a survivor patient to access resources. The advocate's role in safety planning, they're so critical to the process because of the relationship they've built with survivors. When we in the IPV world talk about the components of really great advocacy, we're talking about connecting with clients, understanding what they're offering us in terms of their stories and the terms of what brought them here, what they've experienced, analyzing the situations with them, strategizing with them, and then implementing the plans that they determine are best for them and adapting with clients when those plans don't work out. So each of those pieces of advocacy around safety planning and just in general with survivors strengthens the trust between the advocate and the survivor. So that's what makes the partnership successful. When that's paired with the advocacy and the work and the support that the nurses provide, it's a real pillow. It's a real soft landing for survivors in terms of safety planning and a trauma-informed environment. I know that I have the privilege of knowing that we're going to talk a lot more about this further along, but I think just looking at some of the questions in the chat, I just wanted to put out to everyone that's here that once we get to actually working collaboratively, that section of it will bring all of this together on what the roles look like together versus separate. I just wanted to clarify that because I see some of the questions coming up separating it out. Thank you. Great. Thank you for pointing that out. Yeah, we will, a lot of the questions I'm seeing as well, I know Carla put it in the chat as well, we will cover a lot of this, which is great. But I want to start with talking about confidentiality. So now we have this basic understanding of what do advocates do, what is their role in that space, but what is the benefit of having that advocate there to provide that support? One of the primary benefits to having a trained advocate present for a forensic exam is that they hold a different level of confidentiality, often than nurses, often than systems-based employees or advocates, so someone who might work for a hospital or a law enforcement or the district attorney's office. Sexual assault advocates hold a higher privilege. In some states where I live in Pennsylvania, where I practice as an advocate, we are even legally protected from being subpoenaed to court to testify. They're often only mandated reporters of child abuse, but the specifics of state privilege does vary from place to place. So it's hard to make a blanket statement about what that looks like in every state, but it is typically that an advocate will be able to offer and provide that higher level of confidentiality and a very separate type of confidentiality than what will be present in a system. Advocates who are housed within a department or employed by a college or university and who work specifically on campus might also hold a different type of confidentiality due to things like Title IX and the Clery Act. So they may have different reporting processes or requirements that they're mandated to do because technically a campus-based advocate would be considered a systems advocate. So just making sure to point out that distinction between those things, a campus-based advocate versus a community-based advocate. Carla did put in the chat there is a tool that you can look through to identify your state. Andrea put another one as well to see what type of confidentiality, what are the legal statutes that protect advocates in different states and what do they look like? But that is advocates holding that level of confidentiality is one of the things that makes them such a great asset to have in that space to support survivors and patients through that process. Andrea and Carla, if you wanted to add anything. I was just going to add, I think it's important to know what the statute is in your state. I think a good comparison is a community-based advocate's privilege is very similar to a therapist or counselor's privilege. So if someone's going to hurt themselves, hurt another, or child abuse, those are the cases that rise to where advocates have to report. So that's just a good kind of comparison. Someone had asked about a patient who was talking about suicide. That is something that advocates would have to report. So just wanted to share that. Similarly in Illinois, the advocate privilege is on the same par as a legal privilege. So it is as strong as you can get. And that is critical to the nature of the work. The folks that we see experience violence have come through many systems before they get to us, often have had different parts of their story taken over, different parts of their experience taken over by those systems without permission. So for us to receive what it is we need to provide the services that they are requesting, it's critical that the nature of our conversations is privileged. I think states are getting stronger and stronger in their bolstering of those laws. So please do check out the two resources provided in the chat and look for your state. That might spur more questions or some more advocacy. I did see a question in the chat and I just wanted to address it here while we're taking before we switch slides. If an adolescent patient has shared information with the community-based advocate and would like them to share the story with the same nurse, every case is going to be different. With our community-based advocate confidentiality, the survivor owns their information. So an advocate would share that based on what the survivor requests. And we would just ask them to sign a release form. I would just assume that you would document that in your notes, but hopefully that answers your question. I can chime into there if you don't mind as well. I think that understanding that advocate has provided that information and you have that something in writing from the patient that they're giving consent to do that, I think that's great. Also keeping in mind that you still have the ability to confirm and ask additional questions to go along with that. So you still have a whole exam process that you have to think about as far as providing your medical care and treatment for this patient, as well as thinking about evidence collection. Just keep that in mind that there are additional components that you can actually continue to gather from the patient so that they're not repeating the exact same thing all over again, but you're still getting the information that you need. I hope that was helpful, Amy. This is Andrea. In terms of the IPV perspective, interpersonal violence perspective, we would always encourage as much as the survivor patient can to have them continue to convey that story, even more preferable than signing a release of information to help them see the forensic nurse as a partner, as a support person in this process. A lot of times that's one of the other benefits of an advocate, a community-based advocate, is that they can uphold that nurse as a partner as well. We'd love to see and encourage the survivor to continue to share that story rather than having the advocate continue. This slide kind of touches on things that we've mentioned already so far, community-based advocates holding that confidentiality privilege that often state-by-state differing, but may prevent them from being subpoenaed, which I know was mentioned as a concern. Systems advocates like those who might be based in a hospital or a college campus. I use the word loyalty here, but it's really their requirements. What are they required in that space to do and to report? It's going to be up to that employer and the system that they work within. Whereas a community-based advocate, their employer is telling them that they have to keep this level of confidentiality, so it's a very different kind of system to work under. Thinking about the way that survivors coming into a healthcare space, they may already feel distrustful of systems that have been harmful to them in the past. When I say systems, any kind of system, the healthcare system, the law enforcement, the legal system, and even sometimes they may have had a bad experience or a negative experience trying to seek help before in any capacity. Just keeping in mind about having that person there that you can explain that this person is someone that is not going to take that information anywhere else or use it for anything else except to guide and support them could be a helpful aspect in supporting through the exam process as well. Sarah, that's such an important point, I think, as well. In understanding and intentionally keeping that in our minds, how a patient, a victim might present. That could be in a lot of different ways. That could be no affect, that could be no emotion, that could be so easily startled, just inappropriate anger. All of these things we know because they're coming to us with likely a history of trauma that has built up over years, if not generations, depending on the circumstance, if we consider historical trauma in that as well. It's such a great tool to have to understand why that happens and to not lay the consequences, potentially, of that behavior at their feet, but be ready to understand that has nothing to do with us, it has nothing to do with you, and be able to provide a different experience at the hospital. Do we want to pause for any questions on confidentiality before moving forward? Okay. You'll have our email and feel free to add any additional questions in the chat throughout our time together. Now we're going to jump into talking about establishing relationships and partnerships with community-based programs and other advocacy services, systems-based. I want to start with talking about formalized relationships. We have found that this can be very helpful because when you have a formalized relationship, you're sitting down and writing everything out in terms of who's going to do what, how things operate, this forces conversations that you may think you know the answer to, but you don't, we do encourage memorandums of understanding with the community-based program to talk through. I know someone had asked the question, what's the best way when a survivor comes in, do you call the SANE first? Do you call the community-based advocate first? That's something that you would talk through when establishing a memorandum of understanding to establish what will work best at your hospital, at your facility, what would be best for the community-based program, because they may have someone who is a specific medical advocacy coordinator who would come in and always be that person at the hospital, so it'd be harder to get in touch with them, or it may be someone who is on call for all survivors' needs at a certain time. So it really would depend on what's happening in your community. Yes, that's a great kind of jumping off point of saying, let's start talking and let's think about creating a relationship, like a memorandum of understanding. And I would just support that from an IPV perspective that it's such a critical piece, and sometimes the most complicated piece to maintain, particularly with turnover in staff, but maybe a community-based agency that's providing support, and even at the hospital, or a change in leadership and a change in philosophy about your arrangement or your relationship that's established and defined clearly in your MOU. But establishing these relationships early on where you create that opportunity to talk about the differences in your goals, because while we work together, we clearly don't have the exact same goals, right? We have different responsibilities, the differences in confidentiality, and just establishing a way to work together that benefits the survivor and maintains the standards for each of us, and nurturing that relationship is just so critical. So I think this is an important topic to cover. I just wanted to share an example. NSVRC is working with IAFN on some SANE sustainability programs, and we've talked to several sites where they have social workers at the hospital who almost act as an advocate in providing that patient support. We've talked through, because they don't have the level of confidentiality as your community-based program would, perhaps having someone on call, if the patient wants to have a very confidential conversation with somebody that isn't necessarily needed in the process, but is available if that level of privacy is needed. So thanks for bringing that piece up, Andrea. So establishing those relationships would obviously be the first step. So then how do you build from there and foster that and keep it growing? Andrea and Carla have already mentioned a couple of things and parts of that. One of those things is consistency in service, and that might mean something like trying to maintain the same team of advocates that the nurses know and are familiar with and can work easily alongside and who they trust as well as providers, rather than having potentially a different advocate come at every call. This might be extremely challenging with staffing, especially for centers who primarily have volunteers who may serve in this advocate role, but it is something to consider when setting up a partnership. What does this team of advocates look like? How do we build that relationship between those advocates who are going to be providing this service and the nurses who are going to be calling them in? And that could mean encouraging these meetings and interactions between the forensic nursing team and the advocacy agency. So like encouraging them to have and maintain a working relationship. So this can take a lot of forms. When I was an advocate doing direct service in a lot of medical advocacy, we included the forensic nurses we worked with at the facilities we had MOUs with in some of our center staff meetings. Sometimes they would come and introduce themselves. I worked at a YWCA. So sometimes they would come to our full meeting so that our whole organization could know who they were and recognize their role. We went to the hospital often or the facility they were at and worked with them, even if there wasn't a call, finding opportunities for those interactions. Even things as simple as we at our agency celebrated forensic nursing week alongside the nurses. And we made sure to highlight their efforts and we made gift bags and things for them that we took around. We posted on our organization's social media about what they do and who they are and how they serve our survivors. And something that I thought of to add to this while Karla and Andrea were talking is a part of fostering that relationship could also be revisiting that document that MOU you established. Maybe it's a set interval of time, or maybe it's if there's a leadership change, but I do know that when I was working as an advocate, having this kind of outdated, very static document that maybe has turned over staff so many times that nobody knows that exists. It was so important for us to try to pull that back out and revisit that. And that could be just another opportunity for those two teams to interact with one another and to continue fostering and building that relationship as well. With okay. If I offer a couple of things as well, one of the things that that we did in the program that I oversaw was we actually did a tour of our facilities, of course, for the staff, but every time there was a rotation of volunteers that came through, we did an in-service, invited them in and did a whole tour of the ER so that when they did have the opportunity to come, they knew where the exam room was. They knew where all the things that they needed to have access to was how to get there and they were a little bit more comfortable, we also did the same thing where we had them come to our staff meetings and we did external community based things to also collaboratively. Sometimes we would talk about the response for advocacy and for medical in spaces like college campuses so that they can have an idea of who we are and how we work together. So just keep in mind that there are a couple of different things. The other thing that I would also encourage to go along with those MOAs are really considering an open line of communication between the forensic nursing programs or the same programs and the actual advocacy. So both whether you have an advocacy agency that's separate for IPV and separate for sexual assault or even if it's dual, because it's really helpful not to only communicate when you have an issue, but to be able to also do check ins and see what's going on just on regular times, because every time it may not be that the issue feels big enough that someone is complaining about it, right? But being able to give feedback after your exams and when you do meet together to collaboratively talk, that also fosters that relationship and helps to build and strengthen it. That is absolutely correct. We also did a lot of those things similarly when I was working in direct service. And so I called on that a little bit here as well. So thank you for, for transitioning me perfectly into this next part of, we often would invite the forensic nursing team to either present or attend like a lunch and learn is what we call within our advocacy organization. So the advocates would have something that they could train on that the nurses might benefit from hearing. And that's also just another time that they could be included and involved. Or the nurses could come and speak to their role and kind of educate the advocates and our victim services staff and the advocates who worked in our victim services staff, who didn't do medical advocacy, who worked in our shelter, but could still benefit from understanding and along the way, the goal through all of this, and we've mentioned this already before is to be able to better support our survivors that we're working with. And these partnerships are fostering that, working on that, encouraging that is, is a great way to do that. Empowering the nurses with that broad understanding of what medical advocacy is, I think it's a both ways situation for advocates and nurses, advocates to understand the role of the forensic nurse and for vice versa, I think that can really be extremely empowering and helpful. And I do want to touch on what are called SARTs and MDTs. So sexual assault response teams and multidisciplinary teams. Those are typically community-based that pull from different community providers and stakeholders like advocates and nurses or law enforcement. Maybe it's a campus. They might have a campus in the community, representatives from there. And it's a group of folks who can come together and look at the practices and decide what's working, what's not working. This might look like looking over case studies of something that did happen in the community and being able to identify where we can build and do better and how we can respond in a different way. And so I know that was mentioned as looking at things we've done. So I do want to point out, we've dropped this in the chat as well. So NSVRC has a toolkit for establishing one of these response teams and how to maintain one, how it works, what the logistics can look like, and all of the different things that could go into a group like this, if you don't have one established in your community already, this is a great tool for making that happen. And so just a little bit about the SART toolkit. This was a project funded by the Office of Victims of Crime. They had funded NSVRC to create the first SART toolkit, which still lives on the OVC website. And then this was an update that was completed in 2018. And it is very comprehensive. If you dig in there, you will find more than you need to know. But even if you don't have a SART or your community isn't at a place where you want to form a SART, there are sample MOUs there. There's conversations about relationship building, meeting logistics, things like that, even if you don't have a regular SART or MDT meeting in your community, you could have one once a year, that's like a lunch and learn and getting to know people and have different presentations from folks in the community because you will be working together as you serve patients and survivors. So learning about the services that are offered in your community is great. There's also information in this toolkit around working with different survivors. There's one on international sexual assault, on trafficking, on different cultural communities. We've really tried to be as comprehensive as we could, even as you'll see sex offender management is covered there. So we really tried to take, as I said, a very comprehensive look at the issue of sexual violence in your community. But a lot of it, as I shared, could be applicable to IPV as well, or any other form of violence in your community and community organizing. I just wanted to lift up again, so many relationships either crumble or don't function as well as they can because of the simple lack of understanding of what each other does, what each other is governed by, what each other's philosophies towards the work that they do are, and so all of the things that everybody's offered in these last few slides from MOUs to Lunch and Learns to these groups, these multidisciplinary groups and SART teams are really about creating our own relationships so that we can, don't work that stuff out with a patient or with a survivor in the moment. As Angelita was saying earlier, you can't wait for the crisis time to have these conversations. It just doesn't work that way. It's been our history in the domestic violence movement with law enforcement. We can't deal with why we're not going to let you into a shelter at three o'clock in the morning right now. No, we're not obstructing justice. Sorry, this is not the time to have that conversation. Time to have that conversation is when we can all just sit down together and talk about where we come from and how to get to where we both need to be together. I'm really appreciative of the conversation around this topic. So I want to offer just another opportunity to ask some questions if you have any, and we are curious as well to ask a question, what is your current engagement, if any, with community programs or agencies, and you're free to use the chat to answer this. This is just so we can gauge where folks are at and see like what gaps are there. If so far in what we've talked about, you're seeing some things come up and maybe parts of that relationship that maybe you have one established, but there's pieces of it missing or not functioning, if you want to share that in the chat, you are more than welcome to. And I will just give that a moment for folks to do. I know we had heard from Janet earlier who shared that they're very fortunate to have a great relationship with their forensic team and the examiners are present at volunteer training and also do an emergency room tour. So that's great to hear. It also looks like Angie put in that they have a hospital-based advocate who does their direct referrals and community-based advocacy to community-based advocacy. And then when the hospital-based advocates are not there, they use community-based advocates to provide advocacy and resources. And then Amy noted a really common issue. They said that they have a great start in relationship with community advocates. However, our outlying rural hospital areas need to develop relationships and education, such a common challenge. When you have smaller hospitals, you have less staff, you have fewer law enforcement, you have fewer community advocates. It can be a real challenge to take the time, to dedicate the time away from your respective job duties to build these relationships and come together and talk about your goals and how you support victims. And that is so common. If anyone has any great success stories on that, we would love to hear it. I'm in agreement with that, Andrea. That can be very challenging. Even in that same scenario where you flip it, where maybe the sexual assault or the nurse that's doing the exams may be the only nurse in the community, right? And so trying to be present, to let people know this is what they're dealing with or what the changes are, but having to cover so many different things makes it hard to even engage in that manner. There was some great feedback in the chat there. Almost all of you responded, which is amazing. So thank you for that. I'm happy to see that there are so many folks chiming in saying that they have a SART team or that they are a part of a SART team. That's great. I'm really happy to hear that. I like hearing from Meredith that their advocates help their program participants in court appearances, finding services, resources, counseling. Randy did say that they have a SART to provide all victim services for patients as they're the only victim services in their community, no TB programs or advocate. That is not uncommon. Again, as we were mentioning in certain areas of the country, especially if they are rural, the County that I worked in as an advocate was a very big County and we were based down almost to the bottom of it and in an urban center. And outside of that urban center, it is extremely rural with very limited resources for folks out there. And we would do events further out in the County where folks out there had no idea that we would be the service provider for that area because it is just a large space that does happen a lot. In the interest of time, I'm going to move us forward, but please feel free to keep sharing. So we're going to move now into talking a little bit about trauma-informed care and not that it's really separate from all of these things that we've been talking about. We know that it is part of all the things that we do starting from that relationship building and creating MOUs with one another through to how we interact with a patient. But we wanted to take some moments and just highlight how practically speaking that trauma-informed care shows up in this work. And when we talk about trauma-informed care, we're really talking about some foundational elements of safety. First of all, we're talking about creating a space where a victim patient may come that they can physically feel safe and emotionally feel safe, that there is a level of trust, that there's clarity in what you are about to do, what the process is going to be, that there's transparency in what is going to be asked of a survivor, that there's choice as another sort of pillar of trauma-informed work, that the survivor is in control of what's happening to them in that moment, that what happens to their information, and that they're partners, that they collaborate with you, that as you are conducting your work, as you are conducting an exam, that you're doing this with them rather than to them. It's also an empowerment philosophy where you come at it working with a survivor patient with a strengths-based approach, validating their experience, validating their emotion, validating their concern. And a trauma-informed environment is also conscious of cultural differences and able to respond to them in an appropriate manner. And so we're going to talk about a few ways of supporting and uplifting trauma-informed care. And the first is really prioritizing privacy. It's very possible that a survivor patient might show up with their attacker or their partner. It could be a caregiver or a relative or a person with disabilities. And so we have to think through finding spaces where survivors are safe enough and free enough to actually tell the truth about the things that are happening, and create those spaces wherever they can so that they have that immediate sense of feeling safer and can actually respond to your questions and receive the care that you have to offer. I will add one of the hospitals that I worked with as an advocate was fortunate enough to have a forensic suite that was a designated space in that hospital specifically for survivors who would come in of sexual assault, domestic violence, human trafficking. And that suite was also where those forensic nurses had their office. So it was its own private area and had a door that you had to be buzzed into. There was a little waiting area that had even some toys for kiddos, a space for family. And then it went into another door that had a whole exam suite that had a private bathroom and shower, all of the materials that would be needed for providing an exam and a good amount of space for I think someone to maybe not feel closed in as well. But there were times that someone comes into an emergency department and they are in a crowded emergency department and they are separated by curtains and they are not able to have that really private space. Trying to prioritize moving them to that private space, even if just for the purpose of having that conversation, and then maybe they can return back to the emergency department if they need to. But finding those opportunities in those places. Another hospital we worked with did not have a suite, but they designated a specific office or room that the advocate could then go in with the patient and use that space just for that. So I know that it's very fortunate to have a forensic suite and that is not always the case, but finding those places is really important. So just thinking about for the forensic nurses and the SANE nurses that are on this particular webinar, if your program is expanding beyond sexual violence to actually respond to intimate partner violence, a lot of times there's not as much push for this same exact format for those IPV patients. So we actually do want to try to advocate for that as a nurse. Even if it is just like Sarah said, for the ability to do that safety planning, to do your screening, have a space that you can move them out of those normal settings to be able to do that, even if it's just for a short period of time. I think it's really important for us to think like that, especially if you aren't already or you're thinking of actually expanding beyond seeing your sexual assault patients. So building off of that, a way to do this potentially is to emphasize confidentiality as your policy. Emphasize this is how it has to take place. There has to be this opportunity to provide that level of confidentiality, to provide that confidential space and time, and mentioning or leaning on the fact that advocates require full privacy with patients and survivors in order to provide those confidential services. So leaning on policy is sometimes the thing that you'll have to do, but those things lend themselves into highlighting how this all embodies and encapsulates the pillars of trauma-informed care that forensic nurses are trained in and trying to provide in these spaces. So how can forensic nurses support advocates? We've talked a little bit about the role of an advocate in this space. So how can we foster that relationship in that moment of providing service? I think one of the best ways to do that is to have that broader understanding of the advocate's role and the purpose of medical advocacy, which I feel in the time that I've been doing this work, the term medical advocacy can be such a muddy term that folks don't fully know what that means and what that looks like. I think having that definition and understanding it and reiterating those roles to one another and understanding what purpose that advocate is serving is one of the best ways to support them, to understand what they're there for and to the purpose of their role there. And that one of the best things you can do to support that advocate's role and work is to assist them in upholding that privacy and confidentiality. So if that means speaking on behalf of policy, if that means finding that private space. When I was working in direct service, I was on call a lot. I would come in the middle of the night sometimes and it might be a very tense or emotionally charged situation, particularly if it was somebody coming off of maybe an IPV call and they were in for that. And I know many times I as an advocate, I'm a small kind of woman walking into this space and I would have to assert myself very strongly law enforcement who were in the room to make sure that they knew that I needed that space and they did not have an entitlement to that space while I was talking to the survivor. And so that could also be part of the MOU and talking with your SART team is making sure law enforcement understands that they don't have the right or the entitlement to that space. But I had nurses who knew me and who were on my side and knew what I was there to do and wanted to support me. And if I was dealing with a particularly challenging interaction with somebody who didn't understand my role, they would stand with me and help me assert myself in that space. And that was incredibly helpful. I don't know if Carlo or Andrea, you want to add anything? Again, I feel like I'm the professional relationship builder, lifter upper on this call. Again, we need to remember law enforcement when we talk about relationship building and coming together, talking to one another and say, so this is what you can expect when you come. And these are the things we're going to, these are the reasons why, and here's the statutes that indicate that. We know you have a role to do, talk to us about that. What do you need? And let's see how we can meld these two things together is just critical. Again, that we reach out before we have that confrontation or that tense time or some sort of additional traumatic display in front of a survivor. So can we address another question that was way earlier in the chat? I think that the last slide was a good place for that. One of the advocates on the call had actually said, how much advocacy does a saying do? And I think this is a good spot to actually address that. A health clinician role is not really the role of an advocate at all in the same perspective of advocacy as we're talking about here. So nurses do advocate, but when they're advocating on behalf of the patient's rights, whereas the advocacy that we're talking about for victim services are advocating on the behalf of the patient's victims rights and in their voices and so forth. I think that it's important to understand that in terms of the saying nurse, whether the advocate is the person that's going to introduce the medical forensic exam and explain that, and then the nurse coming in and reiterating the same thing and doing it in a different manner, that is one thing. But if there's no advocate available, it is the role of the saying to be aware of the needs of that patient. So for example, if a patient declines an advocate, but I see that patient is struggling and needs support, I have the ability to go back and talk again about advocacy and see if I can right now in this moment, try to engage that patient with advocacy and reiterate why I would think it would be really helpful. So again, that goes to that relationship building and understanding each other's roles. If I didn't really understand the role of an advocate, it would be very hard for me to know when they've already declined. I really want to push for them to go ahead and try to re-engage with services at some point, even if not right then. But at the same point, I also have to understand from the medical perspective when I need to advocate on behalf of my patients, such as if the physician or the clinicians are not adequately providing the care that patient deserves, or they're not being treated appropriately. From the perspective of the advocate, if they're there and they're witnessing that, they're going to be the voice if the patient can't be the voice to say, hey, this is what I'm seeing. But I'm going to be the voice as a medical provider to say to the doctors, this is what I need to happen. I need that private space. Can you find me that space? I can't conduct this exam in this setting, whatever that looks like. I hope that helps to address the question, but I didn't want to let this section go by. And you guys can please feel free to add anything to that. But I think that may help to clarify that question a little bit. No, it was an excellent explanation. Thank you, Angelita. And I see a comment for Kathleen. The SANE nurse does not want the advocate to explain a SANE exam. And that's fair. That's the right to ask that. And that could be something that's outlined in the MOU. So everybody has a clear understanding of what their role is in that space. And that doesn't have to be negotiated in front of the patient. Just to add to that, Carla, that's when it becomes the community advocate's job to support that nurse in that role. I think this relationship between the nurse examiner and the community-based advocate is one that is mutually beneficial when both are informed of each other's role, because there are going to be possibly some other factors at play where it's not appropriate for them to be part of the conversation, but they're inserting themselves. For example, if police are in the room and the patient does not want them to be there, everybody's knowing their role and advocating for the patient as a team is very helpful. And understanding your agreement with each agency. And I have to say that because just as she said that, it made me think about communities where they have more than one forensic nursing program or SANE program or advocacy agency, where there may be a different agreement between those particular programs that may look different than someone else at another facility. So I know that becomes problematic, but unless it's addressed on a community level and everybody agrees to one thing, sometimes that is actually what it looks like. But again, keeping the communication open and that relationship going, that's helpful there. So I wanted to share also some things. I think we're talking about creating trauma-informed physical spaces. If you have the privilege of having a specific room for victims who are there for a forensic exam, I put a list of some things to think about. Is the space comfortable? Are there visible exits for the person? They may be spending a lot of time in that space waiting. So just creating a comfortable space. Are there people to ask questions of? Is it clear kind of what the process is, what's happening? But different states will have victims' bills of rights, survivor bill of rights, any of those things. Could be something to post on the wall or the community-based programs information or other programs in your communities. Just things that the patient can look at if they're in the space waiting for you or for the advocate to arrive. And the survivor's bill of rights was passed in 2016. Individual states are also passing it, but it is a change, an amendment to the federal criminal code based on the rape exam backlog that was covered by the media extensively around that time. And it gives sexual assault survivors the right to not be prevented from receiving a forensic medical examination and not being charged for that examination. That's another important piece to keep in mind. Every state is different, of course, but most states have VOCA funding that would cover the forensic rape exam and the care received at the hospital when receiving that forensic rape exam. And also this statute covers that the kit will be preserved for 20 years or the maximum available due to the statute of limitations, whatever is shorter, and they will receive written notification if the kit is going to be destroyed after that time. So hopefully that is in place in your state as well, but an important piece of information to post if available and other things that are pertinent to the patient. We were thinking about this too and what type of forms like these bills of rights could take on and where they could be sourced from. Your organization that you work with, your community-based organization, may have created some kind of survivor's bill of rights that they follow or they post or they have distributed. Or even like your SARTs or MDT may have created one. Or if you haven't, it could be something to consider creating as a team and coming up with and posting that, whatever it is that your community group comes together and creates and agrees on. So there was a question that came up a little bit earlier about when do we call the advocate? And we have some recommendations here. However, I'm going to expand on this a little bit. We recommend calling the advocacy agency upon that intake or the disclosure because we also recognize that sometimes folks will come into that space presenting for another reason and then later disclose that something had happened. So whenever that intake, if it's for sexual assault, domestic violence, those issues, or when they disclose, to call the advocate. This allows the advocate adequate time to arrive and provide that support. As someone who worked as an on-call advocate, I actually lived about 35 minutes away from the hospital that I served. And sometimes it would be two o'clock in the morning and I would have to throw my clothes on really quick. But we had an agreement as part of our MOU that it would be within an hour. An advocate would be present within an hour of being called. So we had an hour to arrive. I struggled sometimes with one of our facilities because they would wait until they were discharging to give us a call to then come in and provide support. But sometimes we would completely miss the patient. They would be gone by the time we arrived. And maybe they were handed our brochure, but they weren't provided with that support during the exam or the advocacy and the guidance. So giving your advocate enough time to get there to provide those services is the best thing we can recommend. And that also aligns with if those instances are happening where maybe law enforcement is involved and this patient or the survivor isn't aware of what their rights are prior to having those interactions with those folks, that might complicate things as well. So just trying to make as much time that you can for an advocate to get there, but also to provide that support. And this doesn't always have to be in person. So there's been a few things in the chat that folks have mentioned about the struggle with having facilities that are really far out there in rural spaces. And maybe there isn't an advocate in that community that can come provide that service. Something that we had to shift to, and I'm sure most folks did as well during COVID, was tele-advocacy. A nurse would call us and they would then hand that phone to the survivor. And the advocate was then able to talk to them over the phone. That is still very much an option. If that is something you write into your MOU as your community agency is okay to provide, that could be a great option for those spaces that maybe are far out or don't have a community advocate readily available. The third option is more of a follow-up care option, but there are some community organizations, like the one I worked for, where we had outreach sites. And those were just community locations around the county where folks could come and set up a time for an advocate to go to that sort of satellite space and meet with them. For instance, we had one of our outreach sites was a library. It was a community library really far north in the county that was really out there in a rural space. And they had a private room and that room was available there in case somebody wanted to have an advocate come there to meet with them and all of our information and materials were in that space all the time and outlining that was an outreach space. The thing that's going to guide you the most through all of this is just having that policy and process, whether that's an MOU or whatever the case might be, having that in place to lean on and to reference. So whatever the process ends up being and working well for your facility and your community agency that you have an agreement with, lean on that process and do what it is that's working for you. I also suggest that you be okay with thinking outside, having a conversation about it and really thinking what is beyond the norm, what is beyond the regular thing that's our go-to and talk about how we can try and make that work. I think that's really important. Sometimes you get a little streamlined and it's like it has to be X, Y, and Z when their options are actually readily available to you, especially in those rural communities. The solutions they come up with in those rural areas, I tell you, it's stuff you wouldn't think of, right? But you have to be that creative. And it's a great opportunity to turn to the patient survivor and see what sounds appropriate to them instead of, like Angelita said, our menu of options and how we provide these things, be open to their suggestion. And interestingly enough, there was a large city that we worked with who had a mobile forensic exam unit. And so the patient would be leaving by the time they could get to where that mobile unit was. So they utilized phone advocacy there as well in a larger city, just because it made sense in their community. In the same way that you would provide that private space for an in-person advocacy interaction, you could still provide that private space for that phone conversation. So our forensic nurses would hand off the phone and they would then exit the space, and then survivor could have a private phone conversation. So there are ways to make and keep those types of interactions confidential and safe as well. So part of that process of working with advocates is ensuring, as we've reiterated and emphasized throughout today, is ensuring that they understand their rights and their options. And one of those rights and options is to have an advocate present for that entire exam or visit, if that's what they choose. And Andrea pointed out that one of the guiding principles here that we all want to lean on and follow is keeping that survivor in choice mode. They get to make that choice, whether or not they want to have that advocate there. And we want to give that choice to them if they do want to have that advocate there. So making sure if you're working with advocates that you advise that survivor of that right and offer that to them, but also empowering those advocates as they're helping patients or survivors understanding their rights and options. There may be elements of moving through the healthcare system that they might need a better understanding of in terms of what is being written down, what is being reported, what is going to go into this space or that space, how do they own their information, as Perla said, in the context of that healthcare space. So just trying to keep that transparency, that collaboration, that trustworthiness in place for both the nurse and the advocate to be able to provide that support. Okay. So let's talk a little bit about safety planning in this context. And again, this is what advocates do on a daily basis. And it's simply, it is another thing to be done in the context of the trauma-informed perspective and where we are learning and leaning in from where the survivor wants to start, which may not be full details at the beginning as they work to see if you're a trustworthy person. But this is where we lean into them and find their concerns. What are they worried about in the moment? And then as they walk out the door. And so as they walk out the door might include returning home, which may have an abusive partner there, or maybe a space where their offender knows that they live. What are their next steps? Are they going to continue services? Do they have a follow-up visit to the hospital? Are they going to a shelter? Are they going to try to engage services in some way? Are they safe at work? Let's talk about what that looks like in school. And if they have children, what is the safety concern in all of those things? Are they going to be engaging the legal system in any particular way? Obtaining an order of protection or restraining order, stalking, no contact order, whatever particular brand you have in your states. So this is our opportunity to think about, to find out what is on the survivor's mind at this moment, what the patient wants to do when they walk out this door and ask questions with them on how to best help them feel safer and prepared for those situations. And so likely the advocate will maintain contact while the patient leaves the hospital and then goes on to these next steps. And the hospital staff will certainly be a part of that depending on the continued interaction with the provider. So that's just a basic look at what an advocate's perspective on what safety planning is. Did anyone want to add anything to that one? So I think Carla is going to talk about what safety planning looks like during the exam and the visit. Thank you, Andrea. That's a great overview of safety planning. We want to talk about the role of safety planning within the forensic examiner's role outside of the advocacy role. First, when we talk about allowing empowerment, voice, choice, that's really informing people of every step of the exam, preparing them for what's going to happen, what you're going to do throughout. Initially, before you get the exam started, talking through what the exam is, what you're going to do, where the exam is going to go, and then repeating that information. Because when a person is in the state of trauma, they're probably not going to retain a lot of it. So repetition is fine. Also, sharing materials with people. So if they don't retain the information you've shared, they have it with them. But just making sure they know what to expect and then what to expect afterwards. Where does the kit go? What happens to this medical information that was gathered from them during this exam process? And then also recognizing that throughout the entire exam, safety planning is being done. You are working with someone who has walked in to the hospital after experiencing a very traumatic event. So then while you're spending time with them, you're preparing them, empowering them, getting them ready to walk out the door again. And so allowing that choice, that empowerment, that conversation is really important in safety planning. So we understand that in our nursing care and our medical care that we're providing, we need all of this information for this patient. And you start gathering that information when that patient walks through the door. If you're thinking about that patient's safety, you're thinking about your safety, you're thinking about the safety of your colleagues that you're there with, right? So you understand that component of it. But it's not just about making sure that you're documenting the questions that are being asked in your kit. You're asking all of the things that you need to know to be able to help that patient, that survivor, get through the process of what's going to happen to them during the exam, but also what happens when they get ready to go. Are they supposed to work today? Are they safe to go to work? You really do have to think to yourself, what are the components that I need to be thinking about? If I'm working with advocacy, a hundred percent, like please engage advocacy in creating this safety plan. But gathering that information comes from the moment they walk through the door throughout their entire process. And then you figure out what's going to work best for them. If for some reason you don't have advocacy there, it does not mean that you can't work with someone else who is trained in doing safety planning to be able to make sure that patient has a safety plan in place that gets documented within their charting and that everyone has agreed upon across the lifespan. That's really important. I just wanted to reiterate that is part of your nursing process for the forensic nurses on the phone. And it just ties into exactly what you're being told here. I know that safety planning can seem like a really big, complicated process, but it really is something like Carla said, that you're doing naturally along the way of your process as well. Incorporating that into just the normal process of things. Just a couple more ways that forensic nurses can aid in that safety planning, collecting only the necessary evidence, limiting as much as you can that trauma, the physical trauma that may manifest from an exam itself and from evidence collection. And then in the process of discharging, preparing them to walk out the door, as we've said, is informing them on how they can find and access affirming, safe, affordable, accessible health care for that follow-up care, whatever that might look like that they need. So on the part of the forensic nurse, what that can look like is having a really good understanding of what your local resources are, whether that's a community or a sliding scale health care center. If the hospital is a place that the patient can follow up for care, if you have a patient who may require or need to seek gender affirming care or providers that are going to be gender affirming, knowing where those providers are and how to access them. All of these things are a part of emphasizing and embodying trauma-informed care and keeping your processes survivor-led. So keeping them in charge of making these choices, how they proceed further, and making sure that if we are referring out to places that we know that those places are safe and affirming. And we want to make sure as we're offering these resources, we're offering them as choices and not demands in any way. So making sure that we're handing, even if we're talking about community resources for a sexual assault coalition for counseling or support beyond the incident, being able to say, here's your options. As an advocate, the way that I would typically word it is, I know we're handing you this folder of information. I want you to know that you can access this whenever you're ready. You have this folder of information. When you want to read it, it's here for you. There's no time limit on when you can receive the support services. Don't have to do this when you get home. You don't have to do this now. You don't have to do this in a year. You can call us for counseling. Tapping into that, making sure that they know that they are in control of those choices and those decisions. So I know that some of the folks in this space may be part of campus health care centers or work on campuses. And there are some things to consider. We've mentioned a few things along the way in terms of confidentiality and how those might be different. Those privileges might be different on a college campuses. Forensic nurses working on campus or in campus health care centers. It's important that you know what those differences are. Understand your own confidentiality differences or reporting requirements you might have that are specific to working in a campus environment that might align with things like Title IX, whatever the university's policy is surrounding those things. And along the way, what you can do in terms of trauma-informed care, safety planning, supporting advocates, is ensuring transparency about who has what kind of confidentiality on campus. So when you tell a patient on a campus the word advocate, make sure they know what that means and where that advocate is housed and what it means if they talk to them versus the nurse or the counseling center. What are the differences in those conversations and what could be reported from them? And then you want to make sure that you are providing both on and off campus options for that, for those conversations to take place or for them to find support. For programs or responses that are happening in communities that have campuses but they're not campus sites, it's really helpful to understand these things too, so that when you get patients that come off campus to actually get exams and they're going back on campus, they know who they can talk to, who's going to initiate that, who will initiate a Title IX report. It's really important to engage in those kind of relationships if you have campuses and universities near you to understand what's happening on their campus as well. We just wanted to make sure that everybody understood that there are three national protocols that have been released over time, the latest one I'll talk about in a second, but basically the protocol really reiterates all the things that Andrea, Sarah, and Carla have talked about here. It really encourages understanding each other's roles, it encourages collaborative work, building relationships, it encourages utilizing advocacy for all forms of the exam up front as soon as possible, engaging advocates into the process as much as possible, even if they can't come or the patient declines, at least doing that call, giving that resource, and just re-engaging them. All three of the protocols definitely specifically have sections about defining what everyone's role is, that has information about what should those community responses look like, how you should collaborate with each other, and then how to engage advocacy throughout the exam process. So, the three protocols are the Sexual Assault Medical Forensic Exam, examinations adult-adolescent, that particular protocol is specific to post-pubescent patients, so anybody who's gone through puberty through adulthood. There's a Pediatric Sexual Abuse Medical Forensic Exams protocol, and that is for the pre-pubescent, and then there's the National Protocol for Intimate Partner Violence Medical Forensic Exams, which was recently just released, and that is for adolescents through adulthood, and that one is for any clinician, so it's not geared towards forensic nurses, it's geared for any healthcare clinician in any healthcare setting to do a better job at actually addressing the patients that have experienced intimate partner violence. And I can tell you for sure in the IPV protocol, that protocol has a lot of the information that you have here that we talked about broken down exactly how we talk about it here. I'm referencing that as the newest released up-to-date version, but I can also tell you that the adult-adolescent protocol is in the process of being updated as well, and it's going to mimic what we're seeing with the IPV protocol, but the point is to really look at some of those sections and get a good idea, because you'll see it goes right along with all three of the presenters that we have here today have promoted. So the other thing that I wanted to do was just tell you how to get access to these protocols. So safetyaid.org is a grant-funded resource that we, that IFN has. Our whole goal is to provide training and technical assistance about medical forensic exams to any provider, whether it's community-based, whether it's clinician, whether it's multidisciplinary. So this particular page actually houses multiple different resources on it. So across the top banner here, there is a protocols tab. If you were to click that protocols tab, you'd get a drop down, and this will bring you all of the protocols that we have. So the protocol national guiding documents, that includes not just the two sexual assault protocols that I just talked about, but it also has the national training standards and the best practice recommendations for sexual assault evidence kits. And then there's a national IPV protocol. And then there's also a link to state protocols. So of course, national guidance recommendations, but each state can create their own state protocol, which may further guide the exams within that state. So the state protocols actually has a state-by-state map where you can click on the map and it'll take you to, if that state has an actual protocol, you'll be able to access the protocol through that map. And additionally, and if that state has a state where it's saying coordinator or a state contact, their contact information is available on that page as well. The IPV protocol, the only thing I'm going to point out about that is we have our standard, a downloadable PDF version of the protocol, but there's also an interactive version of the protocol that is more TA enhanced. So by that, it has things such as additional resources. It has some documents and some forms that we created that are in there as appendices. So that part of it is a little bit more interactive and you can click through it. You don't have to scroll through a whole PDF to actually get through it. And with that being said, hopefully we got to all the questions, but please feel free to throw questions in the chat. We'll review the questions. And if anything did not get answered throughout this presentation, then we'll come back together and we'll create some responses and send it out to the folks that are on today. We definitely appreciate you all being here. Andrea, Sarah, Carla, I can't thank you enough for being here. I thought the webinar personally was amazing. I may be biased, but I think you did a good job. I loved it. We just want you guys to know that we're grateful that you guys came here today. This will be archived. It's recorded. Once it's recorded, you'll get a message when it's available in the safetyaid.org and you'll be able to access it. The evaluation should be dropped down in the chat shortly. You also will get a follow-up email that'll have the evaluation. Once you complete the evaluation, you'll either get your certificate of attendance, or if you are a member, you can get your nursing continued education credits. If there's any questions, please don't hesitate to reach out to us. Thank you so much for being here today.

teamwork

advocacy

forensic nursing

domestic violence

sexual assault

collaboration

relationship-building

sexual assault response teams

multidisciplinary teams

trauma-informed care

survivors' voices and choices