Okay. Welcome, everybody. Hi, my name is Dianne Daver, and good afternoon or good morning, whatever it may be. I see some many familiar names on the participant list, and I see some new ones too, so I'm glad that you're all here. This webinar this afternoon was developed by IFN under the guidance of OVC Cooperative Agreement Enhancing Care and Improving Access and Quality of Sexual Assault Forensic Examinations through Telehealth. During this presentation, we will be using the term tele-safe to distinguish the specific type of telehealth, the SAFE tele-safe being Sexual Assault Forensic Exam. The primary goal of the tele-safe grant is to increase the number of highly trained, experienced SAFEs and other medical forensic examiners to provide high quality, trauma-informed care for victims of sexual assault. A key objective for the grant project is to include a support system of community-based advocacy services for the patient during the exam. So today, our hope is that we're able to provide you with a baseline of education about the role of the sexual assault advocate in collaboration with the clinician during the sexual assault exam, specifically the tele-safe exam. Thank you. So our disclosures, of course, this webinar was produced under the OVC, or Office for Victims of Crime, Office for Justice Programs U.S. Department of Justice grant. The opinions, findings, and conclusions or recommendations are purely those of the authors and not necessarily those of the U.S. Department of Justice. The planners, presenters have no conflict of interest, and there will be nursing CEs provided for this course. So on completion, if you fill out a course evaluation, you will then receive the certificate of nursing CE hours. And IAFN is an accredited approver of continuing professional development by the ANCC. So our presenters today are myself, and I'm really excited to be presenting with my colleague, Christina Presenti. So Christina, could you introduce yourself? Hi, good afternoon. Thanks, Diane, for the introduction. Hi, everybody. I'm Christina Presenti, as Diane said. I've been an advocate for over a decade, and it's really nice that Diane and I get to present today, so you'll see that teamwork. So I started as a volunteer at my local rape crisis center a long time ago, and I've worked in a variety of systems and multidisciplinary teams, including setting up transitional housing programs with the Department of Child and Family Services, SANE Programs, and SARTs. So I'm really thrilled to be here today to meet all of you and share more about the variety of ways that advocates can support your patients. Diane, do you want to introduce yourself? Yeah, thanks, Christina. So I've been a registered nurse for 39 years, which is kind of crazy to even say that out loud. But in the last portion of my clinical experience, I developed and managed a forensic nursing services program pretty much the last 11, 12 years of my clinical career in a hospital setting. During that time, I had extensive experience collaborating with SARTs, multiple different county SARTs, and developing really strong working relationships with both our community and system-based advocates. So it's really, I can just tell you from firsthand experience how so important it is to have that great relationship with your advocacy agency and to include them with or include them for the patient during the exam. Excellent. One thing to know as we get started is that Diane and I will be using a lot of terms to talk about survivors or patients today. So you might hear victim, survivor, patient, client, maybe some other things. Typically, a medical provider will use the word patient. You are always thinking about your patients first. As an advocate, I might use the term survivor or victim more frequently. So we really encourage you to use whatever term makes the most sense from your role and your perspective. But some individuals do find being called a victim or survivor triggering. So really rely on, you know, if you're a medical professional, calling somebody a patient is probably the best course of action for you. But you will hear a couple different terms today. Yeah, that's a great point, Christina. So our learning objectives, we hope that at the completion of this webinar, the attendees will be able to describe the role of the advocate, list the benefits of an advocate for both the clinician and the patient, demonstrate how the clinician can explain advocacy services to the patient, and also how you would locate your local advocacy services. So advocates generally offer a lot of different avenues of support to victims of crime. So there's a lot of different types of advocates who can offer a variety of supportive services. And there's some that can offer more limited or specialized range of services. And we'll talk about those in a couple minutes. Advocates might work together to support a victim of violence with some of the following things. So they might help with crisis intervention. So immediately following an incident, an advocate is available to provide support, information, referrals, next steps. There might be emotional support, it can be acute right after the incident or long term. An advocate can provide resources and referrals. So very few people know about their options before an assault takes place and advocates work with the client to identify their needs and support them through any process with which they'd like to engage. Advocates can provide information on victimization and education. So similar to a forensic nurse, an advocate's job is to provide information for clients to make informed decisions about their situation and needs. The situations might vary, they don't need medical care, but we do do that very similarly. Advocates do provide a lot of education on trauma, healing, healthy relationships, triggers, as well as legal and medical options and more. Advocates can help with crime victims' compensation forms, follow up, and depending on the location or your specific crisis center's actions, maybe letters of support that would go with that application. Advocates can provide information on legal rights and protections. Depending on the location, that might be referrals to specific attorneys. It might be a referral to low cost or pro bono services, if those are available as well. And advocates also provide information on the criminal justice process. And the list continues. So advocates can also assist victims and their family members, submit statements to the court. Advocates can provide intervention with landlords, creditors, and employers on behalf of a victim. And advocates can provide information on crime prevention. Another avenue that advocates can support victims with is safety planning. Diane, can you talk a little bit about how you work with advocates to create a safety plan for your patients? Yes, yeah, thank you. I've had, in my clinical experience, we've had many opportunities to work closely with the advocates to ensure the safety of patients. So sometimes patients may be on the run. And maybe we had a particular case that comes to mind, a young girl who had been trafficked and was able to actually get away and came to us for care. And we collaboratively worked with our advocacy agency to arrange for bus tickets and meal cards. The hospital was able to, the nurses, you know, got to the hospital cafeteria and got her extra food and clothing, and then also to ensure that she had the medications for post-sexual assault. Excellent. Thanks, Diane. Again, our roles look a little bit different when we do safety planning, but it's absolutely something that we can do in collaboration to make sure that the holistic needs of the patient are met. Advocates can also assist with in-person accompaniment, so, or with somebody else who comes with the victim. So oftentimes, teens might present with their mother or another caregiver, who, in our experience, may have also experienced a sexual assault themselves. And in addition to their guilt for not being able to protect their child, they might also be triggered by the assault. Some crisis centers, in an instance like that, might actually deploy more than one advocate, one who, you know, really is with that patient, and one, maybe, who is supporting the family. Sometimes when we go for kiddos, that's particularly the case, because a lot of people need some extra support. That's such a great point. I'm sorry to interrupt you, but such a great point. And it happens more than you would believe. And so, as the forensic nurse, you now have essentially two patients on your hands. And so, without the advocate, I mean, you have a lot going on to address both of their needs. So, grateful for our advocates. Yeah, that is a good point, because there's a lot of teamwork that happens to make sure that the needs of the patient are met, but also so that the forensic nurse can really focus on the medical care of the patient without kind of getting lost in some of those tangential needs that the family or the patient have. Advocates can also always believe the victim. We really try to start with that, with every interaction that we have with victims. And then, advocates also do systems work. So, that means we advocate with in SARTs or with other teams. And our goal, really, is to build better protocols. So, we incorporate survivor feedback into those community meetings, and we hold other professionals accountable. So, that direct feedback really helps everyone improve their services. So, other things that advocates can help with are emergency shelter, where and when it is available, financial assistance, where and when that is available, as well. Counseling. Some crisis centers have licensed clinical counselors on staff. Others can provide referrals. And typically, crisis centers have vetted for people who are able to provide trauma-informed specialized services to somebody who's experienced violence. Advocates can also provide case management, because there is a lot that happens after an assault. Advocates can increase access to and the quality of care provided by other service providers. So, thinking about that systems work, we really rely on that feedback back and forth to make sure that we have ongoing continuous improvement of what our services look like. And advocates can intervene with an employer after an assault to help survivor access leave or access short-term or long-term disability, whatever the case may be. You know, it's interesting, Christina, when you talk about increasing access and to other service providers, it's so helpful, because I feel like our advocates know so many other systems in the community and actually know the people and are able to provide like warm introductions for the patient. When I say warm introduction, I mean you're able to say to the patient, you know what, I know this advocate from, let's say, the human trafficking shelter, and we work with them all the time, and they do a great job, that kind of thing, to help the patient feel calmer and to know that you, who has a relationship with her, already knows this other advocate. That's a great point, Diane. And in a lot of cases, the advocate can provide transportation or even go with the survivor for that initial meeting, which really helps, because it's not intimidating to meet somebody new, especially after such a tragic event. So we talked a little bit that there's a lot of different types of advocates, and working in the hospital system, you might be most familiar with community-based patient advocates. For sexual assault patients, there are two main types of advocates they may interact with. So the first is a community-based advocate, and those are going to be really the main focus of today's presentation. Those are the ones who work typically at a rape crisis center. So a lot of what we just talked about is specific to community-based advocacy from, again, your rape crisis center. A community-based advocate typically works for an independent crisis center, and their whole goal and their whole mission is around supporting the survivor with objective information through all aspects of their healing, recovery, and navigating the various systems, such as medical, legal, law enforcement, child protective services, and anyone else they may encounter in the aftermath of a violent crime. Communication between advocates and survivors is privileged, or in other words, confidential. So anything shared with an advocate, with a few exceptions, outside of the scope of today's presentation, are not to be shared without explicit, written, time-limited permission from the survivor. And so a community-based advocate differs from a systems-based advocate in a few ways. So a systems-based advocate typically works for a specific system. So it could be a prosecutor's office, it could be law enforcement, and they are first and foremost loyal to their employer and the requirements of their jobs. So they're typically highly trained in one aspect of a victim experience. So systems-based advocates that work in a prosecutor's office know the ins and outs and opportunities to support victims through the legal system. Systems-based advocates that are located in law enforcement, they know the ins and outs of reporting and working with law enforcement. Often, system-based advocates can only provide support when the client is engaged in reporting or court, so their support is time-limited and specific to the events or the related referrals. When a victim shares something with a systems-based advocate, it can be assumed that that information is always shared with the employer. So it's always shared with prosecution and or law enforcement. And in some cases, that can compromise the safety of a survivor. We all know that information could be shared in a court of law, and that could always get back to the offender. So in many locations, we have both a community-based advocate and a systems-based advocate, and they do work really closely together to ensure that the client's needs are met without providing duplicate services. In some cases, both advocates might offer to provide support, such as filling out victim compensation paperwork to ensure that is done for the victim. So depending on your community, you might have a variety of other systems-based advocates. So you might have a military-based advocate. The Department of Defense provides a sexual assault advocate certification program to standardize the sexual assault response. You might also work closely with a college or university. The role of campus-based advocates, as well as their abilities and limitations, vary from campus to campus. Typically, the role is responsible for education in the form of prevention and awareness programs for all faculty, staff, and students. This includes information for faculty and staff on their reporting responsibilities. Campus-based advocates know the campus system, and they can help systems navigate through any campus-based disciplinary process, as well as practical matters such as changing courses or living situations as necessary. Many campus-based advocates do not have confidentiality. They're not set up to provide 24-7 crisis services, although you might see that in a bigger institution. In some cases, a survivor will work with many advocates to support them with specific aspects of their recovery. Regardless of who you're working with, as a medical professional, it is your responsibility to understand the services provided by the various advocates, as well as their limitations, to provide accurate information to patients, right? That's always your goal. So a lot of multidisciplinary teams will include all advocates, and they will promote cross-training, will orient new staff, and on an ongoing basis. Yeah, and if I could add there, Christina, that it's, as a clinician, it's really helpful not only to know the different advocacy agencies in your community, but also to work with them, because some patients may benefit from more than one advocate. Some of the work I did where my clinical practice was very university heavy. And so that we had multiple campus based advocates, you know, from different universities that we would work with. And not only was it great for the patient, but we totally did have to understand their role and their level of confidentiality. But working with them and getting to know them and the teams within the different universities opens up opportunities for the clinician to be able to educate other professionals on the healthcare ramifications of sexual assault and get involved with other prevention work. And it's just very helpful to have your name out there with the different advocacy agencies. Yeah, that's great, Diane. And we're gonna talk about hospital accompaniment later, but really knowing who is allowed to be at the hospital, why, like Diane said too, who actually has confidentiality and who doesn't. A lot of these folks might be a referral, you know, after care. So thanks, Diane. I think it's really important what you just shared. So from here on out, we're really gonna be focusing on the role of the community-based advocate. That's gonna be really your primary partner in most instances. So as a reminder, this is typically the only advocate that can provide privileged communication to a survivor and support to a survivor throughout their recovery from an assault. So we've gone over a lot of the services that advocacy can provide to a patient, but we wanna stop and reiterate how unique the relationship is between a survivor and a community-based advocacy organization, because advocates can provide support for that survivor throughout their life. So both in the immediate aftermath of the assault and in the long-term. Forensic nurses are critical in helping to establish the initial contact and referral between a patient and advocacy, so your patients can tap into a lifetime of support. The way that you provide the referral and the respect that's demonstrated between the advocate and the forensic nurse during the exam can really set the stage for healing experience goals short-term during that exam and long-term for the patient. Diane, is there anything else you wanted to add here? Yeah, I do, thanks. I think that it is absolutely crucial for the clinician, for actually for the whole CERT or multidisciplinary team to really understand each person's role. While everybody's role is a little different and we all have different boundaries in our profession, we are working towards the same goal. But understanding the role of the clinician and, I mean, understanding the role of the advocate can help the clinician to really explain the role of an advocate to the patient themselves. I think it's crucial here to mention that a nurse is not an advocate. While a nurse may advocate for their patients, right? We advocate for our patients no matter what area of nursing we work in. We do not come, we do not have the same knowledge or skillset to offer the patient the same kind of objective support and resources that a very skilled and educated advocate can. I mean, one of the things that Christina just said is how the advocacy can support patients long-term. And once the patient has left our four walls of our facility, that's pretty much our last contact with them. So sometimes I think nurses do think they can do this role. And sometimes we have to do this role because there isn't advocacy available. But hopefully there is a process in place to refer patients to advocacy after the exam if there's no way to have accompaniments. I also think it's really important for the clinician to offer the patient time alone with the advocate and have the advocates, knowing that the advocate can potentially accompany the patient to law enforcement to make a report or if law enforcement comes in after the exam, advocacy can stay present with the patient to support the patient. Thanks Diane. So we wanna talk to you a little bit about community-based advocate training. So what makes an advocate? So any representative from a community-based crisis center should be well-trained in the breadth and depth of advocacy services provided during medical accompaniment. So it is really common for advocates and volunteers to receive a minimum of 40 hours of training. So in many states and territories, the required training was developed by the Office for Victims of Crime, which is certified by the Office of the Attorney General. In a lot of states or territories, it could be provided by the statewide or the territory coalition or it's reviewed by the coalition. Most training programs require an additional number of hours of on-the-job training. So that includes additional hours of observation of a trained advocate and then for hospital accompaniment or other types of accompaniment, there might also be a specific number of required observations. So a little bit like a preceptorship, which you're familiar with, where they're being observed before they are signed off to provide individual hospital accompaniment. And I'll just pause here. So we talked a little bit about how those multidisciplinary teams support communication. We really, this is one of those areas too, if you have advocates that are not well-trained or who say or do things that are inappropriate, you should have a relationship with the crisis center where you know who the supervisors are, you know who you can call and who you can contact. That's critical, right? Everybody wants to be part of that continuous improvement. So hospital accompaniment and information about the medical forensic exams are often part of that initial training that an advocate or a volunteer advocate would go through. So many states, and this is something that you might actually be able to participate in your role as a forensic nurse, is that within that 40 hours of training, it includes a medical forensic examiner who walks through a sexual assault exam. So they walk through the different parts of the kit, they talk about what's gonna happen, and that might even be an additional in-service or supplemental information to an advocacy organization. So that's another way that you can work together. It's really good that everybody has an understanding of what is actually happening during that time to be able to explain that to the patient. So advocates can, so whoever's showing up at the hospital who's an advocate can be paid staff of the crisis center or they could be a volunteer from the community. So regardless of how an individual comes to work or volunteer at a crisis center, they really should be trained and they should all be well-trained on the same information to provide the breadth and depth of advocacy services. Christina, I wanted to add that you mentioned that having a forensic examiner at the 40-hour training for the advocates is something that's included in the training. And so I used to do that with our advocacy agency and it was such a great opportunity to be able to talk to them about, again, the healthcare piece of sexual violence and the health ramifications, but also to be able to show them every step of the kit and the appropriate way of doing it. We would also, sometimes we would have them come to our hospital to do that portion of their clinical or their training so that they could also see where to park when they came to the hospital, which door to enter, where's the emergency department. We'd show them where the snack refrigerator is because that is super important. And also things like, don't let the triage staff put you, park you in the waiting room and make you sit there as like be persistently, persistent so that you can get back in the back and help us meet the patient. So things like that, that seem kind of simple, but it's so important for new advocates to know. Because they're getting put in a foreign environment there in the emergency department. The other thing that we've done is we've, when we're running our 40 hour didactic, same training is we invite the advocacy to come in and do a portion of the training. So they'll maybe not only talk about their services and their center, but they may also talk about the myths of sexual assault or maybe do a presentation on the neurobiology of trauma, things like that. And they're really helpful to have everybody meet each other. And those are really great points, Diane. So thinking about advocacy, one of the main things that the community-based advocates have that most of the other advocates do not have is privileged communication. So the information that we're gonna talk about today is really, really general. Each state has specific statutes that drive any exceptions and advocates should be well-trained on those exceptions and circumstances. In most cases, when privilege is limited, it is to ensure that advocates disclose information for public interest. So that might include a pre-certified left of a child, vulnerable adult, perjured testimony, or intent to commit a crime. So as a medical professional, you're familiar with patient confidentiality and the rare cases when you may need to disclose information about a patient. So the rules for advocates and medical providers or other mental health providers are different depending on your profession, but it is another good area for cross-training. So forensic nurses should have a basic understanding about the privileged statutes for advocates and how they relate to the advocate's roles and responsibilities while they're at your facility. Privileged communication is a legal right. So it exists by statute that ensures a professional cannot disclose information without the client's consent, including from the witness stand during legal proceedings. Privileged communication is a right held by the victim when receiving services. There must be a victim of domestic or sexual violence and or stalking for this to apply. In most instances, only victims can waive their right to privilege and it cannot be waived on their behalf. Privileged communication is specifically defined in state legislation, so be familiar with what that looks like in your area. Now that you know what privileged communication between an advocate and a survivor is, you might be wondering why a victim's right to confidential communication or a victim's right to privacy is so essential. So really big picture, an assault can be very disorienting and very disempowering. A large aspect of recovery is to empower the victim to heal. So advocates provide objective information about a victim's rights and options, empowering the victim to make well-informed decisions throughout their healing process. Advocates provide support, information, education, and empowerment that is free of judgment, coercion, and betrayal to a victim. And that's an essential part of their healing process. So an advocate isn't like a family member where we have any kind of exterior interest. Really, it's all about what does the patient want, what information do they need, and how to help them make the decisions that are best, which is really important because a lot of patients, a lot of survivors may or may not know who is or isn't safe after an assault and safe could be physically safe, could be emotionally safe to share information with. So really having a place where you can share information and talk through your options, talk through your safety plans, and you might make safety plans for different instances. It might be a safety plan for work, safety plan for disclosing to your parents, for your partner. Those are all really important things to have an option to have in a confidential conversation. So that right to privacy really guarantees that information is not shared with friends, family, peers. It also guarantees that that information is not shared with media or newspapers. Also an advocate's not going to post anything on social media with good intentions or not, and family and friends might do something like that. So the right to privacy really guarantees that confidential place, which is really essential for healing and also for safety. Advocates can also help victims maintain their right to privacy when working with other service providers. So in the situation, they might talk to an advocate before they talk to law enforcement about what to disclose or what they're maybe not ready to disclose yet. So advocates can really fill a critical role in providing victims with a safe, unbiased place to process their options and heal. So a lot of people have really good intentions when they share information, but we never know how that information will be repeated or used. So in a world that's increasingly interconnected with increased entries into privacy, it is critical your patients have a safe space away from all the noise and influence to process their options. I worked with a woman who was assaulted by a coworker in her family's business, and she didn't feel comfortable talking to her family, her coworkers or friends, and she really needed a safe place to discuss and understand what her options were, both to get the medical exam and if she wanted to report to law enforcement before she made decisions about reporting. She also needed support to develop a plan on how and when to disclose the assault to her family. She really struggled with thinking the assault was her fault and she needed space to process outside of the pressures of work or the watchful eye of the individual who assaulted her. Without a confidential place to heal and process her options, she would have felt less prepared to approach her family and ultimately keep herself safe in that environment. Another time we worked with a man who was assaulted by a roommate. He was in a different relationship at the time and felt like his partner never would have believed that he was assaulted. We worked through his feelings of shame and questions he had about his biological response. So working through those things again in a really safe space promoted his ability to heal and be prepared for his partner's possible reactions. So in many cases, particularly when the assailant is at large or an intimate partner or a stalker has access to a lot of location information about the individual, safety planning is a critical component of keeping themselves and any minor children safe. So in those cases, the offender might exercise intimidation and control over a long period of time with threats to the wellbeing of the individual, friends, family, or children if they disclose anything. In cases like that, it's extremely critical that the patient has an opportunity to plan in a confidential space where they know nothing will be shared by their offender. Again, there's a lot of people who are well-meaning in our lives that may or may not understand the implications of sharing what seems like really benign information. It's really empowering for survivors to be able to keep themselves safe. So those are some examples of advocates and when confidentiality can be really essential. We'll give you one more example and then we'll continue on. There was this other woman I worked with who came from a country where women could not get a divorce. That was not legal in her home country. And there was actually a woman in her home country that was stabbed when they tried to get a divorce and that was never prosecuted, nothing happened. So that survivor in particular had a really horrific fear of law enforcement, court, and any authorities. And her husband in this country really encouraged that. He was also from the same country. But we worked together for a long time. We went to the police department together, went to the courthouse, we met with an officer, we spoke to some bailiffs and other professionals in the building who let us in a closed courtroom to see the space. And before we met with those people, we planned what to say together so that she wasn't disclosing any information, but what she was doing was she was practicing. She was getting ready to be able to call police if she felt like she needed to. She was getting ready to be able to go get a medical exam if she felt like she needed to. So we spent a lot of time together building trust in our laws and our institutions and seeing her community as viable resources here. And building that trust really empowered her to shift through what she was being told and understand that her right to privacy and her other rights in this country. So having that confidentiality and really protecting her privacy, let us go through that process together. Thank you for sharing those. Yeah. So there are a couple other things to think about when thinking about privacy. This probably applies to a lot of you on our call today, but there are certain geographic or other areas where maintaining privacy can be really a challenge. Maybe not so much in a place like New York City, but when the community is small, the victim might know the advocates and might not want the individual or that agency offering support. So the medical provider has a role in making sure they're not introducing anybody who's unsafe for that victim. So they really should be doing everything they can to notify the victim of who is attending the hospital prior to the victim, prior to introducing the victim to that person. So in some cases, it's routine that the advocacy organization will provide the name of the advocate or volunteer on the phone at the initial call. So the victim has the opportunity to accept or deny services. You're part of the team to make sure that, again, everyone in that room is a safe person. And Diana and I keep talking about those multidisciplinary teams as well. And this is part of building those protocols, right? So if the victim denies services from a specific organization or an individual, there should be a backup organization available. And those services might only be available by phone or tele-advocacy. But if this applies to your community, having those protocols kind of developed is really critical. Medical, excuse me, medical providers should establish those relationships in advance. They should also make sure they have working phone numbers, especially in states where calls are routed via statewide hotline to the closest geographic center. So doing all that in advance, again, really helps you streamline everything when you're actually in the moment of providing services. This also applies for interpreters, especially when there are only a few people in a community that speak a specific language. So again, getting the name and any information about the interpreter or advocate is essential prior to introducing them to the victim. So, yeah, I think you're absolutely right with this, especially with this project, working with the smaller rural spoke sites, this can be a potential problem in many of the sites. I think we've heard that from our site in Alaska because the villages are so small that there's a good chance that the victim might know the advocate or the advocate might be related to the alleged assailant or those kinds of things. And I believe even our demonstration site in Texas had shared similar concerns. Yeah, good points, Diane. And some teams, especially when they're getting started, really shy away from those hard questions, but it's okay to ask them. And I'm sure you all know Diane very well, but reach out to us if these are some of the things that you're trying to figure out in your community as well. So typically, advocacy is done in person. That's always our preference. It's the gold standard. So we should ensure everything we can, we should do everything we can to make sure that's possible. This past year with a pandemic and the closing of medical centers, we saw advocacy go virtual in a lot of communities. We've also saw that patients were less likely to accept a virtual advocate as opposed to an in-person advocate. So that really reiterated, again, the importance of in-person advocacy. They're more likely to accept them so that that lifetime of support, right, that they're not accepting that phone call, they might be missing out on all of that. So when making a referral to a virtual advocate, be sure to explain to the patient how and with whom they will connect, reiterate what advocacy services are and what confidentiality is, be sure to thoroughly explain any consent forms and assess the security of the connections to the patient as well. So survivors can connect to advocates in a variety of ways. Most often survivors will call a hotline and they're routed to their local crisis center. Most communities have a 24 seven hotline. Some do not, that's not available in all areas. Most crisis centers do have brick and mortar buildings that survivors can visit. Advocates can help survivors plan to visit the office in a safe way, free of tracking, hopefully if the survivor has concerns of stalking or is otherwise being monitored. Virtual appointments are also a possible option that are being explored by some crisis centers. These have been increasingly common since the pandemic. So we're gonna probably continue to see that in the future. We're hopeful to have more research on the effectiveness of tele-advocacy for survivors from this project. So the jury's out on that, but we'll continue to see what that looks like. There are also national hotlines and crisis centers that offer chat options. So again, that's newer, growing, and advocates also offer in-person accompaniment when it's safe to do so. No, Christina, this is just slightly off, but something you said on the slide reminded me that it's a good thing for the clinicians to go ahead and get to the advocacy center, that actual brick and mortar building, the building that you're gonna be referring your patients to so that you can tell them like, oh, you know where it is, it's like down the street, it's across from the CVS or whatever, and tell them a little bit about the building and how nice it is that they'll walk in, there's a receptionist that, the security issues that might be there. I think that's just a little something that's helpful to the patients. Well, it helps the clinician to really know like you're referring this person off to this advocacy center and you don't know anything about it. So it just kind of helps to develop relationships as well. Excellent addition. Y'all talk too much. You and Sam. Just make sure that you're on mute. But I did wanna say if anyone has questions to please put them in the chat and we will address them as we go along. Thanks for that reminder. If you don't already know who your local advocacy group is, there's two great resources to identify it. RAINN has a website where you can actually go in, type your zip code and it will show up with most of the closest centers. Another tip maybe is to call your coalition and build a relationship at the state levels. They'd be able to share with you which crisis center or centers might respond to patients in your area. Christine, I was just gonna say that we have been, we've reached out to the coalitions on the two demonstration sites for this project that have multiple spoke sites. And the coalitions have been so helpful to provide us with a virtual introduction to the executive director of the actual center where the spoke facility is gonna be. They couldn't be more helpful. That's great, that's great. They usually are. I'm glad to hear it too. You might actually work with multiple coalition or multiple crisis centers, depending on where your medical facility is and where you provide services. So kind of understanding the catchment areas for the various centers and just understanding who to call when is an important part of protocol development. So you're really connecting people with the right resources. So next we're gonna move into how advocates and medical professionals work together during a sexual assault exam to ensure a patient receives optimal medical care. So really thinking about those two roles. So the goal of the advocate is to support the victim. That's the primary goal, the whole really reason why they're in the room. They provide information about services, they provide emotional support, they explain options and consequences of options to the victim. And so that might look a little bit different than the forensic examiner because the patient might have questions that have to do with, if I do ask what happens in court, right? And that might be something that forensic examiner can provide, but an advocate who's been to court hundreds of times might have more context to add. So that's kind of a teamwork thing. A teamwork thing that we would do together, or it might be something where the forensic examiner is in another room and the advocate has that confidential conversation. Advocates also empower victims to make the best decisions for themselves and they provide immediate and long-term support for all aspects of the emotional, medical and legal care. The forensic examiner provides trauma-informed medical care. They seek informed consent for all aspects of the sexual assault exam. They provide explanations for each step of the sexual assault exam, provide medical care, and they collect and maintain the integrity of evidence. They also provide a safe discharge plan and referrals for follow-up needs. Diane, anything you want to add? Not really, but the safe discharge plan is very different for the forensic examiner. We're making sure that acutely this patient has a safe place to go, that they are safe to themselves, that they are not worried about hurting, that we don't have concerns that they would be hurting themselves or somebody else. Whereas the advocate's safe discharge plan incorporated so many other aspects of the patient's life that you have just shared with us. So it's really that, I just think that that validates the fact that the forensic nurse plays an amazing role, but we aren't an advocate, and that we still need an advocate to work together to provide the best trauma-informed care for our patients. Great, thanks, Diane. When we think about the benefits of advocacy, so some benefits that the patient has when an advocate is in the room is that they have a confidential ally with them at all time. For the patient, the advocate ensures that the victim's rights are protected. So the advocate also provides support for the patient's support people or persons, and they can support with paperwork, billing, filing claims, victim's compensation, and they can help the patient assess the safety at the time of discharge like Diane just talked about, and also identify different housing or other options and safety and follow-up services. For the forensic examiner, the patients report having less secondary trauma when an advocate is present in the room. The advocates provide support for the patient so the provider can focus on medical needs, and Diane said that a lot. Everybody has a role in the room, and if you're trying to do too many things, not only is it inappropriate, but very challenging. So the advocate provides support for patients and their support people as well. That's a benefit the advocate provides to the forensic examiner really, so they can focus on providing medical care to the patient, and the advocate holds the forensic examiner accountable, and the advocate can discuss the legal options with the patient that maybe go beyond the medical services. Diane, do you want to add anything for this one? Yeah, I'm sorry. I think my internet just clicked out for a second, but I did want to add to the advocate the piece about the advocacy helping the forensic examiner so that we can focus on the work that we have to do, and I've always said, like, you know, it's really hard to hold the patient's hand and a speculum at the same time. So while that sounds kind of just like, you know, ingest, it's true, though, if you're focused on the patient, it's true, though, if you're focusing, the advocates are so great on helping the patient either focus on something else during the anal genital exam, you know, I've seen them talk about vacations or whatever the patient wants to talk about or breathe with them or sing with them or whatever to help them get through the difficult parts of the exam. And also, I've had personal experience where you have a very difficult case, and afterwards, if the advocate has the energy to help kind of like talk it out between the forensic nurse and the advocate, like, oh my gosh, we could have, I wish I could have done this better or, you know, things like that, but just also just kind of supporting each other at the end of a very difficult case. Yeah, that's true. That relationship is key between the forensic nurse, yeah. So there's a couple other benefits to having an advocate in the room, and one thing we don't mention enough are some of the study benefits from the existing research. And some of these come from when the advocates in the room during an interaction between a victim and a system, so like a medical system or law enforcement. So having an advocate in the room helps victims in numerous ways. Victims feel more supported and informed when advocates are present. Victims experience less distress. Victims are more likely to receive information on STDs, HIV, and prophylactic treatment. Victims are more likely to be tested for pregnancy. Victims are more likely to be treated with trauma-informed care. Victims are more likely to receive a medical forensic exam. So in some ways, we are your best ally in making sure that victims actually show up at the hospital when they need that type of care. That is so true. I have such an interesting, lots of examples, but the one that kind of burns a hole in my heart is related to your last bullet, the victims are more likely to receive a medical forensic exam. So there was a young boy, he was around 10, and he was brought in by, so our practice was PEDS as well as adolescent adult, and he was brought in by his mom and his grandma who were pretty distraught, and the young man had disclosed some sexual abuse by a family member. Mom and grandma, they were resistant to me talking to him or examining him at all. I offered an advocate, and they were a little hesitant, but then they finally agreed. And so when the advocate arrived, it was a young man, he was probably in his 20s, and just immediately created a great rapport with this young boy so that I was able to talk to mom and grandma alone. At that time in our clinical setting, our unit was a separate unit, so we weren't in the middle of a busy ER. Advocate and the young boy have created a makeshift basketball game out in the area that we had there. And by the time I finished talking to the mom and grandma, they could see that the child was having so much fun and had developed such an amazing rapport with this advocate that they then did, not only did mom and grandma consent to the forensic exam, but more importantly, the young man agreed to it. And it wasn't about the basketball game necessarily, but it was about the rapport that the advocate created with that child. And it doesn't have to be a child. I'm sure you all have amazing stories that we'd be happy to hear if you want to share any of those. And we mentioned before how the advocates can help when the moms come in, if it's been their adolescent daughter is usually the way that the story goes, but helping that mom to, and support the mom and help the mom to start with her healing process, which maybe had never been addressed when mom had their own victimization. I also think it's been, I've had so many occasions when the advocates have been so helpful to the patient to be able to explain like, how can I talk to my partner about this? They're never gonna believe me. They're gonna break up with me and all of those kinds of things. And it's just absolutely amazing to watch the advocates work with patients on those kinds of tough decisions and scenarios in life. Thanks, Anne. I love that example. So we're gonna talk a little bit about the nitty gritty of your role in actually introducing the advocacy service to the patient. So what needs to happen before the nurse talks to the patient about advocacy? And Diane, do you wanna talk a little bit about how you do this? It might be better from you firsthand. Yeah, sure. I mean, I could talk about how I do it, but I mean, I'm sure that there's some nurses on this call that do have very different ways of doing it. For me, advocacy is one of the first things I talk to the patient about. It's because right after I introduce myself and my role and explain to the patient that from this point on, everything is in their hands, that control of anything that there's nothing that's gonna happen to them or their body without their complete informed consent. And then I introduce the idea of an advocate, which most of the time patients don't really understand what an advocate means. And so I'm able to explain the role and the services that the advocate can provide. So some agencies want to be called right away when a patient presents to the hospital. Some advocacy want just to be called sexual assault patient with sexual assault complaint, just call us. And others would prefer to have the patient's consent prior to being called. So you'd need to figure that out in your own community. But know that it is evidence-based best practice to have an advocate during the exam. And it's best practice to call both the forensic examiner and the advocate at the same time. Ideally, the advocate should be present at the hospital and ready to meet the patient before the medical provider introduces advocacy. So that is something that we could talk about, Christina, but sometimes that's a challenge, right? To wait to start the exam before the advocate arrives. So if your program, and there's just some things to think about. So if in your program, it's the triage staff who may not have any experience as in sexual assault care, if they're offering the advocate and the patient declines, it would be best practice for the forensic examiner to readdress advocacy and be able to explain the advocate's role in a more knowledgeable way. Some programs, gosh, I wish there were more of them. Some programs actually have advocates physically available so that there is no delay for the response. And some programs do have forensic nurse examiners available, so there's no delay. And that's probably more common than having the advocate, but we have to think about the fact that advocates may have to travel, especially if we're talking rural. Some of the advocacy agencies that I've been working with on this project are telling me their drive is an hour to two hours, and that's indecent weather to get to the facility. So it's not always feasible to delay the sexual assault medical forensic exam until the advocate arrives, but there should be certainly process and planning in place for that. And important to explain to the patient that there might be a delay, and how are you going to introduce the advocate when they do arrive? So we have found, too, that most patients, especially those in the middle of the night, when they're offered an advocate, they'll say, oh, gosh, no, I don't want to bother them. No, no, just let's get this done. Well, I mean, it's really important for that clinician to say, you know, this is what they do. They want to be called, they want to be here with you, so that the patient really doesn't feel like they're inconveniencing anyone. And this is how, if you are doing tele-advocacy in your program, if there is not live advocacy available, that is a way that you can actually provide the advocate sooner through a virtual communication. In the references, too, I wanted to let you know that there are research articles that address the importance of having the advocate and also, you know, just some of the benefits of advocacy. I'm wondering if any of the nurses that are in attendance have any other ideas of how they might introduce an advocate? You're all muted right now, but you should be able to unmute or reach your hand. Either that or you can put it in chat either way. No, thanks, Diane. I think another, if somebody has a question, I'm going to go ahead and unmute you. I'm going to go ahead and unmute you, Diane. I think another, if somebody has refused an advocate at the end of the exam, it might be really helpful, particularly if you know it's going to take, you know, time to do the discharge paperwork. And sometimes that's, you know, they're sitting in the room for an hour by themselves, something like that. Again, not ideal, but that's another good time to have an advocate and just say, hey, I know you said no to this earlier. Now you're going to have some downtime. Do you want to talk to somebody? Because sometimes people will say yes. Sometimes they're exhausted at that point, which I'm sure you're familiar with, and want nothing to do with anybody, but that might also be a time when they will say yes to speaking to an advocate, and just another time where you can calmly introduce the advocate's role. Yeah, and it's a good idea to kind of get that down like an elevator presentation for the patient, you know. You know, plan, kind of get used to, as you become more experienced as a sexual assault nurse exam or forensic nurse, you know, to be able to say, you know, we work with this amazing organization and they provide advocacy, which means that there is an advocate or a person who will come here to support you. You know, so the patient knows it's just for them during this exam, and that the center offers additional services such as support groups for survivors, safety planning, you know, whatever your advocacy agency offers. And they can even accompany you when and if you want to talk to law enforcement, or possibly in the court proceedings if, you know, things end up going that way. Okay. Excellent. I think the next slide is, we have, I don't know if the next slide is the video. Oh, we do have the video here. Yeah, so let me start that. So this video shows an example of a tele-safe introducing the advocate, also a tele-advocacy. I will say that this was produced, well, I'll tell you after. Sorry, I started. Oops. Medical advocate. She's here to support you and to provide you resources you may need once your exam is completed. Is it okay if I give you two, a few moments alone so she can review what those resources are? Sure. Okay. I'll step out for a little bit and I'll come back. Okay. Hi there. As Victoria said, my name is Catherine and I work for the Local Rape Crisis Center and I use the pronouns she, her, and hers. Is Ellen what you'd prefer me to call you? Yes, please. And would you like to share your pronouns with me? Sure. She, her, and hers. Great, thank you. I'm here today just to be another person to chat with about any of your questions or concerns. One really important thing that I want to let you know about is confidentiality. All of our services at the Local Rape Crisis Center are completely free and completely confidential. This means that when you and I are talking because I'm an advocate, I'm not allowed to share any information that you tell me without your permission, with only a few minor exceptions like the safety of any children that might be in your home. Healthcare providers have a different level of protection. So it's really important that you know your privacy rights so that you can make decisions about information that you'd like to share or not. It's all totally up to you. Do you have any questions about that? No. Great, is there anything else that's on your mind? I'm just kind of worried about this exam if it's going to hurt. Yeah, that's a totally normal, normal worry. This shouldn't hurt, but parts of the exam might be uncomfortable. So you can pause or stop at any time. Okay, thank you. Well, I'm here if you have any additional questions. I did want to ask you if you have a plan for getting home and if you feel safe when you get there. I'm planning on going to my sister's for a couple of days and I'm thinking about maybe changing the locks at my house. Okay, we can definitely help with that if you need it. You can? Yeah, we often work with local companies to help survivors with that kind of thing. Do you want to talk about logistics now or would you like to wait until after your exam? No, I'd really like to get this exam done. Yeah, I understand that. If it's okay with you, I'll ask your nurse to come back in the room. Okay, thank you. You're welcome. Okay. So I'd like to, before we go on to questions, I'd like to thank our partner in this grant, the Massachusetts Department of Public Health National Tele-Nursing Center for creating that vignette on introducing advocacy through a tele-safe exam. I think it's important, just like if you're introducing an advocate live, we need to be able to explain their services. Clinicians need to understand what they can offer and how to offer the advocate, ensure that the patient understands that it's confidential, that it's secure, that there's a private connection, however that tele-advocacy is occurring, whether it's through the same tele-safe technology or if it's through some sort of compliant phone system. Some advocacy agencies actually require the patient to sign a waiver to allow the advocate to connect them to a phone during the exam. And also that the clinical site should have brochures or cards for the patient too that have the advocacy center's name and phone number on it and potentially their 24-7 hotline. The vignette resources will be on our IFN tele-safe resource page. And there are other vignettes too that you'll be able to use and certainly look at and use in your trainings if that's what you'd like to do. And they've been created all of them by the National Tele-Nursing Center. So thank you. I saw that Randy was on the participant list. So thank you to NTC for all that. And Diane, to an earlier point, back to an earlier point, Nancy Harris did share in the chat that they call an advocate in the beginning before they even start the exam. That way the advocate can show up and talk to the patient and the patient doesn't feel like they're waking someone up or inconveniencing them. So they start out that way. Yeah, that's great. Thanks, Nancy. And that's absolutely best practice, right? So I think Diane had said to call the advocate and the examiner at the same time. So they're both at the medical facility, hopefully relatively the same time. And then the advocate can have a couple moments to really have a one-on-one conversation that answer any questions. The other thing I know Diane mentioned talking to triage about training for advocacy, but also training receptionists, any intake, because sometimes advocates will show up and if they don't know the process, they don't know who an advocate is, they're not gonna bring them back. And Diane did mention we don't want advocates waiting in the waiting room, right? So, and knowing which physicians have higher turnover, it's not, none of this is one and done training. It really is kind of an ongoing process to make sure that everybody who might be involved in this process and your facility really knows their role in making sure that the advocate gets in the door, gets connected to the patient, that everybody is called. And even if it is intake or triage's job to call the advocate, that's frequently something the medical examiner might need to double check that it actually happened. Again, there's a lot of turnover in different positions. So making sure that all those things are happening is definitely part of the process. Absolutely, Christina. And as a forensic nurse examiner, I would never count on anybody else calling the advocate or explaining the role, right? I mean, hopefully they do it, but I would always do it too. Exactly. Are there questions? I think you can unmute yourself if you would like. Questions, thoughts, challenges that you're seeing around this in your local environment. We'd love to hear all of it. So open for discussion. Also, maybe you've had some great examples of working with an advocate and how that's worked out very well. Or maybe there was challenges. Well, if not, if there are no questions, Christina, if you go to the next slide here, in case you think of a question later, here's how you can get in touch with us. So the telesafe at Forensic Nurses, there's my email, Diane Daber. And then for Christina, the bottom two membership at Forensic Nurses and cpresentee at forensicnurses.org. You can reach out to any or all of them and we will respond and find your answer or talk to you about whatever is going on. There are a lot of advocacy organizations and a lot of lead national TA providers for specific types of advocacy as well. So if you're struggling with something or you're really not sure who the right TA provider is and TA's technical assistance, it's a lot of what you're experiencing right now with Diane and Andrea, reach out to us and we'll get you connected to the right person too, if it's not us. So Jennifer Midget is one of the panelists here, one of the attendees. And she said she's done exams both ways with and without having an advocate and said that it's much more comfortable for all involved to have the advocate present. Thanks for sharing that, Jennifer. Jennifer, where are you from? You can either type in or unmute yourself. So we do have all the references for you on here and this will be available on our IFN website, which is under resources, tell us safe. And it will. So if you, your colleagues want to watch it, you can, oh, she's so thank you. Jennifer Midget is from the Turning Point Rape Crisis Center in Collin County, Texas. It's interesting. There's a turning point in just outside of Detroit as well. So in New Hampshire as well. Yeah. So please tell your colleagues about this and that they could just go to our website there and they can, they can be routed to this webinar. And Babs says there's one in PA too, turning point must be a common name. Well, thank you all. We appreciate you coming today and sharing your time with us. And we hope this is useful to you as you go back to your, your programs and you continue to develop and strengthen those protocols. We understand this is a process. You know, I think that every time we do something, particularly cross agency, it is a process and we do need to kind of continue to be attentive to it, right? Whether it's turnover on either side or just continuing to understand what the best practices are and how to improve things for the patient survivor. So we appreciate you taking the time to be here, even if this is something you have done for decades and you picked up some new tips to bring back to your community. Thank you all so much for sharing your time with us today. Yeah. Thank you all. And Nikisha says, thank you too. Thank you to everyone. Don't hesitate to reach out.

sexual assault advocates

tele-safe examinations

advocate services

crisis intervention

emotional support

legal processes

medical processes

community-based advocates

confidentiality

collaboration

quality care