Good afternoon, everyone. Welcome to today's webinar, Quality Caring Model, What That Means for TeleSAVE Programs. I am Andrea Kalpana, the TeleSAVE Project Coordinator for the International Association of Forensic Nurses. You can change. This webinar is supported by the Cooperative Agreement 2019-MU-GX-K009, awarded by Office for Victims of Crime, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this presentation are those of the authors and do not necessarily reflect the views of the Department of Justice, Office for Victims of Crime. Learning outcomes of this webinar will include the participants reporting and increased knowledge of Duffy's Quality Caring Model and how to incorporate the model into their TeleSAVE practice. The planners, presenters, and content reviewers of this course disclose no conflicts of interest. Upon digitally signing into the webinar, attending the course in its entirety, and completing the course evaluation, you will receive a certificate that documents 1.5 continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is an accredited provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. If you indicated upon registration that you are an RN, then in the next few days, you will receive an email that includes the instructions on how to access the evaluation in order to receive CE. Please be sure to check your spam folder, as sometimes these emails will end up there. In addition, today's webinar will be recorded and available for later viewing. To eliminate background noise and phone feedback, please know that we have muted all participants. However, we would still love to hear from you. Please use the chat feature to ask questions and answer our polling questions. We will answer all questions either at a natural break or after the webinar is complete. Now, I am pleased to introduce today's presenters, Susan Chaston and Rachel Preece. Susan Chaston is the statewide sexual assault nurse examiner coordinator for the Utah Coalition Against Sexual Assault. For more than 25 years, she has helped hospitals and communities create programs for providing healthcare to victims of violence in Utah. She provides care to patients across the lifespan as a family nurse practitioner at the Merrill Gapmare Family Medicine Clinic in Provo. She is a sexual assault nurse examiner for Wasatch Forensic Nurses in the Utah County Children's Justice Center. Working closely with the International Association of Forensic Nurses and the American College of Emergency Physicians and many other content experts, Susan was the lead consultant on the OVC TTAC SANE Program Development and Operation Guide. Susan is the immediate past president of IFN. Rachel Preece graduated from Manhattan College in 2004 with a bachelor degree in biology and peace studies. Rachel started her career at Mount Sinai School of Medicine studying herpes simplex virus, mediated apoptosis, but after a year as research coordinator, Rachel decided that her passion lay in applying scientific knowledge to the care of patients. She spent a year volunteering in China teaching English while applying to nursing school. Rachel was accepted to Boston College and graduated in 2008 earning a master's of science in nursing and met the criteria to sit for the Women's Health Nurse Practitioner Certification Exam. Rachel Preece has been practicing as a sexual assault nurse examiner in the Boston region since 2011. As the educator at the National Tele-Nursing Center, she coordinates training for tele-nursing staff and remote site clinicians while continuing to provide patient care through both the Massachusetts SANE Program and the National Tele-Nursing Center. Rachel also maintains her practice as a Women's Health Nurse Practitioner and International Board Certified Lactation Consultant at the DMOC Center in Roxbury, Massachusetts, providing obstetrical and gynecological care to women throughout the lifespan. I am pleased to turn this over to our amazing presenters. I want to thank everyone for being here today. This is Susan Chaston and thank IFN for this opportunity to talk about one of my favorite things, which is Dr. Duffy's quality caring model. And to get off, get everything off to a start, would those of you out there listening, please type into the chat box where you are right now. Do you feel like you're familiar with Dr. Duffy's quality care model? Either yes, no, or unsure. That'll also let us know who's actually on the call today. So if you could take just a minute and do that and type into the chat box. Okay, here they come, too. Yay, good. Seeing some yeses, some noes. Great. Not familiar. Some yeses. So we have a multidisciplinary group on this webinar, too. So some are not clinical. So maybe had never heard of this. Great. Okay. It feels like that we're doing something useful today. So to understand why we are asking you to use Duffy's model, you need to understand a little bit about the history of sexual assault nurse examiner programs. And they asked me to do this because I'm old. So what happened in the 70s is women became activists with survivors of rape. And they realized that when a woman disclosed rape, they would go to an emergency room and sit there, my emergency room, the record time was seven hours. Because the providers who were doing these exams in the emergency room setting really wanted to clear the emergency room out before they started to take care of these patients. Some for reasons of evidence preservation, but others is they just didn't want to be seeing these patients. And so women who were very much involved in the women's rights movement became victim advocates for these patients. And they were frustrated about how the care was giving. So they wanted something different. At the same time, nurses who were in the emergency room and saw the type of care that patients were getting were also frustrated. And they thought, first of all, they were doing the majority of the care. They were going in, getting the history, preparing the patient. And then the physician would come in and basically do a pelvic exam and leave. And the nurse would be left to package the swabs. And they just felt that this wasn't adequate and that they could do the entire exam. And so that is how SANE programs first developed. And they basically took two tracks. One of them were very patient-centered and patient-focused, meaning they really looked at the care of the patient. And others became very much evidence-focused. And these programs were very closely aligned with law enforcement. So I would say the first group of programs, the patient-centered programs, came out of advocacy programs, wanting something better. And the evidence collection focus came out of law enforcement programs wanting something better. So in 2015, when we looked at revising the SANE program development guide, we intentionally sought to make SANE care patient-centered and sustainable. And at this point, we are now almost 30 years later into SANE care. And we actually have some good research to guide what we're doing. So as part of creating the SANE program development and operations guide, we identified five key principles. Those principles being patient-centered care, trauma-informed care, evidence-based practice, recognition of community uniqueness, and a multidisciplinary approach. And this importance of this approach was highlighted in the research. And I just want to stop. And in this time where we're all facing the crisis of a pandemic, these principles still apply, that we need to be patient-centered and trauma-informed. And we need to end the trauma that patients are dealing with now goes far beyond possibly just being sexually assaulted. But we need to continue to use evidence-based practice and recognize community uniqueness and keep our teams involved. So what the research showed us is that the things that patients wanted out of a medical forensic exam was being provided with clear and thorough explanation of the exam, being given choices during the exam, and being treated with care and compassion. And we felt that all of these things were very much part of what we wanted to emphasize in the new SANE care guide. And what patients found harmful is not providing enough explanations, not giving enough options or choices, and acting distant. And one of the things we heard patients say is the nurses who had this evidence-focused approach, their philosophy was I am just there to collect this evidence, I can't show compassion for my patient because that would demonstrate bias. And these patients who experienced this evidence-focused process felt like they were treated, as one patient put it, I felt like I was being treated like a piece of meat. And so with the research, we went on to look at how can we change this process or how can we encourage a process that is more patient-centered and trauma-informed. Again, what we found with the research is that if we start with this trauma-informed, patient-centered approach, two things happen. First of all, if I go in there and work closely with advocacy and law enforcement, we all have better ratings from our patients. So if we show each other that we have respect for each other and that we care about what they're doing and that they're an important part of the team, everyone looks better at the end. But the other thing is if we can start that process with a patient-centered trauma-informed response, those patients are much more likely to stay engaged in the criminal justice system. Because as we've researched this subject, we know that many patients, while they will, well, first of all, many patients never report, but of those patients who disclose and come in and want a medical forensic examination, many of them drop out of the process. And what we're trying to do is make sure that these patients stay engaged in what we are doing in order to get the criminal justice outcomes. Susan, this is Diane. A lot of feedback there, but I'm wondering if I could just ask a question about that with your experience of developing so many SANE programs in your history, is how did you create an MDT that had that mutual respect? So in my own community, this is a quick story, but not too quick. We had a woman who reported, who called up her primary care provider after an assault wanting healthcare and was told, we don't do that kind of care. She then went to her OBGYN, and he said, you'll have to go to the ER. She called the ER, and they said, we'll only provide you care if you report to law enforcement. And then she went to Planned Parenthood, where they gave her trauma-informed, patient-centered care. But what this woman did that was even more remarkable is she sat down and wrote a flaming letter to the editor and included all of these healthcare providers who had denied her care. So at that point, our community came together with a qualified mediator and sat down, and we said, basically, we're going to just let everything go right now. All the past, we're going to let go, and we're going to start from scratch. And we as a group sat down and decided two things. First of all, we would have a chain of command, meaning if I got angry at an advocate and I didn't feel I could discuss with the advocate, although that's always the best way, is to talk with them at the time, then I would be able to go to their supervisor and that we would solve problems and that we would not just cut people out of the problem-solving process. So that's one of the ways I think we've been very successful is we have a chain of command. We know that if I can't deal directly with an officer who I'm having a problem with or if they don't feel they can act directly with me, then we do have someone who communicates at a higher level who can solve the problem. And then we've always looked at solving community problems. We've not been specifically case-based. Our goal has been to make sure the patient goes through smoothly through the process, and I think that's one of the ways we've been most successful because we've said, what does our patient need to get through this process, and how can we make the process better? And that way, we're not criticizing. No one's saying, well, you didn't collect the swap correctly, and I'm not telling law enforcement they forgot to find a piece of evidence. We're looking at how do we get this patient through the process in a way that's patient-centered and trauma-informed. Yeah, thank you so much. So, we had our five key principles, but now we wanted a nursing theory that we could hang our hat on. And so, we looked at Joanne Duffy's quality care model, and Dr. Duffy was actually willing to consult with us and gave us permission to use her model. And I'm an old nurse, but I like concrete tasks. I like to be told, this is how you do something, and we felt that the Duffy model was something that every nurse could embrace because it's very clear in what she's asking from you as you apply this model. So, the foundation of her model, and I want you to think about this like a table with four legs, are four caring relationships. First of all, you care for the patient and their family. Secondly, you care for others. And the way we have defined this in forensic nursing is for the other team members that we deal with on a daily basis, and that includes law enforcement and the lab tech and anybody else that is on that healthcare multidisciplinary approach team that you're going to be working with to take care of these patients. Then there's caring for the community, because if we just sit there in our same programs and wait for people to come to us, nothing's going to happen. We have to be out there and in the community and letting them know what we're doing, but also getting involved in the communities. But the most important leg of this table, I think, is caring for yourself. And we know that this is a very highly, this is a very stressful job. There's a high amount of burnout. And if we don't incorporate that care for self, this table is going to completely collapse. So in addition to the four caring relationships, Duffy describes eight factors of caring. And I want you to think about what the research said earlier as you try to apply these eight factors of caring, but they include mutual problem solving. In other words, we're not going there and telling the patient what to do. We are very much sitting down and giving options to patients and letting them be part of the decision-making process, that attentive reassurance that when your patient is scrunching up their face during a pelvic exam that you stop and say, is it hurting, can I do this differently, human respect. And again, we, I tell my own SANE nurses that we don't see the doctor's wives who get sexually assaulted. They know how to access healthcare without ever going through the criminal justice system. But we see a lot of patients that the rest of the world might not have a lot of respect for, but by taking these most vulnerable patients such as commercial sex workers or IV drug users and giving them compassionate care, we are certainly enacting this factor of caring. We're encouraging and we appreciate the uniqueness of meetings, meaning we are tied into our different communities and understand what's happening culturally in those communities and what that might mean to our patients. Just to give you a recent example, I was having a conversation with our local refugee group, and she was explaining how much fear some of the African refugees had about COVID-19 because they had lived through the Ebola epidemic in Africa. And so their feelings about this were very different than my feelings about COVID because of what they had seen and what they had survived in Africa. And we work really hard to have that healing environment. We bring in those warm fuzzy blankets. We have, if you have your dedicated SANE room, you typically have nice paintings on the wall. But we can do things even if we're in a typical emergency room to create that healing environment. We meet our patients' basic human needs, and we allow patients to have the support people there that they want to have. Go ahead. So this is the end of where I'm going to talk, and Rachel's going to take over. But my question is, and if you'll take a minute to put it in the chat, what aspects of the quality care framework are currently included in your SANE practice? And I gave you a few examples, but go ahead and if you have other examples that you feel meet either the four pillars of caring or the eight care concepts that you want to share with everyone else on the call. Yeah, while we're waiting for those chats to come in, I just want to thank you, Susan. That was a great overview, and I love the examples. And I just really appreciate your expertise and sharing of it. You're welcome. Oh, I know you guys have some aspects of the quality caring care framework in your practice, but I'm not really seeing a lot of chats right now. I can go on and on about the things that we do to try and incorporate this model into our care. They're suggesting we go back a slide. So I did that just to give them some ideas. And asking about a copy of the PowerPoint, you know, I just want to remind you that this is being recorded, and it will be posted in every community, every demonstration sites community. So you'll have access to it, and you'll be able to share it with your spokes sites as well. Is anyone on this who is from one of the tribal communities? Because again, there are tribal communities who have allowed spiritual healers to come in for part of the SANE exam and to be there and to meet the spiritual needs of a patient. So I think when you're looking at appreciation of unique meetings, that includes that very important spiritual care that's so important to many patients. Yeah, they might not be on the webinar right now, but I know that a couple of the demonstration sites will be working with tribal communities. So Eileen Arnold explained that their victim services provided artwork in the SANE room. That's awesome. So it could be healing. Sherry from Arkansas said, oh, she has a question. Do you suggest to allow advocates to come into the ER when COVID patients are present in the ER? Yeah, so Sherry, that is a big question. And most of the hospitals are saying no, and most of the advocacy agencies have pulled that face-to-face. But what we're also hearing across the country is that the same units that are functioning out of the ERs are being displaced out of the ER to other areas. Some of our local rape crisis centers are doing telephone support, so they're willing to be there on the telephone for the entire exam. And others are actually looking at platforms in which they can do a video support from the patient's phone. So they're still trying to get in there and be with our patients here in Massachusetts. That's great. Eileen also from Alaska said that their staff is almost entirely Native Alaskan, which is often not represented on the MDT. So that is definitely culturally responsive. Yeah, and Barb Schaefer from NSVRC said the same thing about advocacy responding by phone. Just making sure that we're using the most HIPAA-compliant HIPAA-compliant or the most private and secure forms of communication. And again, I think what's important if you're going to have a telephone advocacy that you need to pass that off. Remember going back to, if we say here, here's a phone number for an advocate, you can call them when you're done. That's nothing compared to us saying here, here's my phone, I'm gonna have you just introduce yourself to the advocate, she's gonna get your follow-up information. And when this is over, she can talk to you and help you fill out any paperwork that didn't get filled out during the exam. But if we say this is an important partner that we work with, and they're just not able to be here at this time because of the pandemic, but we really want you to be connected to this person, that's gonna go over so much better than if we just hand them a business card or hand them a flyer, which they're too much in trauma brain to deal with. Yeah, absolutely. And Melissa, she said that she doesn't practice as a SANE, but she's a clinical psychologist and has just reinforced the importance of giving choice and control back to the patient. So, okay, thank you so much for these comments. It's really helpful. And we're gonna move forward again. And now we'll hear from Rachel. Great, thank you so much, everyone, for having me here today. And thank you, Susan, for that great overview on the quality caring model. I agree that this is a model that feels really usable as a nurse, which is often the best type of theory. There are so many cerebral theories that I think it's hard to really engage nurses who are out there on the front lines. So I think that this is a great theory to add to our practice. So I wanna talk to you a little bit about, oh, actually- Sorry. So what I'm gonna talk about today is how the Massachusetts Department of Public Health Sexual Assault Nurse Examiner Program uses this model to ensure that our tele-SANE program provides excellent nursing care. So you need to know a little bit about why I'm here and why Massachusetts DPH is here. So we're gonna give you a little background on the tele-SANE from Massachusetts. So in 2012, the U.S. Department of Justice, Office for Victims of Crime, issued a competitive solicitation that sought to solve a problem that we all know about. There are just not enough sexual assault nurse examiners or sexual assault forensic examiners to go around. The kind of care that Susan was talking about before this kind of revolution in advocacy still exists in many places. Other places just can't put together a sexual assault nurse examiner program. Perhaps their hospital is too small. Perhaps their resources are otherwise tapped. And sometimes when you have a really small program, it's also really difficult because patient volume is low and it's hard for SANEs to remain competent and confident in their skills. So this grant sought to use telemedicine to expand the reach of expert SANE nurses to underserved and remote sites. Next, please. So the vision of what would become the National Tele-Nursing Center was to improve sexual assault patient and clinician experience. We wanted to increase the quality of forensic evidence and provide support and guidance to clinicians and sexual assault patients in underserved communities. What was really important to the Massachusetts Department of Public Health was that we integrate with local rape crisis advocacy. As Susan mentioned, they are in really an integral part of the work and really an integral part of each exam and practice. And we wanted to work with the community to improve the response for sexual assault victims. So why would we do this? Massachusetts has a unique sexual assault nurse examiner program. It's run by the Massachusetts Department of Public Health. So it's not a hospital-based program. And in this program, sexual assault nurse examiners respond in person to 30 hospitals across our commonwealth to provide trauma-informed forensic nursing care. Our program, which is now in its 25th year, felt that the experience of running such an extensive SANE program that employs about 150 SANEs, some of whom have over 10 years of experience, would really inform its ability to pilot the tele-SANE response. And so the DPH applied for and received the OVC grant. This grant asked us to partner with four pilot sites in different settings. And these are the pilot sites that we initially partnered with. One of the really interesting things about this program was that when it was being launched, the hospitals that initially applied as our remote sites or our spoke sites for the first four pilot sites, and you can see them here, the Robert E. Bush Naval Hospital in Twentynine Palms, Naval Hospital Camp Pendleton in North San Diego, California, Sutter Lakeside Hospital in Lake County, California, and Hopi Health Center in Polaca, Arizona. These were sites where they already had trained sexual assault nurse examiners, but they were the places that we spoke about earlier where the case volume was so low that it was difficult to gain a level of forensic expertise and really feel confident in the services that you're giving to patients. In 2016, the grant allowed the National Tele-Nursing Center to expand to two additional sites. These Massachusetts pilot sites were staffed with spoke site clinicians who were not sexual assault nurses examiners, but rather emergency room nurses who volunteered as part of their regular work to be a group of nurses who would connect with tele-saints during their shifts to collect evidence for patients who presented after an acute sexual assault. This gave our program additional experience, what it meant to train nurses specifically for an encounter, caring for a patient who's been sexually assaulted. When the grant ended in 2019, the Massachusetts Department of Public Health felt the work that we were doing was so important that they issued additional funding to expand the program in Massachusetts. So today, we no longer have those national partners in California, but we did continue to give services in Polaca, Arizona. And what we did is we took our two sites in Massachusetts that did have the spoke site clinicians who were not saints, and we continued those sites. And then we looked to expand our program. And so this is where we've been in the past year or so. We've been adding all of these hospitals. And so the hospitals that you can see on this slide are all in different points of their development. So some of them, we've just started to have our site visits and have our meetings and engage with communities, while other ones are up and going and launched. It's really amazing that this grant funding allowed Massachusetts to establish a tele-nursing center and create a program that was staffed by expert saints or tele-saints who respond to these spoke sites on a 24-7 basis. Our center is a center-based program. So our tele-saints do report to a center rather than doing this work from their home. All of our nurses are experienced saint nurses. We look at everything in a trauma-informed patient-centered lens. And we provide support and guidance to both the nurse and the patient. It's one-on-one in that room, collaborating with nurses, collaborating with patients, and really getting this back and forth to make sure that patient is getting the most choice and the best care. We do this through an audio-visual platform. So our technology is bi-directional video conferencing technology, essentially a speaker, a microphone, and a camera. And through HIPAA-compliant software, it's what's called end-to-end encryption. So essentially, there's very little ways that hackers could get into our system. In our program, as I said, we felt it was important to have a center rather than work from home so that we could have the components for patient privacy, such as sound dampening panels. You may hear my child screaming in the background. I have a one-year-old, and we didn't want that for our patients during this process. And so we wanted to make sure that we could control the setting a little bit. Our initial staffing plan was intended to be onsite for rapid response, but we've fairly quickly realized that the model wasn't cost-effective during the grant period for a low volume. So right now, we work on an on-call system. And as we continue to expand, we're looking at various staffing models. The National Tele-Nursing Center also provides continuing education to our remote-site clinicians or our spoke-site clinicians so that they can continue to improve their skills in evidence collection and patient care. So how does that bring us to the quality caring model? One of the biggest concerns when switching to an electronic platform for care is that we would lose the essential elements to nursing. We'd lose that focus. We really wanted to make sure that we were checking all of the boxes and engaging with our patients in a way that was healing. In building a center, figuring out the technology, staffing, policies, and procedures, it could be really easy to forget the simple elements of what good nursing care is. How do we maintain that focus? How do we make sure that the patient and the team feels cared for? Are we taking care of these nurses in these sites? In order to keep that goal in the forefront, the National Tele-Nursing Center looked to integrate nursing theory into our practice. We all know that research theory and practice are essential to the nursing profession, and theory gives us the knowledge upon which we can base our practice. These relationships are reciprocal with practice leading to research and further clarification of theories. And the NDC found that Joanne Duffy's quality caring model was a good fit for our program as well. And it's also been adopted by the International Association of Forensic Nurses for SANE Practice. So in the next few slides, I'm going to talk about some of the ways that we apply the theory to practice. Now, one of the things I do want to say is that all of Duffy's caring relationships lead back to one thing, patient feeling cared for. So that is the most important part. Fostering all of these relationships goes back to that patient feeling, that central goal. Today, I'm going to describe each of the relationships in an order that makes sense to me when building a new Tele-SANE or Tele-SAFE program. But it's important to keep in mind that even when looking outside of the patient relationship, the work that we're doing maintains the patient focus. So with that, I'm going to start with caring for community. So we know that SANE programs in general benefit the community by helping patients heal. We know that those patients can go out and approach life in different ways when they've received really good care. We know that SANE programs influence community safety. When a SANE is involved in a case, the patient's more likely to report to law enforcement, police collect more evidence, and cases are more likely to be forwarded to prosecution and complete their prosecution process. We expect that the Tele-SAFE or Tele-SANE program would provide many of the same benefits. But when Duffy writes about caring for community, she speaks about the nurses' roles in community groups and teams, bringing nursing perspective to healthcare issues. So today, I want to focus on the importance of partnership and collaboration, which I feel is part of the spirit of Duffy's caring for community. Before we do that, I think that we had a polling question. No. During the grant phase, the National Tele-Nursing Center worked to collaborate and integrate many different communities into building our program. With the NT3 and with the NTCs, or National Tele-Nursing Centers, three types of pilot spokes sites, we are working in big systems. The United States Navy, Indian Health Services, and these partners helped us navigate the system. So you can see some of our partners here on the slide. But we had tons of partners and tons of partners that we collaborated with them. They gave us insight, we gave them insight, and the program built and became much stronger through this process. The partners that you can see on the screen joined us for regular team phone calls. They monitored our progress and troubleshot issues that arose as the program launched. We worked with our partners to engage our tele-sames in training surrounding tribal culture and military life, other aspects of care, evidence collection, some of these places. In some sites, law enforcement joined our spoke clinicians in continuing education offerings. So again, we were forming some of those relationships even on the spoke site list level. For example, one group invited law enforcement to our lecture on trauma-informed interview. And this joint understanding between those spoke clinicians and the law enforcement agents who might respond to a case facilitated both parties' ability to work together during the patient history. So it's getting this out into the community, out into these groups, but also brings it back into that patient care area. The NTC also worked with an evaluation team which helped us understand the experience of both tele-sames and spoke clinicians, which gave us some insight into the patient experience. Beyond these members of our team, we partnered with individual spoke sites on their levels with the nurses and administration to find out how the program would impact their individual communities. So it's really important to consider the difference in each setting when we developed our policies and procedures. If the National Tele-Nursing Center had come to each site with a one-size-fits-all model, it's unlikely that we would have met with such success. You have to consider the knowledge that these sites have of their own communities. So just as we provided training to our spoke sites on different aspects of sexual assault care, many of our spoke sites participated in helping the tele-sames understand the patient population through training. This is a practice that we've continued as we've moved to providing services within our own state. You can go to the next slide. We believe that community partnerships are key in making sure that our program runs smoothly so that patient has the best care and experience. So we start with site selection. We really wanna make sure that hospitals that we partner with wanna become a part of the program. We want them to want to give back to their community and be engaged. We want them to know that this is a need and that they're going to become more involved and more connected. When we reach out to hospital leadership, we wanna make sure that there's buy-in at all levels. And we engage the hospital in a memorandum of understanding that outlines hospital and program responsibilities. Each hospital agrees to provide spoke site liaison with protected time to help facilitate the program and time and pay for nurse training, ensuring that there's adequate coverage for a trained nurse to access the tele-same program 24 hours a day, seven days a week. Then as we add hospitals as a tele-same spoke site, we start with a site visit. We meet with the emergency department leadership to determine how the program will work best for the hospitals, the nurses, and their patients, because they are their patients. The hospital brings their policies and procedures around sexual assault, and we consult to make sure that they follow protocols for patient safety and best practice, but we don't rewrite them or provide them with their own policies, because we want them, again, to be engaged and also to be thoughtful about their own patient populations. We provide nurse training at each of the sites, which we'll talk a little bit more when we're talking about caring for the healthcare team. And finally, each hospital is responsible for holding a community meet and greet. And during this meet and greet, it's an event where they invite whoever they feel is important to this process. And we give them lots of suggestions, and we give them a list of people that we feel like must be there. And some of the attendees include local police, district attorneys, rape crisis centers, children's advocacy centers, anyone who is part of the network of support in response to sexual violence. Often, the media also attends these meet and greets, so the word gets out to the larger community. And this meet and greet gives the community opportunities to ask questions and shape how Telosane responds for each of these sites. Great, Rachel, this is Diane. I just wanted to ask a question on that, on the community meet and greets. And so how much did you, on all the different sites that you developed, did you do some background research on the culture of the community and maybe the history or their laws and things like that? For our grant program, we certainly did. We relied a lot on those communities to inform us about their culture. So for instance, military culture is very different from civilian culture, so we relied on them a lot to give our Telosanes and our program training on how to figure out what policies and procedures would work best for that site. So that took, it took a long time to build a center, and it took a long time to really figure out the best way to work with all of these sites so that we were giving them really tailored, good care. In our Massachusetts sites, we definitely do that as well. We go in, we work with the hospital, we learn about their patient population. So even in Massachusetts, patient sites are not homogenous. It's very different coming from Fall River than coming from Metro West. And I know that you guys don't necessarily know where those places are, but they're very different cultures. There are different sets of people who access care. And so it was important for us to understand that going in. Yeah, thank you. That makes sense, that there would be learning on both sides, not, you know, you would have to learn a little bit about their community before you just walked in and, you know, started, you know, presenting your program. Absolutely. Yeah. I find that a program really works when you engage the community, when you really feel, and when they feel like they need you, not need you in a like, oh my God, we need you sort of way, but they feel like the service is listening to them, engaging them, and really is going to provide something worthwhile. So definitely partnering with those sites and learning a lot about them is really important. Likewise, one of our most important partnerships, deserving of its own slide is with local rape crisis agencies, not just any rape crisis agency, but the local rape crisis agency. This has always been a part of the Massachusetts Sexual Assault Nurse Examiner Program, the coordinator response of sexual assault nurse examiners and rape crisis advocates. Whenever a patient presents to the hospital in Massachusetts, they're paged, they page both the same nurse and rape crisis. So this was integrated into our grant program response and now into our state-based telecine response. Part of our memorandum of understanding for these hospitals says that the spokes sites will call the rape crisis center when the patient discloses their sexual assault so that the medical advocates can respond in the same way that they do to in-person sites and be available to the patient. We also really work to include local advocacy group in our nurse training. So we want those nurses who will be taking care of these patients who will be the hands and eyes and ears and really that patient's primary nurse, we want them to know the medical advocates and know what the agency is about. And it really helps those nurses make the connections between the agency and resources for their patients. Sometimes before we go in, we find that our hospitals aren't really calling the rape crisis agencies, they didn't know about the support or they're just kind of like half, like, oh, maybe I should do this, but I don't really know where the number is. We're just gonna kind of get things done and get the patient out of there. And then our training really emphasizes how important it is to have that connection. Likewise, telecine leadership also participates in the rape crisis training statewide. So we help advocates understand what kind of care their patients can expect through the video conferencing equipment and from same care in general. So, the perspective from our program is that the local rape crisis centers really, what they add, their value is above and beyond anything that we could come up with ourselves. It's just invaluable. All right. So, in Delphi's relationship-based model, there's an emphasis on the relationship between the nurse and the healthcare team. So, we've got our community, and then we have to think about our healthcare team. This is one of the reasons that we felt like the model fits so well with our program's tele-SANE care. The relationship between the tele-SANE and the nurse, or SANE, on the other side of the monitor is a partnership. And that partnership, when you go in as a team, you're really going to be giving the patient better care. With both the experienced forensic examiners and the emergency department nurses who did not take a SANE certification course, it's important to make sure that there's a collaborative response to patient care. Team building leads to a better patient experience. In focusing on the healthcare team, we wanted to integrate Delphi's caring behaviors, so some of those caring actions that Susan talked about. So, our relationship starts with the training that I mentioned in the previous section. Before remote site clinicians can connect, we could do a five-and-a-half-hour training, and we threw out this as Delphi's encouraging manner. We assert their abilities. I'm the first one to say that I'm not an emergency room nurse by training. I never have been, and that the nurses that I train in emergency rooms perform tasks that I don't, I can't even think about the things that they would, how, the way that they do these things, the things that they do, the complexity of their work. So, we work on empowering nurses to feel like they can do and are qualified to do this exam because they are. We also focus on the basic human need of self-esteem. We talk about teloscenes as the nurse's support in the room and the ways in which the teloscene can give advice without having the nurse lose face in front of the patient, so that we can form a healing environment for the nurse in addition to the patient. We review basic evidence collection steps and the paperwork for the sexual assault exam, but consistently reiterate that the teloscene's role is to help the nurse throughout the entire exam and evidence collection process. One of the things that we know about caring for patients who have been recently sexually assaulted is that there can be a lot of anxiety for health care providers around providing the best care. You can go to the next slide, please. Clinicians want to avoid retraumatization and are aware that the actions they take in the moment can have implications for patient healing and legal procedures. Sames who are new or who care for patients and frequently may have these anxieties, as well as these nurses who don't have all of that baseline training. So, you can see by the quote on the screen, an emergency room nurse calls sexual assault cases the most daunting. This is a person who does so many complex tasks for patients who are very sick and they feel like this exam is the most daunting. A central portion of our training focuses on trauma-informed care, so that we can teach these nurses how to interact with patients to reduce the risk of retraumatization and empower patients. Next, as we were creating a professional practice model, the MTC knew that it needed to build in time to establish a good relationship between the telethane and the spoke site clinician. The process for connecting to the telethane has three distinct phases. In the pre-encounter, the nurse and the telethane connect outside of the patient space. In the encounter, the telethane, nurse, and patient all collaborate to develop which steps need to be completed. And in the post-encounter, the telethane and the nurse connect to finish the encounter and finish off the documentation and reconnect. So, as you can see, the pre-encounter and the post-encounter are designed with the relationship between the telethane and the remote site clinician in mind. So, again, building the team is what leads to good patient care. During the pre-encounter, the telethane discusses the spoke site clinician's experience as a nurse and also with the evidence collection exam. You can see how there might be a different unique meaning for nurses who have never completed a kit versus a nurse who's done several before the telethane launched, or how a new nurse might feel like she needs more support, and the more seasoned nurse might worry that a telethane would judge her abilities to provide care. Allowing the clinician to request the level of assistance that they anticipate needed brings in the behavior of human respect in that pre-encounter. This is another time, in addition to the training, to acknowledge any anxiety and stress related to performing the exam and encourage the remote site clinician. You're really doing that encouragement and saying, you can do this, we're going to do this together. You can go to the next slide. During the pre-encounter, the telethane and the remote site clinician engage in some planning and mutual problem solving in preparation for the encounter. For instance, the telethane asks the remote site clinician how they'd like to be interrupted if the telethane would like to add something or direct the clinician, often using code words so the patient would never know that there was something going on. For instance, I like to use, when I do a case, I like to dot dot dot. I always give this example. I was on a telethane case with our spoke site clinician, and I noticed that she wasn't wearing any gloves as she was starting to do the head hair combings. So I just said, you know, when I do a case, I like to grab a bunch of gloves and keep them next to me and that way I can change my gloves between every step. It wasn't me pointing out, hey, you, you're not wearing gloves, you should be wearing gloves all the time. It was me just saying like, oh, here's a tip for me. When I do this, this is what makes this easy. And she got the hint. So she changed her clothes, she changed her gloves between every step after that. Other telethanes have said they use things like, I couldn't see but. So I couldn't see, but were you able to get the external genital swabs? You blame the technology for the question, not the person themselves. So again, it's a way to kind of give these subtle hints. Another way that we like to work on these sort of gentle interruptions or these negotiations between ourselves and the nurses talk about, you know, how we can give them instructions without giving them instructions. So we can start teaching the patient and giving the patient choices. Okay, so your nurse is going to take out step three. Step three is the toxicology paperwork. Now when we talked about your history, we talked about this, we talked about that. And meanwhile, the nurse is like, oh yes, I am going to take out step three and I am going to take out that paperwork. So again, they don't lose face on their nursing skills because their nursing skills are fantastic. This is just something that takes a little bit more expertise. We also work with our nurses during the training about messaging this to patients so that again, they can still feel like they have that respect. They can still feel like they're not losing any face. So one of the examples that our Spokeslight clinician said is that she said, I know exactly how I'm going to message this to patients. Whenever there's something really important, we always have two nurses. When we give blood to patients, we always have two nurses check to make sure that everything is okay. This is something that is so important that we feel like you deserve two nurses for your care. So all of this pre-encounter work works so that when the Telescene and Spokeslight clinician begin the patient encounter, the Spokeslight clinician feels that attentive reassurance and support. The Telescene is watching for nonverbal and verbal cues and assisting, but never undermining the nurse's work. Finally, the post-encounter, another time just for the Spokeslight clinician and the Telescene or Telesafe, is a time to debrief. Again, understanding the unique meaning and impact of each case will be different with different clinicians. The Telescene can offer to review what the clinician did well and offer encouragement for their next case. And it's also a time to appreciate the nursing work well done and caring for the patients. So you are part of this group of people who are really working hard to take care of these patients with those affiliation needs. You are part of this team. If you go to the next slide, you can read a note from the same nurse that we quoted at the beginning of this section. And I feel that this shows clearly how the nurse felt cared for as part of the process of the tele-nursing center. Not only do they assist in obtaining the most comprehensive evidence collection, they provide peace of mind to the nurse and patient that the process was completed correctly. So again, she also describes the nurse on the other end of the screen as being her support when caring for the patient. We really want to make sure that we are uplifting our nurses and their work. So we're really augmenting. All right. So let me go to the next slide. So this next polling question asks, what aspects of the quality caring model will be incorporated into policies and procedures and training? So any thoughts so far about the trainings that you've had, policies and procedures? I know you're kind of mentally thinking about what sorts of things you should integrate. Sherry asked, can you repeat which site Rachel the speaker is from? I am from the National Tele-Nursing Center, which is a part of the Massachusetts Department of Public Health Sexual Assault Nurse Examiner Program. I was just trying to type that, but thank you for catching it. All right, guys. What aspects of quality caring do you think that will become important in your own policies and trainings? Are there things that you've already started to build into these policies? While they're thinking, I'm going to, this is Diane, I'm just going to say it, thought it was a great idea to include one community that included the law enforcement in their trauma-informed care training. And because certainly law enforcement need to hear that information and understand that as well. So anytime you can include your MDTs at the spokes sites, that's a great idea. All right, we've got some good news that some of our sites seem to be incorporating all of the quality caring model with ideas for training and policies and procedures. That's really great. Wonderful. Yeah, I was really astounded that law enforcement was willing to take the time, willing to send people, become a part of the training. It was really great to see that partnership in that way that law enforcement was engaged in the program. All right. And I also really liked the fact that the incorporation of advocacy in the training, we did that in the community where I live and it's not rural, but we would always include advocates in our same trainings. And we advocates would have a nurse come to the advocacy training too, and kind of talk about what the exam really looked like. You know, I think that we do so much as examiners, that there's no way that we would be able to be that person that connects our patients to all of the resources out in the community. And that is really a huge role for rape crisis. And I think having them come into our training and talk about the things that they can offer patients. There are things, every time I have a new rape crisis agency come, they're like, oh yeah, we can directly have that patient's locks changed. They don't even have to go through a process for that. There's always surprises in the ways that they've really worked out making patients feel safe and making sure that they have what they need. Exactly. I've always been amazed. And Andrea says that she really likes that you and your program take as good a care of the spoke nurse as you do of the patient. That's nice. Yeah. Okay. Well, now let's hear about caring for the patient and the family. Yeah. So here is our central focus. We're caring for our patients and our family. And we've talked about this a little bit, but even before we get into the room and the patient encounter, the National Tele-Nursing Center is thinking about how to best care for the patient. It includes that policy review I talked about in the first few slides, ensuring the policies, ensure that the patient's basic needs are met, that they get medical clearance and medications to protect their body. Thought is given to the best room to conduct an exam and to create the healing environment. There are some of our hospitals that choose their room to be in a quiet corner. So the patient doesn't really feel like there's that energy and that back and forth and that movement in the emergency department. Other places have chosen rooms that they know have a bathroom inside or attached to the room so the patient wouldn't have to leave to go to the bathroom. So a lot of thought is given to that healing environment. And we've talked about the training for the nurses, but there's also training for providers on trauma-informed approach to care, making sure that they know all of the up-to-date information on non-occupational post-exposure prophylaxis, emergency contraception, medications for prophylaxis. So we really want to make sure that those patients are, their basic needs are being met even before they, the scene arrives on the scene. Again, as we mentioned earlier, rape crisis advocates must be called to each telosane case to offer the patient support and resources, and again, to create that healing environment. We want to make sure that things are attended to even beyond the emergency room after discharge. And finally, prior to the encounter, the patient must be medically cleared, ensuring that the patient's basic human needs are met. So again, medical care trumps forensic care, but we really want to make sure that that is facilitated in a way that is quick and timely and complete. So in the beginning of an encounter, the telosane uses some scripting to review the role. The telosane asks for introductions and we make sure that we use the patient's preferred pronouns focusing on our human respect. So this is how we move into the room. We've had our pre-conference with the spoke site nurse. They bring us up on the screen and we talk a little bit about our privacy. We talk about confidentiality. We talk about what we can do and what we can't do. We talk about introductions and make sure that we're talking to everybody the way that they want to be talked to. And we really just reaffirm consent. So again, putting that control back into the patient's hands. Is it okay that I'm here? I'm really glad you're here. Thank you so much for allowing me to help take care of you. We talk about our private exam rooms, our sound machines, our sound paneling, our HIPAA compliant software. These go back to the patient's basic needs of feeling safe and secure so they don't have to worry that anything is ever recorded. We also verify their understanding and their consent and the fact that they actually want us to be there. And then throughout the exam, we also check in to see if the patient has any concerns, appreciating what might be most important to the patient. So you think about this in your normal, sane life. Is that patient really worried about getting home to their kids? Do they have to have this exam happen a little bit faster? Do they need to call somebody? Are they starving? And do you want to focus on doing those oral swabs and smears first? And that's a place where an experienced examiner can talk about flexing the order of exams, talk about how exams can be modified to go a little bit faster or a little bit slower if the patient's having a really hard time. You know, we check for, you know, are you hungry? Do you need to drink something? Do you need to use the bathroom? Again, basic human needs that are sometimes forgotten when clinicians are really focused just on everything. So Susan talked about this at the beginning when she talked about some of those programs that were more integrated with law enforcement and were just about getting the evidence. Again, we have to think about, make sure that the patient is comfortable. As the telecine and the rheumatic clinician take a collaborative history, the telecine might acknowledge how hard it is to discuss the details of the encounter of the assault and participate in the exam. They'd appreciate the unique meaning to a patient. So what this means to this patient, it might be different from a teen, it might be different from depending on who the relationship was with the assailant, and we really encourage the patient to go at their own pace. So we do a lot of modeling in our interactions with the patient to make sure that they're getting everything that they need. The telecines use trauma-informed history-taking techniques, so asking those open-ended questions, avoiding asking for timelines so that we can really facilitate getting the most information from the patient in a way that doesn't focus on that, like, pinpoint questioning method. Throughout the exam, the telecine engages in mutual problem-solving with a patient and the nurse. They all explore the options for evidence collection and what steps mean to the patient so that they can make informed care choices. The telecine can watch the patient's non-verbal cues, so sometimes when the nurse is packaging the equipment or doing a part of the exam, they can see the patient's face a little bit better if the patient allows that, and they can suggest comfort measures such as draping techniques or pauses with attention for reassurance. So, you know, we can say, oh, do you feel like you need to take a break? Do you want to take a big deep breath? Everything going okay over there? We can really cue into that from our vantage point, and it's just an absorbing of the patient's response to the exam. Part of our telecine procedure is also to check in with a patient verbally during the exam and verify that they feel comfortable continuing the encounter and continuing with us. Are they feeling fine with the video screen? They might also, our telecines, offer supportive messaging and encouragement as the patient completes each part of the process. You're doing great. You're so amazing. We're almost done. We're really getting there. Some of the things that we've heard from our remote site clinicians were that the telecine became a part of the team, almost as if they were in the room, and I believe it's this focus on making sure that the practice encompasses the caring behaviors and meets the clinician and the patient that creates that feeling. Yes, and I did want to add, too, that we had a comment that the advocates can also help with addressing the needs of the patient and the needs of the family, too, if they are there during the exam. Absolutely, and again, we're thinking about the whole group. Is it a family member that's there? Do they have friends that are there? What are their affiliates? Do they need somebody to hold their hand? Do they need somebody to be on the phone? What does that patient need in the moment? You really want to connect with that patient and focus on those things, and the telecine is able to do that as well. You can see here in our practice model, this main focus on the patient is during the encounter phase, so we're doing all of our collaborative history and our evidence collection, and we're still taking care of that nurse, so we're still using those techniques that we discussed in the pre-encounter phase, but we're really focusing in on that patient and making sure that we're modeling and making sure that we're a part of the team and doing all of this creative problem solving. I think that I talked about all of these different behaviors and gave some examples, but I really like this quote. At first, the patient was a little unsure with the telenurse, but when we got to the pelvic exam, the telecine asked if the patient would like the screen to be covered for more privacy, and the patient said, oh no, she should stay. She seems to have a lot of really good ideas, or you should stay. You seem to have a lot of really good ideas, and that was a real wow moment for me. It was just great, so when we think about each of these caring behaviors and we really pay attention to making sure that we're meeting all of them, the patients feel that connection, even though there's a video screen, even though there's a monitor, even though they're miles away, you can really give good care to the patient. All right, so here are a few other quotes. When we launched our grant program, we did not interview patients directly, but we did interview our remote site clinicians, and we asked them how they felt about the patient's interactions with the telecine in their exam, and these are some of the things that they said. The patient was very comfortable talking with the telecine. Seeing her on the equipment, it was like she was here. It's like another person's in the room. You develop a relationship by the end of the case, so that is what our goal is when we're really thinking about providing telecine care, and I strongly believe that adhering to these behaviors is what makes this work. All right, next slide. All right, so our next polling question is what self-care strategies could be integrated into your telecine practice, teleseaf practice? So when you type in your answers, if you make sure that drop down says all panelists and attendees so that everybody else can see your great ideas for self-care. So we're waiting, but some might not have thought too much yet about self-care, although I'm sure in your own SANE programs, you do some self-care. So team debriefings. I think one of the most important things is having someone available when you've had a bad case that you can talk to afterwards. So having identified in the beginning, who can I call now that this case is over and I need to talk about it? Exactly, like that lifeline. Who's your lifeline? Yeah, we're seeing a lot of that in the chat box, team debriefings, decompressing with other nurses. When we're doing our training, our associate director always says that she has a couple of people in her phone on speed dial that when she's driving home from a case, she can just call them up and chat it out. It's definitely important. And the program that I ran, we used to, at the end of the case, usually we would plug in aromatherapy. And it was, you know, cause the nurses would have still another hour or so of work to do. And it was just amazing how it would calm you at the end of the case and to help you to put your thoughts together. So someone's, so Rihanna says, for me personally, I use meditation, excellent, as well as work-life balance that allows her to become, to go outdoors more often. That's perfect. One of the things that I always ask during my trainings are what are the things that we all know we should be doing? So eating well, exercise, that sort of thing. And so elders in our area advise to focus on being grateful. Grateful for the Telesafe program, grateful for the patient, that the patient has the safe space. It's wonderful. It's really great. Yeah, yeah. During this shelter months and weeks, it's been a challenge for me every day to think about how grateful we are for there's so many things to be grateful for. This is also important for us to share with our patients for their self-care to help them respond to the trauma that they've experienced. So whatever it is they love to do, try having conversation with them about taking care of themselves. Absolutely. Any other examples? All right, well, we'll let you talk a little bit about caring for self then. Excellent. Caring for self is the last of our four relationships, but it is not the least important. As Susan said, without this table leg, all of everything can crush and fall down. I often tell the nurses in our trainings, I need you. I need you. My family needs you. I need you to continue to be strong and continue our profession. So we need you to take care of yourself. But we also know is that sexual assault nurse examiners are more likely to experience vicarious trauma than other women's health nurses. And that the work that we can do can have significant personal impact. Working with patients who have experienced trauma, even through a computer monitor can really hit home. And caring for self is important for being able to continue to do the work and provide good care to our patients. This is one of the areas that we promote for both the remote site clinicians or our spoke site clinicians and our tele scenes. So as I said, during a training, I often ask, what are all the things that we need to be doing to take care of ourselves? So I hear things like exercise and eat well, get enough sleep. I hear things like play with the kids. I also talk to people about ways that you can reward yourself or kind of make the end of a case really good. So I always give this example that in the Boston region, at all of the seven hospitals that we respond to, I know where every Starbucks is that's next to a hospital. And I know that when I am done with a case and I usually take the overnights, that I can just treat myself with whatever I want. So that's one of the ways that I take care of myself is I give myself something good after I do something hard. As I mentioned earlier, but didn't talk about as much as I wanted to, our post-encounter is a time to discuss the case and debrief. So partially it's a time to finish your paperwork and make sure that the chain of evidence is maintained, but it's also really a time for that nurse and the tele-saint to say, that was a really hard case. This, this, and this happened. You know, next time I might think this or I might do this. How are you feeling about this? And so you can have that sort of informal debrief. One of the other things that I want to talk about is that we also offer both our remote site clinicians and our tele-saints the opportunity to speak with a vicarious trauma expert. If they feel like they're having a negative response to this type of indirect trauma. When we do teaching and when we do our trainings for both our tele-saints and our remote site clinicians, we talk about protective factors when it comes to vicarious trauma, which include education, peer support, professional support, self-care, and self-evaluation. I've talked about our remote site clinician or our spoke site clinician training, but it's really important that our tele-saints feel confident both in their skills as sexual assault nurse examiners and also in their ability to precept. All of our tele-saints have two to three years of experience as saints and are experienced saint preceptors. They attend a training which emphasizes the quality caring model, effective precepting, translating hands-on practice to a telemedicine response and vicarious trauma. If you go to the next slide, I just want to share this really great resource with you. The Office for Victims of Crime funded a vicarious trauma toolkit that includes a training slide deck. We use components of the slide deck in both our spoke site clinician and our tele-saint training. It helps participants identify the signs and symptoms of vicarious trauma in themselves and others. And with both groups, we really try to use this to talk about what could happen to them, but also how to prevent vicarious trauma and move things along the spectrum of response. So you can see that this model of vicarious trauma says that you can manage that response to listening to patients' stories in a variety of different ways, and you can push it to the positive where you're getting more vicarious resilience and more vicarious transformation. And so we talk to our tele-saints and we talk to our spoke site clinicians about how to do this, how to connect what your level of professional support is, both with the support from the hospital, but also the support from our vicarious trauma experts, the support from the tele-saint. We really focus on making sure that everybody has that good education. Everybody feels prepared to engage in these encounters so that they can mitigate any of the absorption of that patient's personal trauma. We also talk a little bit about self-evaluation. I use the PQL scale, so I give that to all of our participants. And it's just a check-in to see where you are as far as compassion satisfaction or compassion fatigue. And I give it to our participants, have them fill it out. We don't talk about what their scores are, but they can kind of see where they are on this spectrum of responses. It's a way and it's a tool to check in and make sure that yourself is ready to keep on giving this care, because we really are giving a lot of ourselves when we're giving this care to patients. And so maintaining that love of self is really important and integrated, and to be integrated into our practice. The other way that we focus on peer support for our tele-saints is that we do have staff meetings. And this is a time where all of our tele-saints get to connect, debrief about cases, talk about our work, see each other's faces. We use Zoom meetings, so we're pretty used to doing this distance meeting. And we still like to see each other's faces and really have that moment to connect. Okay, so with that, I would love to open up the floor to questions about the model and how we've integrated the model and how it's become a part of our policies and procedures. Yeah, great, this is your chance to ask the experts. We have Susan and Rachel waiting for your questions. So Rachel, we always include in our debriefing immediately after a case our advocates too, because they may have a different perspective of what we did or how things went. So that's always good to make sure you include your team members, especially if they're present during the exam. That's a really great idea, that's really lovely, yeah. So Sherry's asking if you would be willing to share policies and procedures. So I do believe we're going to be providing some information on that, Sherry, soon. And Yvette says, speaking of advocates, she would love to hear how you might deliver tele-advocacy and what that might look like given the COVID health crisis and advocates not being able to enter the ERs. Yeah, so some of the things like I mentioned earlier that are happening in Massachusetts is that our advocates are still on call. So they're not able to go at this time, but they will call into the patient room and will actually be on the phone for the entire exam if the patient would like them to be there. We've also had times where the patient said, you know, I don't want to keep you on the phone line, but why don't we talk again at X time and the advocate called them back. And then finally, one of our advocate groups is way ahead on the technology and they're working to use a video chat to connect with patients during their exams and also after. So that's how it's working here. Yeah, I see. One of the things that we're looking to is whether or not during this time period, we can also bring an advocate into our space. So our technology and how that would work and whether or not that would still maintain. Yeah, we're working on it. Barbara Schaefer said, some advocates are trying video phone via doxy.me for hospital accompaniment. And Sherry says, do you allow your spoke site patients to reach out to the Telesane after their visit if needed or requested? We haven't ever had a request. I think that most of the time in our practice in in-person scene and our Telesane often reflects that is that once you've had your SANE exam, you wouldn't see that SANE again, partially because of that possibility that your SANE might be testifying in a case if you decide to report and go through the criminal justice system. But they can reach back to the spoke site clinician? The Telesane can reach back to the spoke site clinician can reach back to the Telesane, yes. And the patient can reach to the spoke site clinician? Yeah, the patient could go back to the spoke site as well. And Barb said that we've had conversations around what method is confidential and secure as far as the video phone for advocates. So Jennifer Canton's on, if you're still on Jen, I know they're doing some advocacy or some telehealth with advocacy if they can't be face to face. I don't know if you're still on Jen, if you can let us know how that's going at your site. To have the advocate at your SANE response. I'm not sure what all that background noise is there, but oh, there she is. So Jen says that they haven't had to have one provide advocacy services yet that way. So they would be providing, if they couldn't have an advocate face to face at their spoke site, they could potentially have that advocate through Telesafe from their site. Any other questions on anything? I actually have a question. Oh, wait, here's some more. With the Tundra Women's Coalition in Alaska, we have been having the interviews and exams in the Children's Advocacy Center instead of the ER. So when available, as well as offering phone advocates, advocacy with the rural victims, that's excellent. Keeps them out of the ER, boy. People just don't really want to go to the ER these days. And we are talking about doing that with all our sites now that advocates aren't presenting to the hospital but haven't worked it out yet, according to Jennifer Canton. That's what she said. So it sounds like people are trying to be creative and help the patients in any way they can. Especially with the advocacy piece. Rachel, if you could speak just to one, one thing that I was picking up when you were talking about working with the spoke clinicians was that you had said there was a dedicated team or that there were certain spoke clinicians that did this response. Yeah, so there are a couple of things that we feel are really important. One, we want these clinicians to want to do this work for a couple of reasons. You know, if they're the kind of people that are hiding in the bathroom all of the time when these patients come in the emergency department and they've been doing that for 20 years, they may not feel like this has worked for them. And that might come from a bunch of different places. But we also have to think about the fact that the history of trauma is incredibly common in our society. And so some of these patients or some of these nurses may not be able to take care of patients. They may be worried about their own trauma coming up. So we want them to be, they're not volunteers because they're working, but we promote a model where the nursing staff members say that they want to participate in the program. So that's one part of them being a dedicated group is that actual desire to take care of these patients. And then the second part that we think is really important is the training. We really think that doing some training with each of these nurses is important. We emphasize trauma-informed care. We talk about the kit. We talk about vicarious trauma. And so we want the nurses that are responding and taking care of these patients to be nurses that have been trained in those things. We've seen from our evaluations of our trainings, these nurses are always learning new things. And the comments that they sometimes make are things like, well, I'm not gonna ask patients why anymore. And I'm not gonna judge. And I'm not going to do X, Y, or Z. So we see that they really needed a lot of this training to help them figure out how to respond in a way that decreases retraumatization. I think it improves their confidence. It improves their practice. And so that's why we think having that designated group is important. Yeah, thank you. Rachel, do you have any kind of orientation or introduction to the entire nursing group to then let people know exactly what this entails? Because we've found with our SANE training, even though we have patients, people going through 40-hour training until they actually see what an exam is like, they're not able to make the decision, oh yeah, I can do this work or I can't do this work. Is there some way that you approach a spoke site to do the recruitment? So a lot of our sites do some of that training ahead of time. So most of them have nurse educators. The sexual assault program in Massachusetts has put out a lot of training information for our sites that formerly didn't have any SANE response or any tele-SANE response. So most of the time they've had an orientation to the process and the kits in that way. We also throughout the state offer a lot of trainings on the kits, particularly for those hospitals that don't have an in-person SANE response or tele-SANE response so that they can get a little bit more confident when they're doing the kits because they don't have that level of assistance. So we don't do a general, when we go in, we don't do a general presentation to all of the nurses to see if they wanna be involved. But most of the time they have some level of training before we start launching our program. But that's actually a really great idea. It is a great idea. Any other questions? Well, it's such an investment to train a nurse, whether you're training her to be the frontline SANE or in any program. So if you can do, we're trying to figure out how to screen people better so that we don't do this entire investment in training and then have them last 24 hours. Right, it's always really hard when you have a SANE who goes out for their first case and says, oh, this isn't for me. And you're like, well, we've done your 40 hour training, we've done your precepting and here you are not ready. And of course you don't want that person to go out if they feel like they can't, but it's hard to figure that out ahead of time. And I think about it, it's hard when you have new SANEs in a program where you're working face-to-face with other nurses, but then to add the complexity of working remotely in a hospital that may not have anybody else for you to lean on other than this expert on the screen, that increases that challenge for that nurse. So really the importance of that hub support for the spoke is so valuable for their sustainability and their retention. Absolutely, I would think that in places where the spoke sites only had a couple of clinicians who might be performing this exam, it might be good for them to have a monthly or bimonthly meeting with their different sites so that these people could really decompress and talk about their experiences much like we have our SANE staff meetings. Just to form an official or an unofficial support group of people who are doing similar work. It's a great idea too, yeah. Okay, well, I'd like to thank you both for your presentation today. And I wanna thank everyone who's in attendance, knowing that if your colleagues were unable to make this presentation during this time, that it is gonna be recorded. It will be up on your community sites. Nurses, you'll be given a evaluation and we're being clapped. We get claps from Chris in Alaska. Thank yous. We just fill out the evaluation and then your 1.5 hours of CE will follow through with that. So I do really wanna thank the presenters. You guys are amazing. Thank you for all your time and all the attendees. Thank you too for being present and everybody take care of themselves. Do some good self care. Okay.

tele-SANE program

Massachusetts

expert SANE nurses

underserved areas

Duffy's Quality Caring Model

collaboration

trauma-informed care

patient-centered care

Delphi model

empowerment

self-care strategies

rape crisis centers