Patient-Centered Care

Physical exam of patient

Patient-Centered Care

Sexual assault is a traumatic event, and no assault experience is the same. Health care providers can reduce the risk of further trauma by providing person-centered, trauma-informed care that recognizes the patient has recently experienced neurobiological trauma.

Patients have the right to have a sexual assault medical forensic assessment. Pre-authorization by law enforcement is not required. Law enforcement must document, in the manner required by the OAG, their requests or denials of sexual assault examinations for all reported sexual assaults. See the Law Enforcement Request for Sexual Assault Exam (Texas Code of Criminal Procedure §56A.251; §56A.303)

Trauma-informed care takes the vulnerabilities and lived experiences of the patient into consideration, while acknowledging the impact of trauma (OVC, n.d.). Patients have the right to decline any part of the assessment, even after they have signed informed consent and authorization forms.

A patient who is a victim of a sexual assault has the right to have a sexual assault advocate present during the forensic medical examination (Rights of Crime Victims – Presence of an advocate Texas Code of Criminal Procedure 56A.351).

Use trauma-informed practices when discussing gender at birth and self-identifying gender preference.

There is no “normal” behavior following sexual assault. Exposure to trauma causes neurobiological changes that may impact behavior. Behaviors that may be observed include:

  • Flat or blunted affect;
  • Agitation, fidgeting or poor eye contact, especially while speaking of the assault;
  • Difficulty staying awake;
  • Difficulty remembering details about the traumatic event, especially chronology of events and peripheral details;
  • Focus on sensory details of the assault such as perpetrator features (e.g., tattoo, facial hair, mole, etc.), colors, smells, or physical sensation;
  • Difficulty answering questions or making decisions; and
  • Emotional lability.

Trauma impacts cognitive function. To assist patients:

  • Inform everyone about what will occur before it occurs,
  • Offer choices,
  • Allow time to respond to questions,
  • Take breaks if patients appear overwhelmed, and
  • Ask patients what they need to feel safe.

There are essential questions about the traumatic event the health care professional must ask to properly treat injuries and prevent further adverse health outcomes:

  • Consider beginning with less stress-provoking general health information and explain the rationale for questions asked.
  • Prior to obtaining the history of the incident(s), inform the patient that it is necessary to know what occurred to provide the best treatment options.

Trauma can impact cognitive function and memory. Ask open-ended questions or clarifying questions and avoid “why” questions. Patients seen immediately following sexual assault who have not slept may have more difficulty with memory. They may need comfort measures, including medications.

Neurobiological changes can lead to long-term conditions such as post-traumatic stress disorder (PTSD), chronic pain disorders, depression, anxiety, substance use disorder and suicidal thoughts that disrupt day-to-day functioning. Therefore, health care professionals should address patients’ mental and physical health needs.

Telehealth

Telehealth nursing “encompasses independent and collaborative practice during encounters that use telehealth technology in a virtual environment.” “RNs use evidence-based information across a variety of health care settings to achieve and ensure patient safety and quality of care while improving patient outcomes” (American Academy of Ambulatory Care Nursing (AAACN), 2018, p. 10).

The option of telehealth uses innovative, secure and confidential video technology to connect on-site clinicians with certified Sexual Assault Nurse Examiners (SANEs) to reduce barriers for survivors in accessing trauma-informed care.

Patients utilizing telehealth services have the same rights as patients who utilize face-to-face sexual assault services and have the right to have an advocate present.

Telehealth also offers the capability to support patients who experienced an act of sexual assault with 24/7 access to experienced forensic nurses.

TeleSANEs support on-site emergency department clinicians in completing a medical forensic examination. This support may include everything from proper documentation to evidence collection and is designed to provide patient-centered care as quickly as possible for survivors. The forensic nurse experts remain visible to the patient during the entirety of the exam, are available for the patient and remote provider to ask questions during the exam and are an optional resource for patients seeking care. In partnership with the Texas A&M Health Center of Excellence in Forensic Nursing, the Texas Teleforensic Remote Assistance Center (Tex-TRAC) is currently utilized by four hospitals in rural Texas. Tex-TRAC provides 24-hour coverage by expert TeleSANEs to ensure patients who have experienced sexual assault and other forms of intentional violence have the option to receive specialized care in their own community.

The Tex-TRAC Hotline offers consultation with a forensic nurse expert to support all health care providers and law enforcement officers offering the following services:

  • Toll-free hotline 1-833-TEX-TRAC (1-833-839-8722)
  • 24 hours a day, 7 days a week, 365 days per year availability,
  • Consultation with clinicians seeking guidance in treating patients surviving sexual assault,
  • Referral to nearest facility with SANE availability, Rape Crisis Center or Child Advocacy Center.

Presence of an Advocate

“Advocate means a person who provides advocacy services as an employee or volunteer of a sexual assault program” (Texas Government Code §420.003). Per Texas Code of Criminal Procedure §56A.351, health care professionals must offer access to a sexual assault advocate during the medical forensic examination if that service is available.

Sexual assault advocates must be trained by a certified sexual assault program AND must be an employee or volunteer of a sexual assault program as defined by Texas Government Code. Advocates for child patients may be provided by local CACs and/or in coordination with rape crisis centers, according to local protocols.

Regardless of age, it is the patient’s right and choice to have the community advocate present during any or all parts of the medical forensic assessment process. The presence of an advocate is not only a right afforded to the patient by Texas Code of Criminal Procedures §56A.351 but is an integral part of the medical forensic assessment process. The advocate is distinct and separate from hospital and law enforcement personnel. Sexual assault advocates from sexual assault programs are community-based and differ from the criminal justice system–based victim services or liaisons. (See Texas Local Government Code §351.251)

Advocates provide non-judgmental support to the patient and explain response options and other support resources available to the patient. Advocates might be the only consistent support throughout the entire healing and legal processes.

It is vital for medical professionals to understand community SART protocols to accurately describe the role of the advocate, which is to provide crisis intervention, support services and information regarding the rights of crime victims for future counseling (Texas Code of Criminal Procedure §56A.351).

See advocate roles.

Use of Interpreters

Patients have the right to information in the language and format of their choosing. As with any other patient, family or support persons should not be used as interpreters.

If the provider is not fluent in the patient’s preferred language, the provider shall utilize an interpreter, following facility protocols. The availability of interpreters for patients who are non-English speakers, vision or hearing impaired is key to all aspects of the medical assessment and forensic evidence collection process and required by federal law under Title III of the Americans with Disabilities Act (ADA).

Verbal and written consent and information is required for all patients, including those with limited English proficiency. Verbal and written consent from patients who have limited English proficiency may require the use of foreign language interpreters—for verbal consent, for written consent to have the translators provide a sight translation of written documents, and for the translation of any forms into other languages.

Most health care facilities have access to interpreters; however, the following resources may be of assistance to ensure patients fully understand every aspect of their health care and are able to appropriately provide an informed consent:

Culturally Aware Care

When performing a medical forensic sexual assault assessment and evidence collection, the health care professional shall provide trauma-informed, person-centered care that is culturally aware and compassionate, and is accepting and respectful of cultural differences. All patients should be seen, heard and respected.

Care will be guided by and sensitive to the patient’s culture, customs, beliefs, religion, and individual needs, recognizing that all patients are individuals and may identify or belong to ethnic groups or have belief systems that are different from the health care provider’s own and may not be readily apparent.

Patients will be provided with a qualified, trained, medical interpreter in their preferred language. Certified interpreters shall be utilized as directed by facility policy.

Any patient may decline any part or all the medical forensic assessment for any reason; in addition, the exam may be adapted to meet the preferences of the patient as needed. It is important to educate the patient on the possible outcomes of accepting or declining any portion of the examination or health care process.