Much of the literature on sexual assault focuses on national or urban data, resulting in limited availability of research centered on the issues unique to post-sexual-assault service providers in rural areas. Subsequently, a good deal of what is known regarding sexual assault in rural communities is based on the anecdotal experience of providers. By partnering with a network of existing service providers, sexual assault nurse examiner (SANE) programs can identify and address the unique set of challenges rural populations face such as geographic isolation, mistrust of community service providers, reluctance to accept services, and enduring cultural misconceptions surrounding sexual assault. Collaboration and communication are instrumental in building a successful rural SANE program and improving service response when working with patient populations struggling with poverty and a lack of both formal and informal systems of support.

Challenges, Barriers, and Solutions Building a SANE Program

The gap in services and resources for patients experiencing sexual assault was a contributing factor that resulted in the funding of the Health Education Learning Program for Sexual Assault in Rural Appalachia (HELP SARA) program. The grant, funded by the Health Resources and Services Administration (HRSA) through the Advanced Nursing Education-Sexual Assault Nurse Examiner (ANE-SANE) program, was written to focus on eight rural counties of Northeast Tennessee. In 2018, there were no certified SANE nurses serving the targeted eight counties of Northeast Tennessee. With a total regional population of 516,931 residents (United States Census Bureau, 2020a), a lack of SANEs in rural northeastern Tennessee not only was problematic for patients needing sexual assault services but also created a training gap for rural nurses interested in the field of sexual assault examination. As the grant initiatives grew, efforts extended into Southwest Virginia to include nurses who worked for the regional healthcare system or leading rural community partners.

HELP SARA immediately focused on recruiting nurses interested in training to build a base of potential preceptors in the northeast region of Tennessee. Within the first 3 months of grant implementation, HELP SARA collaborated and contracted with certified SANE trainers from Forensic Consultants of East Tennessee and the Children's Hospital Intervention & Prevention Services to offer both SANE-A and SANE-P training opportunities to area nurses. With certified educators and preceptorship opportunities secured, HELP SARA entered a training partnership with the region's largest healthcare system to establish communication and build relationships with registered nurses working in the 22 hospitals throughout the region.

Within the first 2 years of the funding period, HELP SARA facilitated three grant-funded on-site SANE-A didactic trainings, two on-site SANE-P didactic trainings, and SANE-A precepted clinical check-offs using standardized patients. The opportunity to attend SANE-P clinical preceptorships at the Children's Hospital Intervention & Prevention Services in Birmingham, Alabama, was also funded for interested nurses to prepare for practice. By mid-2020, SANE training was available to all eight counties in Northeast Tennessee that serve the target population of Appalachia, and sexual assault services and resources were available in each of the 22 regional medical facilities.

Although nursing shortages are not unique to East Tennessee, extenuating regional circumstances further exacerbated the challenges to developing a SANE program. The average annual compensation for registered nurses in Northeast Tennessee is $45,000, compared with the national mean of $80,000 (U.S. Bureau of Labor Statistics, 2021). Even before COVID-19, nurses from Northeast Tennessee were enticed to leave the region because of opportunities for substantial financial gain. The COVID-19 pandemic further compounded the existing nursing shortage. At the onset of the COVID-19 pandemic, 47% of nurses left the regional healthcare system (T. Tull, personal communication, April 6, 2021). In November of 2020, the largest healthcare system in the HELP SARA service region had 350 permanent nursing positions to fill (Floyd, 2020), and as of August 2021, there was a need to hire roughly 500 nurses (K. Wilhoit, personal communication, September 8, 2021). A lack of coordinated, evidence-based training and education, limited financial assistance for SANE training and certification, and a drastic reduction in regional nurses contributed to the absence of SANEs in rural Northeast Tennessee and created a barrier in the development and implementation of a SANE program.

Recognizing the pressure rural hospitals were under, in the third year of the grant, HELP SARA chose to expand sexual assault training efforts beyond the traditional emergency department setting by funding online SANE-A training for nonprofit organizations offering free medical care to the most remote service areas in the region. Two additional community partnerships resulted in training nurses who worked for health units that serve rural, vulnerable, and underserved populations of Appalachia. Despite COVID-19-related challenges, as of August 2021, HELP SARA trained 140 SANE-As and 25 SANE-Ps and will continue to offer ongoing education and training until the end of the grant period.

An additional key objective of HELP SARA was to increase the number of SANE certified nurses. Therefore, the program committed to paying certification examination fees and collaborated with several universities and organizations to offer online training to assist nurses in accumulating the required practice hours for exam eligibility. One such training was a 9-hour online course developed in collaboration with two other HRSA ANE-SANE recipients. The training was invaluable not only to newly trained SANEs but also to SANEs in rural areas who may not have the opportunity to conduct examinations as frequently as SANEs practicing in more populous areas. For SANEs who met the standards for certification and were scheduled for an examination, grant funding was used to purchase review texts, host a 3-hour virtual SANE-A and SANE-P review class, and cover the enrollment costs for a 12-week, self-paced online course. To date, HELP SARA has funded 18 nurses to take the SANE-A certification examination and nine nurses to take the SANE-P certification examination. By absorbing the necessary costs for certification and offering a multitude of platforms for training and practice hour accrual, the grant created an achievable path to certification for nurses interested in becoming a certified practicing SANE and taking call to support the region.

Geographic Isolation and Poverty

The lack of access to healthcare and exaggerated levels of poverty in the eight counties the grant serves were key concerns. Barriers to accessing healthcare were primarily related to the geographic isolation of the counties. Two of the most isolated communities in the region are Johnson County and Hancock County, both of which are designated as Health Professional Shortage and Medically Underserved Areas (primary care and mental health) by HRSA. To illustrate the geographic isolation, a sexual assault patient from the two most remote areas would be required to travel 125 miles round trip to the nearest SANE facility. In addition, the two counties each lie between mountainous ridges connected by narrow mountain roads making travel to seek post-sexual-assault medical care not only lengthy but also difficult and potentially dangerous.

Further exacerbating the issue of geographic isolation in the grant service area is the poverty level. All eight counties have higher poverty levels (15.1%–26.3%) than both the state (13.8%) and national (12.3%) figures (United States Census Bureau, 2020b; United States Department of Agriculture Economic Research, 2021). Two counties in the HELP SARA service areas have poverty levels that are more than double the national rate; therefore, many patients lack the transportation and finances necessary to travel the distances required to access SANE services.

Although a plethora of challenges required attention during the 3-year tenure of HELP SARA, a core objective was addressing the service gap that existed because of poverty and geographic isolation. During the first 6 months of the grant, HELP SARA delivered on-site priority SANE training to the region's most remote locations, thus removing the need for nurses to travel for education and improving community access to essential care. Through funding from HELP SARA, the clinics in the two most rural counties have SANE-A trained nurses on-site and the grant purchased Mobile-ODT EVA devices with telehealth capabilities. Patients no longer need to drive over 100 miles for a SANE to perform a medical forensic examination. The focused efforts of the grant successfully mitigated many of the geographic and income barriers that once prohibited patients of rural Northeast Tennessee and expanded access to patient-centered, trauma-informed post-sexual-assault care.

Stigma, Distrust, and Potential Disenfranchisement

More compelling than the measurable barriers of poverty and geographic isolation lies a hidden layer of cultural challenges for rural patients of sexual assault (Edwards, 2015; Lutgendorf, 2019; Neill & Hammatt, 2015). Although more difficult to quantify, the complex sociological challenges rural patients of sexual assault face are no less difficult to navigate. Rural sexual assault patients are faced with long-held cultural beliefs that discourage postassault care. A lack of community education, combined with the belief that women should be passive and submissive, places women at an elevated risk of being victimized, receiving inadequate support, and therefore experiencing the prolonged adverse effects of victimization (Sheldon & Parent, 2002; Yuvarajan & Stanford, 2016). For HELP SARA to build a sustainable, effective program, recognizing the existing culture regarding sexual assault was essential. Training SANEs and equipping clinics will not lead to success if patients remain reluctant to seek or accept services and key stakeholders fail to support collaborative efforts.

Rural communities in the southern United States are overwhelmingly conservative and tend to hold traditional gender attitudes encouraging male dominance and female submissiveness (Dudgeon & Evanson, 2014). Although women are not the only group of people to encounter sexual assault, a substantial gap in the literature was identified regarding rural sexual assault of gender minorities and sexual assault against men in the Appalachian region. The framework of conservative values and fundamentalist religious views fosters a generational acceptance that women are not equal to men and, therefore, have fewer rights. Rural patients cite cultural concerns as a primary factor in the decision to not seek care at significantly higher rates than urban survivors (Logan et al., 2004). In addition, qualitative research surrounding this topic reflects a pervasive concern about an “ol' boys' network” that functions to maintain the status quo and reinforce the subjugation of women (Rennison et al., 2013).

These cultural beliefs go beyond a community level and negatively impact the seriousness with which sexual assault is investigated and prosecuted in rural regions. In the entire East Tennessee region, 23% of forcible rape cases received an exceptional clearance, meaning the case was closed or cleared for reasons other than prosecution (Tennessee Bureau of Investigation [TBI], 2014, 2021). By contrast, the exceptional clearance rate was 67% and 82% in the two largest counties covered by the HELP SARA program, significantly higher than the regional average (TBI, 2021). Further examination of the data revealed a region-specific issue that warranted concern and intervention. Sexual assault cases in the region served by HELP SARA were being cleared because of a refusal to cooperate with law enforcement at a staggering rate. For the entire region of East Tennessee, the rate of victims refusing to cooperate with law enforcement was 12%; however, in the two largest counties serviced by HELP SARA, the rates of victims refusing to cooperate with law enforcement were 88% and 26%, both higher than regional trends (TBI, 2021). Although there is no further explanation detailing the specific reasons victims refused to cooperate with investigation and prosecution, law enforcement attitudes toward sexual assault crimes and approaches when interviewing victims were often cited as a challenge by advocacy-based community partners. Although SANEs are objective healthcare providers and not agents of law enforcement, HELP SARA chose to work with the region's law enforcement agencies to prevent further traumatization and encourage best practices.

To change the comprehensive response to sexual assault, improving support for patients and increasing reporting rates by offering evidence-based sexual assault training to law enforcement was important. Northeast Tennessee is fortunate to have a local trauma-informed care expert who partnered with HELP SARA to develop a 2-hour online course titled “Trauma-Informed Policing” specifically designed for law enforcement agencies. The online training addresses how to provide evidence-based trauma-informed care to survivors when investigating sexual assault crimes. The training was evaluated and determined to meet the educational standards for law enforcement and received Peace Officer Standards and Training Commission approval through the state of Tennessee. The Peace Officer Standards and Training Commission approval was key to implementation considering law enforcement officers are required to have 40 hours of approved training each year (Tennessee Department of Health, n.d.). The training was first implemented in the most populous county supported by the grant with the intention of having the training mandated for yearly in-service sessions and disseminated to all newly hired personnel. Making evidence-based education available to law enforcement officers may inform internal policies surrounding sexual assault, improve communication between patients and law enforcement, and increase reporting and prosecution rates (Clements et al., 2020).

To provide ongoing formal education for a multidisciplinary audience, the HELP SARA conference was created at the initial outset of the grant. In 2019, the first annual conference was a 2-day in-person event with 14 different speakers presenting a wide range of topics centered around improving forensic care and promoting trauma-informed, evidence-based practice for patients of human violence. Sessions covered topics such as mandatory reporting, emerging trends in violent crimes against children, protective orders, forensic photography, pediatric case studies, strangulation, vulnerable populations, and variations of normal physical examination findings that can mimic child abuse. Presenters and attendees represented a mix of different disciplines, including law enforcement officers, physicians, attorneys, patient service advocates, and forensic nurses.

As a result of the pandemic and social distancing, the second year of conferences converted to quarterly offerings delivered remotely and targeted healthcare providers, nurses, social workers, law enforcement, advocates, and childcare agencies. HELP SARA enlisted several content experts to deliver relevant materials to conference attendees. Content experts presented topics such as familial violence and pet abuse, elder abuse, and nonfatal strangulation. The final quarterly session for Year 2 focused on the high rates of stigma and marginalization surrounding sexual and gender minority populations at a considerable risk for abuse, including sexual assault. In total, the conferences were attended by 200 sexual assault service professionals from across the country.

Coinciding with strict religiosity and conservative values, patients experiencing sexual assault in rural communities face a lack of anonymity and confidentiality. For example, Hancock County has a total population of 6,662 (United States Census Bureau, 2020a), highlighting that interaction between parties involved in a sexual assault is unavoidable. The close-knit nature of rural communities can be beneficial in many aspects of life, but it can also discourage sexual assault patients from seeking medical care because of the sensitive and “taboo” nature of the offense. The simple act of seeking postassault follow-up care and services can be problematic for patients in rural communities; neighbors can easily identify patients' vehicles parked at the local rape crisis center and spread the word throughout the community (Averill et al., 2007). Combined with an enduring perception that sexual assault is a taboo topic that should be handled privately, cultural beliefs and misconceptions can prove to be a significant barrier in building and sustaining rural SANE programs.

In an effort to decrease stigma and normalize conversations about sexual assault, HELP SARA partnered with multiple community organizations to launch a region-wide “Start by Believing” campaign in April 2021 during the sexual assault awareness month. The campaign was selected because it simply and effectively addressed a systemic problem the region's victims often face—not being believed. Through collaboration with area nonprofits and service providers, access to community connections and contacts increased and strengthened, and the initiative reached a level of support and momentum once unthinkable. Mayors of the three largest cities in the grant service area issued proclamations declaring April 7th “Start by Believing Day”; several of the region's most recognizable local businesses showed support through advertising, local news outlets reached out for coverage, and each agency and organization was involved in a coordinated month-long social media campaign. Although the campaign was a simple step, exposing the taboos surrounding discussions of sexual assault and changing perceptions toward patients who experience sexual violence remain imperative.

The concerns surrounding lack of anonymity are coupled with a mistrust of healthcare providers, an issue that was particularly heightened in rural Appalachia just before the HELP SARA grant. In 2017, there was one certified SANE providing post-sexual-assault care in the HELP SARA service region (Kuebel, 2017). Unfortunately, in 2018, the SANE was convicted of tampering with evidence, unlawful disclosure of confidential child sex abuse information, and criminal conspiracy to tamper with evidence after an incident where the SANE unlawfully turned over evidence to the mother of an assailant (Tennessee Department of Health License Verification, 2020). Understandably, in a community where there are concerns about privacy and anonymity when seeking services, this situation exacerbated those very fears. The SANE was sentenced and her nursing license was suspended, but the community damage was done. The region lost the only certified SANE nurse, and the creation of a SANE training program was not immediately supported by the community at large.

Unfortunately, addressing mistrust that is deeply culturally embedded in 3 years is challenging, if not impossible. HELP SARA nurse training focused on the importance of respecting patients' choices regarding reporting to law enforcement and emphasized that forensic examinations are essential medical care regardless of law enforcement involvement. In addition, HELP SARA aimed to foster the SANE's commitment to protecting patient confidentiality, which was intended to promote community trust and confidence in the SANE nurses. To mediate feelings of disenfranchisement born of mistrust and stigma, HELP SARA is launching a website to provide easy and instant access to patients' rights. Secondary to legislative changes in Tennessee, effective July of 2022, all sexual assault evidence collection kits will be tracked, and patients can access a website if they wish to track the kit anonymously. The grant team is working with the TBI to embed the HELP SARA information within the victim facing website. The website will be promoted throughout the community to ensure patients have information regarding their rights before seeking care. HELP SARA aims to improve feelings of empowerment for patients during interactions with law enforcement and medical professionals by providing direct and easily accessible information.

Sustainability

HELP SARA grant funding afforded opportunities to train and certify SANEs, provide invaluable medical equipment to rural clinics, and offer ongoing forensic education, all key efforts intended to improve post-sexual-assault care. However, regional needs remain, and with the funding window of the grant ending, the focus shifted to ensure that the work and goals initiated by HELP SARA would continue long after the close of the grant. In examining the path forward, retention of rural nurses and providing enduring training opportunities were identified as critical to sustaining a SANE program in rural Appalachia. In rural areas, many SANE-trained nurses perform examinations infrequently, leading to skills attrition and retention issues, which must be met with creative solutions.

A partnership between HELP SARA, the International Association of Forensic Nurses (IAFN), and two key community stakeholders resulted in an opportunity to establish sustainable SANE care in rural Appalachia. Project sustainability surveys conducted by IAFN allow for SANE program weaknesses and opportunities to be identified with recommendations for improvements and suggestions for capitalizing on program strengths, in addition to ongoing support and communication for a year after the completion of the survey. Offering this service to HELP SARA healthcare partners improves the likelihood that the region's existing SANE programs have the tools and information necessary to continue to grow and succeed in the future.

The development of a Forensic Nurse Certificate program was a key grant initiative to provide ongoing training of forensic nurses in the community, region, and state. The postbaccalaureate program was designed for nurses already trained as SANEs. The intent was to focus on the broader scope of forensic nursing practice, which incorporates domestic violence, stalking, human trafficking, elder neglect and abuse, child neglect and abuse, cybercrimes, death investigation, and nonfatal strangulation. The inaugural class was scheduled for Fall 2021 as a 12-credit-hour program offered through the university at graduate-level tuition costs. However, upon further consideration and discussion, HELP SARA wanted to provide education to a wider audience that may not have the finances or time to enroll in a full-time university program. To reduce costs and better meet the educational needs of SANEs across the state and region, HELP SARA pivoted and redirected the forensic nursing program. The forensic nursing education is now offered as continuing education through the university's Office of Professional Development. The content consists of 16 self-paced online modules focusing on patient-centered, trauma-informed care. The realignment of the forensic nursing education curriculum lowered enrollment cost and made the material available to SANEs nationwide.

Before securing the grant, there was no formal system of support or coordination between SANEs practicing in different regions of Tennessee, which led to a lack of consistency in practice and education. In 2020, HELP SARA brought together SANE leaders from across eastern, middle, and western Tennessee to form a statewide chapter of IAFN. This forum has served as a place to discuss practices in different areas, share resources, discuss legislation changes, and improve the retention of SANEs through support and ongoing communication. The formation of the Tennessee IAFN chapter highlighted the need for greater access to SANE support and education, prompting the development of a HELP SARA website to host low-cost, easily accessible continuing education opportunities to be shared by Tennessee IAFN members across the state.

Implications for SANE Programs

Every new SANE program will need to evaluate and address the specific challenges and barriers of the community they serve. However, there are valuable lessons HELP SARA learned that may benefit others looking to build or expand sexual assault services and resources in rural areas. These include ongoing education for postassault care providers, investment in multidisciplinary partners, and facilitating evidence-based interprofessional practice.

Ongoing Support and Education

Although the primary objective of the HELP SARA grant was to train and certify as many SANEs as possible within the grant's 3-year tenure, it became clear in the final year that the focus needed to shift toward building sustainability if the program was to continue to serve the region. Training more than 100 SANEs to serve a region lacking in post-sexual-assault care is an achievement, but without mechanisms in place to provide education and training when grant funding no longer exists, the program is at risk for eventual failure and collapse. Investing in partnerships with local family justice centers, nonprofit service providers, and healthcare facilities with the goal of connecting them with national organizations capable of providing ongoing support and program resources was one step HELP SARA took to foster continued success.

The second area that plays a significant role in determining the longevity of a SANE program is creating enduring training and educational materials. To promote long-term engagement, collaboration, and learning, HELP SARA purchased multiyear professional organization memberships for key nurses who were highly engaged in the efforts. The ongoing memberships combined with material offered in the Forensic Nurse Certificate form a solid foundation for the nurses practicing in the region to continue to grow and learn professionally.

Multidisciplinary Partnership

In rural regions facing issues of poverty, geographic isolation, and lack of support, the importance of building strong ties within the community is essential. A key strategic decision the grant team made was to include a local Sexual Assault Response Team coordinator, on the core HELP SARA team, who provided a unique perspective and offered a better understanding of the existing regional and cultural perspectives. Working with community stakeholders, such as advocacy groups, healthcare organizations, law enforcement, local prosecutors, and nonprofit organizations, builds investment and engagement in postassault care and establishes a network of support that will continue the work initiated by the grant.

Taking a multidisciplinary approach to building a SANE program fosters communication and collaboration among the partners involved in the response to sexual assault. When existing resources are shared, barriers and gaps in service are minimized, and postassault outcomes improve. Community-level conversations can potentiate awareness of the benefits of seeking post-sexual-assault care, ultimately building community trust and confidence in SANE programs. Improved public awareness increases the likelihood that patients will be willing to accept the services and resources available. The efforts and achievements of the HELP SARA program have not occurred in isolation, and the importance of strategic partnership cannot be overstated.

Conclusion

Rural Northeast Tennessee counties face substantial obstacles related to poverty, geographic isolation, and cultural belief systems. Although rural settings can create challenges and barriers, there are tremendous strengths found in Appalachian communities. Connections, collaboration, and the building of interagency networks to bridge service gaps are made more easily and quickly by virtue of personal ties and social matrices. Regional collaboration between all community partners has been paramount in the success of HELP SARA postassault care initiatives.

The initial aim of HELP SARA was to provide accessible SANE training to even the most remote counties served by the grant and increase the number of trained and certified SANEs in the region. Substantial training goals were achieved by training 140 SANE-As and 25 SANE-Ps and funding 27 nurses for certification examinations. However, it was through expanding access to postassault services and cultivating a patient-centered model of care that the ANE-SANE HELP SARA grant substantially changed the landscape of sexual assault services in rural Appalachia.