Person with stethoscope hanging around neck Sustainability 101 Long Range Thinking for Sexual Assault Nurse Examiner Program Managers This project was supported by Grant No. 2006-WT-AX-K052 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women. The content of this publication may be reprinted with the following acknowledgement: This material was reprinted, with permission, from the National Sexual Violence Resource Center’s publication entitled Sustainability 101: Long Range Thinking for Sexual Assault Nurse Examiner Program Managers. This guide is available by visiting http://www.nsvrc.org. © National Sexual Violence Resource Center 2009. All rights reserved. Sustainability 101 Long Range Thinking for Sexual Assault Nurse Examiner Program Managers Jenifer Markowitz, ND, RN, WHNP-BC, SANE-A Sustainability: of, relating to, or being a method of harvesting or using a resource so that the resource is not depleted or permanently damaged (Merriam-Webster, 2009) Sustainability is a frequently used term that people intuitively understand yet have difficulty defining. When pressed to identify the hallmarks of a sustainable program, most people cite money as the operative characteristic. Yet financial resources alone do not guarantee the success of a venture. Other issues, such as infrastructure (e.g., staffing, training, leadership) and relationships (e.g., collaboration with healthcare institutions and victim service providers), can also impact sustainability. Even the most affluent, well-staffed programs need to evaluate themselves and ask the question, “If (hospital CEO, funding stream, program coordinator) changed tomorrow, would our outlook still be as positive as it is today?” If the answer is anything but a confident “Yes!” consider the following: Invest in People First, Things Later Technology is valuable and can complement a quality program, but if the infrastructure is not sound or if there are problems maintaining competent staff and committed leadership, all of the high-tech, expensive equipment in the world cannot make up for these deficits. To build a strong infrastructure of committed staff, Sexual Assault Nurse Examiner (SANE) programs might consider reprioritizing funds to provide on-call pay, stipends for taking the most shifts in a month, reimbursement to maintain clinical skills, and opportunities for personal enrichment. A people-first approach may mean reexamining priorities: is a higher priced piece of equipment, such as a colposcope, at the top of the list? Instead, could you consider a less expensive, high quality digital camera and target more fundraising efforts to better compensate staff? Recruitment and retention are issues across all nursing disciplines, not just forensics, but SANEs may feel it more acutely because the general shortage of nurses means staff members are working longer and harder in their primary jobs. With hectic work schedules, it’s hard to ask people to give even more without incentives. Know your Budget and Sources of Funding Through the SANE Sustainability Technical Assistance Project, we learned that many SANE coordinators have little understanding of their programs’ budgets. Some reported they had no funding or operating budget because they did not have financial resources independent of the emergency departments or community organizations where they were housed. In these instances, the SANE programs were essentially a small piece of larger departments or agencies. Others stated they had no funding or budget, even as independent programs, because they didn’t have operating expenses beyond the money used to pay nurses for individual cases. In both circumstances, programs failed to recognize that a vital part of their fiscal resources includes: • in-kind contributions such as exam room space, patient care supplies, and telephones; • volunteer hours; and, • state or local reimbursement for performing sexual assault medical forensic exams. Every program should have a budget, even if it is a piece of a larger budget. For example, SANE program managers, housed under the umbrella of a larger agency or institution, could speak with department managers or agency directors to discuss budgetary issues and resources relating to SANEs. Remember to count actual dollars and donated time, space, and supplies. By becoming knowledgeable about program budgets and funding issues, SANE coordinators can realistically assess needs and set fiscally sound priorities. Ultimately, it is difficult to ask for more resources when you don’t know or can’t articulate what resources you already have. Reframe Traditional Notions about Education One of the most frequently mentioned issues when discussing the challenges of sustaining SANE programs is obtaining education for nurses, particularly as it relates to completing clinical requirements for new SANEs or maintaining competency for existing SANEs. Today, SANEs have more training options in a broader number of formats than ever before. One of the most promising tools available is the Sexual Assault Forensic and Clinical Management Virtual Practicum DVD (http://www.iafn.org/ displaycommon.cfm?an=1&subarticlenbr=174). This tool gives the user the experience of providing the medico-legal examination through detailed online simulation. It also includes crime laboratory and courtroom testimony experiences. While it doesn’t replace the need for hands-on clinical education, it can supplement the process, particularly in communities where presenting sexual assault numbers are low. Beyond the Virtual Practicum, there are a host of other training options available at little or no cost. Many agencies, including CALCASA’s Prevention Connection (http://www. preventconnect.org) and the U.S. Department of Justice’s Office for Victims of Crime (http:// www.ovc.gov) offer a variety of webinars on topics ranging from risk management (http://nonprofitrisk.org/training/webinars/ webinars.shtml) to primary violence prevention. While they won’t necessarily fulfill requirements for initial SANE education, they can certainly help to enrich and inspire existing SANEs and SANE program managers. State, territory and tribal anti-sexual violence and anti-domestic violence coalitions2 can also provide a wealth of inexpensive educational opportunities on sexual assault and intimate partner violence, elder abuse and neglect, child witnessing, human trafficking, and more. Not only do coalition staff members have expertise and perspectives that may expand SANE’s distinctly clinical focus (such as effectively engaging in public policy), but working with coalitions can help enhance collaborative efforts between disciplines. Those looking for more flexible education options may be interested in the increasing numbers of podcasts offered. Podcasts allow users to download audio content to MP3 players and certain types of cell phones to be reviewed at the user’s convenience. Sites such as Podcast Directory (http://www. podcastdirectory.com) make it possible for users to search by topic, location, language, and more. For example, Nursing Studio, available through Podcast Directory, is a site devoted to nursing podcasts from a variety of sources, and includes emergency- and critical care-themed content. Most of these are free. The potential for offering forensic nursing-focused content via podcasting is limitless. Further, both Apple (http://www.apple.com/itunes/whatson/ podcasts/specs.html) and Microsoft (http:// windowshelp.microsoft.com/Windows/ en-US/Help/0957D74A-AB72-421B-9D61- DE415A6B32BA1033.mspx), among others, have step-by-step information about creating and publishing podcasts. Mentor Future Leaders Every program manager should consider who is available to assume leadership during staffing transitions. Succession planning is a critical aspect of program success, yet little attention has been paid to how forensic nursing management can support and encourage the next generation of leaders. Having a plan in place to develop leadership within a SANE program can help maintain a continuation of services with the departure of a coordinator, even if retirement is not on the immediate horizon. There are some relatively simple ways program managers can mentor potential successors: • Encourage staff to attend professional development courses/workshops that emphasize leadership. Many such opportunities can be found locally through larger hospital systems, community foundations, and area colleges and universities. Opportunities may also exist online through webinars, interactive presentations, and podcasts. • Create occasions for staff to interact with organizational leadership. Provide them with the opportunity to attend meetings, present information, and participate in interagency committees as applicable (i.e. emergency preparedness, customer satisfaction). • Assign tasks to key staff that give them the opportunity to develop new skills such as scheduling and billing or educating and precepting (Lubar Price, 2006). Since program coordinators are often nurses with great passion for the work, it is crucial to balance their perspective with the business knowledge and leadership skills needed for success. Nursing school curricula do not educate healthcare providers on how to run a small business, such as a SANE program. By providing ongoing, on-the-job business training for SANEs, programs can mitigate this knowledge deficit and begin to build an ensemble of staff ready to assume fiscal responsibilities. Create Strategic Alliances to Alleviate Resource Shortfalls One of the defining attributes of SANE practice is collaboration with law enforcement, advocacy agencies, prosecutors, and other community stakeholders. SANEs, however, frequently do not collaborate with other SANE programs beyond general information sharing and basic education. While institutional competition may limit the extent to which alliances can be formed between SANE programs, there are multiple innovative opportunities for forging new working relationships that can enhance SANEs’ infrastructures. For example: • Can adjacent county SANE programs schedule an informal educational meeting to discuss materials from a national conference? • Can the coordinator of the SANE program in County X be available, even if only by phone, to back up the nurses in County Y if County Y’s coordinator is unavailable, traveling, or on vacation? • Can coordinators make themselves available in a given region to mentor a new coordinator when she finds herself thrust into a position she didn’t expect to have? Creating alliances does not have to be formal, and it does not have to be a long-term commitment. The impetus for intra-program collaboration should be similar to that of Sexual Assault Response Team (SART) collaboration— the desire to create alliances that ultimately improve the capacity of members to provide a victim-centered response to sexual violence. Rethink how SANE Services are Provided in your Community Most service providers can agree that 24/7/365 coverage is the standard to which programs strive (particularly those who care for adolescent/adult patients). The criminal justice system also emphasizes the need to provide medical/forensic exams around the clock. However, some programs simply cannot operate within this model. If a program is struggling to cover call shifts and nurses are sagging under the weight of their omnipresent pager, it may be appropriate to consider modifying service hours. Although SANEs provide a model of patient care that appears to be more beneficial than the standard emergency department experience3, some SANE services are preferable to no SANE services. Rather than have the program grappling with unfilled call shifts and expectations for coordinators to cover all gaps in the monthly schedule, negotiate with emergency medicine and trauma services providers to discuss realistic options for sexual assault care during non-SANE covered hours. The Virtual Practicum (http://www.iafn.org/displaycommon. cfm?an=1&subarticlenbr=174) can help improve the sexual assault evaluation skills for healthcare providers who have not completed a medico- legal examination or have not performed one in some time. Scaling back SANE’s response schedules does not have to be permanent and the development of long-term strategic plans that include building service capacity are critical for sustainability. A temporary reduction in on-call coverage can serve to provide some breathing room while recruitment initiatives and budget reviews are implemented. SANE programs are continuing to become the standard of care for sexual assault patients across the country and around the world. While there appears to be funds available to start programs, sustaining them is a different challenge altogether. Over the next several years the National Sexual Violence Resource Center plans to create a range of tools to ensure that sustainability is a fundamental component of SANE programs. The intent is to demystify the business aspects of small nonprofit business management and create a repository of evidence-based practices that will help maintain stability and improve the long-term outlook for all SANE programs. Visit our website at (http://www.nsvrc.org) to read about the latest information on sustainability issues and access relevant resources. Works Cited “Sustainable.” Merriam-Webster Online Dictionary. 2009. Web. 24 June 2009 Lubar Price, Mindy. “Succession Planning and Sustainability in Nonprofit Organizations.” Leading Transitions Executive Transition Initiative 1.2 (2006). Web. Notes 1 The next installment in this series will focus on writing business plans. Visit http://www.nsvrc.org/ projects/sane 2 View a list of state and territory sexual assault coalitions at http://www.nsvrc.org/organizations/ state-and-territory-coalitions. View a list of state domestic violence coalitions at http://www.ncadv. org/resources/StateCoalitionList.php 3 Program evaluation of SANE practice as it relates to health care outcomes is fairly new in the literature. See Campbell, Rebecca, et al. “A participatory evaluation project to measure SANE nursing practice and adult sexual assault patients’ psychological well being.” Journal of Forensic Nursing 4 (2008): 19-28. The Sustainability Series The Sustainability Series is a component of the Sexual Assault Nurse Examiner (SANE) Sustainability Technical Assistance Project, which aims to address sustainability issues holistically by working with program coordinators to creatively examine the challenges that individuals and communities face in maintaining healthy, successful, and appropriate medical-legal services for victims of sexual violence. Additional information can be found by visiting http://www.nsvrc.org. National Sexual Violence Resource Center The National Sexual Violence Resource Center (NSVRC), founded by the Pennsylvania Coalition Against Rape, opened in July 2000 as the nation’s principle information and resource center regarding all aspects of sexual violence. The NSVRC provides national leadership in the anti-sexual violence movement by generating and facilitating the development and flow of information on sexual violence intervention and prevention strategies. About the Author Jenifer Markowitz, ND, RN, WHNP-BC, SANE-A, is currently the project manager for the National SANE Sustainability Technical Assistance project with the NSVRC. In addition, Ms. Markowitz teaches and consults nationally on a wide range of topics related to the practice of forensic nursing. www.nsvrc.org NSVRC 123 North Enola Drive, Enola, PA 17025 Toll free: 877-739-3895 resources@nsvrc.org A publication of the National Sexual Violence Resource Center Founded by the Pennsylvania Coalition Against Rape