Report to the Legislature — Increasing Access to Forensic Nurse Examiner Training (Commerce, October 2022)
Summary
A report to the Legislature, dated October 1, 2022, from the Washington State Department of Commerce on increasing access to forensic nurse examiner training, pursuant to Chapter 269, Laws of 2021 (SSSB 5183). Commerce states that it conducted three stakeholder meetings and distributed a survey to subject matter experts. Barriers listed include having to use vacation time to attend trainings, health care facilities' costs to excuse nurses, and total out-of-pocket cost. The recommended strategies include a comprehensive and sustainable training fund, a one-year forensic nursing workgroup, and minimum standards of care for forensic medical exams at state health care facilities.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
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“Report to the Legislature — Increasing Access to Forensic Nurse Examiner Training (Commerce, October 2022).”
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Increasing access to forensic
nurse examiner training
Pursuant to Chapter 269, Laws of 2021 (SSSB 5183)
October 1, 2022
COMMUNITY SERVICES AND
HOUSING DIVISION Report to the Legislature
Director Lisa Brown
V3.0
Acknowledgments
Washington State Department of Commerce
Office of Crime Victims Advocacy Washington State Department of Commerce
Rick Torrance, managing director,
Rick Torrance, managing director
Office of Crime Victims Advocacy
Trisha Smith, assistant managing director 360-725-2059
richard.torrance@commerce.wa.gov
Kirstin McFarland, section manager, Injury and
Violence Prevention
OFFICE OF CRIME VICTIMS ADVOCACY
jd Nielsen, program manager
1011 Plum St. SE
Mikah Semrow, Sexual Assault Services Program P.O. Box 42525
manager
Olympia, WA 98504-2525
Community Assistance and Research Unit
www.commerce.wa.gov
Alice Zillah, section manager, Research Services
For people with disabilities, this report is available
Jeremy Walker, management analyst 4
on request in other formats. To submit a request,
Kate Fernald, research analyst, Research Services please call 360-725-4000 (TTY 360-586-0772)
James Vogl, research analyst, Research Services
Rebecca Duncan, commerce specialist 2
Jordan Laramie, research analyst, Research
Services
Washington State Department of Labor and
Industries
Crime Victim Compensation Program
Cletus Nnanabu, program manager
Nancy Nyman, billing supervisor
Maty Brimmer, management analyst 5
Washington State Office of the Attorney General
Lauren Vlas, policy analyst
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING
Table of Contents
Executive summary...................................................................................................................................... 2
Introduction ................................................................................................................................................. 3
Findings ...................................................................................................................................................... 6
Recommended strategies ............................................................................................................................ 9
Appendix A: Stakeholder meetings and training survey............................................................................... 18
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 1
Executive summary
Overview
Survivors, forensic nurse examiners and victim advocates have long identified the need for more forensically
trained nurses in Washington. A forensic nurse examiner (FNE) is a Registered or Advanced Practice Nurse
with specialty training to provide specialized care to survivors of sexual assault, domestic violence and/or
nonfatal strangulation. Forensic nurse examiners provide necessary patient care, gather evidence, and provide
testimony about their exam findings for criminal and civil proceedings. The trauma-informed treatment they
provide, the evidence they gather, and the expert testimony they deliver in the courtroom are crucial to victims
and their legal proceedings.
The Legislature's 2021 bill to support victims of nonfatal strangulation (Chapter 269, Laws of 2021 (SSB 5183),
Section 3 (3)) directs the Department of Commerce’s Office of Crime Victims Advocacy (OCVA) to “develop
best practices that local communities may use on a voluntary basis to create more access to forensic nurse
examiners [FNEs] in cases of nonfatal strangulation assault,” which were to be completed and published online
by Jan. 1, 2022. In addition, the bill directed OCVA to “develop strategies to make [FNE] training available to
nurses in all regions of the state without requiring the nurses to travel unreasonable distances and without
requiring medical facilities or the nurses to incur unreasonable expenses.” Commerce developed the strategies
in this report in response to the second directive in the bill.
Key findings
To understand the most common barriers preventing nurses from attending FNE training and develop
strategies to address these barriers, Commerce held three stakeholder meetings and distributed a survey to
subject matter experts across the state. During meetings and in response to the survey, stakeholders and
subject matter experts identified the following as the most significant barriers preventing Washington nurses
from accessing FNE training:
Having to use vacation time to attend trainings
Health care facilities' costs to excuse nurses for training
Total out-of-pocket cost (including program fees, travel, lodging, child care and lost wages)
Insufficient opportunities for mentorship, which are particularly impactful for nurses at smaller or rural
health care facilities
Incompatible times/locations for currently available trainings
Summary of recommended strategies
After consulting stakeholders and subject matter experts, stakeholders recommend the following strategies to
make FNE training accessible to nurses in all regions in the state without requiring unreasonable travel or
expenses:
Establish a comprehensive and sustainable FNE training fund
Form a one-year forensic nursing workgroup to create recommendations for statewide FNE curriculum
requirements, statewide protocols and procedures for forensic nurse examiners, and health care facilities'
minimum standards of care for emergency assault services
Require state health care facilities to adopt minimum standards of care for forensic medical exams
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 2
Introduction
At the Legislature's request, Commerce's OCVA researched the health care response for people who need
medical and forensic services due to sexual assault or nonfatal strangulation. Strangulation involves external
compression of the victim's airway and blood vessels, causing reduced air and blood flow to the brain.
Unconsciousness may occur within seconds and death within minutes.
Nonfatal strangulation rose to legislative importance because it has come to be recognized as one of the most
lethal forms of domestic violence and sexual assault, and one of the best predictors for the subsequent
homicide of victims of domestic violence. However, because victims may show no or minimal external signs of
injury, they might leave a simple physical exam with unidentified, life-threatening internal injuries, including
traumatic brain injury. Forensic nurse examiners (FNEs) must receive specialty training in nonfatal
strangulation to better address serious internal injuries and reduce post-incident impacts.
Legislative mandate
The nonfatal strangulation victims bill, Chapter 269, Laws of 2021 (SSB 5183), Section 3 (3), directs the
Department of Commerce’s (Commerce) Office of Crime Victims Advocacy (OCVA) to develop strategies to
increase FNE training:
(2) The office of crime victims advocacy shall develop strategies to make forensic nurse examiner training available
to nurses in all regions of the state without requiring the nurses to travel unreasonable distances and without
requiring medical facilities or the nurses to incur unreasonable expenses. Among other important factors deemed
relevant and appropriate by the office of crime victims advocacy, the strategies should take into account the unique
challenges faced by medical facilities and nurses operating in rural areas.
(a) When developing the strategies, the office of crime victims advocacy shall consult with:
(i) The Harborview abuse and trauma center;
(ii) The department of health;
(iii) The nursing care quality assurance commission;
(iv) The Washington state nurses association;
(v) The Washington state hospital association;
(vi) The schools of nursing at Washington State University and the University of Washington;
(vii) Forensic nurse practitioners; and
(viii) Other organizations deemed appropriate by the office of crime victims advocacy.
(b) The office of crime victims advocacy shall report the strategies to the governor and the appropriate
committees of the legislature no later than October 1, 2022.
Chapter 269, Laws of 2021, also added forensic medical examinations for victims of nonfatal strangulation to
the services for which hospitals and emergency medical facilities can be reimbursed by the state's Crime
Victim Compensation Program. The exam must be performed for the purpose of gathering evidence for
possible prosecution to be eligible for reimbursement. Reimbursements by the Crime Victim Compensation
Program for these exams will expire on June 30, 2023.
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 3
Subject matter experts
OCVA consulted with representatives from the organizations identified in statute and additional organizations
deemed appropriate.
Table 1: Subject matter experts consulted
Name Title
Katherine Espy Sexual Assault Nurse Examiner/Clinic Nurse
Jordan Ferguson Domestic Violence Unit: Spokane Police Department
Katie Rose Fischer-Price Jefferson County Public Health
Shana Johnny Nursing Care Quality Assurance Commission
Jamie Kautz MultiCare
Leslie Kees Confluence Health
Megan Kilpatrick Washington State Nurses Association
Kyra Laughlin Common Spirit
Heather McCleod Providence Sexual Assault Clinic and Child Maltreatment Center
Kelsey McKay McKay Training and Consulting
Melissa Mertz Providence Intervention Center for Assault and Abuse
Paula Newman-Skomski Advanced Registered Nurse Practitioner: Providence
Paula Reed Children’s Advocacy Centers of Washington
Juliane Rohr Community Sexual Assault Nurse Examiner
Victoria Sattler Professional Development and Global Programs Lead Faculty: WSU
Jody Shively Astria Health
Zosia Stanley Washington State Hospitals Association
Terri Stewart SANE Program/Medical Training Program: HATC
Chelene Whiteaker Washington State Hospitals Association
Background
Starting in 2016, the Legislature tasked Commerce's OCVA with several projects concerning the health care
response to people who need both medical and forensic services due to sexual assault or nonfatal
strangulation assault.
Chapter 50, Laws of 2016 (SHB 2711) directed OCVA to study the availability of sexual assault nurse
examiners (SANEs) in Washington, including an analysis of which areas of the state have an adequate
number of SANEs and which do not and to recommend strategies for increasing access to SANEs in
underserved areas.
Responding to Chapter 88, Laws of 2018 (SHB 2101), OCVA provided a set of recommended best
practices for providing sexual assault examinations and expanding access to SANE services and
developed strategies to expand access to SANE training.
Chapter 269, Laws of 2021 (2SSB 5183) directed OCVA to develop best practices to increase access to
forensic nurse examiners in cases of nonfatal strangulation and develop strategies to make forensic
nurse examiner training available to nurses in all regions of the state. OCVA published its recommended
best practices to increase access to forensic nurse examiners in cases of nonfatal strangulation in late
2021. This report describes OCVA’s recommended strategies to make forensic nurse examiner training
available to nurses in all regions of the state.
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 4
To develop the recommended strategies, Commerce convened three stakeholder group meetings. Commerce
also distributed a survey on barriers to training and changes that could address them to subject matter experts
following the first stakeholder meeting and researched relevant programs in other jurisdictions. See Appendix
A for a detailed discussion of the stakeholder meetings and survey.
Co-occurring issues for health care facilities and nurses
Both health care facilities and nurses face several challenges outside the scope of this report, and
stakeholders stressed that these challenges undoubtedly affect nurses’ access to forensic nurse examiner
training.
Stakeholders identified burnout, secondary trauma, compassion fatigue and staffing shortages as pressing
challenges affecting nurses’ ability to do their jobs and maintain sustainable careers. Managing these
challenges can also prevent nurses from seeking and receiving additional training, like that required to perform
forensic medical examinations.
Secondary traumatic stress and compassion fatigue result from repeated exposure to the trauma and
suffering of others and can lead to depression, anxiety, diminished job performance and a reduced ability to
empathize with patients.1 Burnout describes a state of extreme fatigue and disillusionment because of
excessive job stress and is prevalent among nurses and other health care workers.2 A 2021 survey of over
1,100 health care workers in Washington found that 84% of respondents reported feeling very or somewhat
burned out by their jobs, and 49% of respondents reported that they are likely to leave their jobs in the next few
years.3
These challenging working conditions make it difficult for health care facilities to retain nurses, contributing to
staffing shortages that only put greater demands on remaining nurses. Staffing shortages also make it difficult
for health care facilities to backfill shifts so nurses can attend forensic nursing training. The COVID-19
pandemic put enormous added strain on health care systems, inflaming the already significant problems of
burnout, secondary trauma and staffing shortages for nurses.
Stakeholders also reported that some facilities lack the competency evaluation policies necessary for trained
nurses to provide forensic exams with adequate protection from legal liability.
The recommendations in this report will not directly address these broader challenges since they fall outside
the direct scope of increasing access to FNE training, but stakeholders stressed that these challenges will
continue to hamper access to training for nurses and timely FNE services for survivors.
1 Frontiers in Psychology, “Secondary Traumatic Stress, Mental State, and Work Ability in Nurses—Results of a Psychological Risk
Assessment at a University Hospital,” (2020), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197484/
2 Cureus, “Burnout in United States Healthcare Professionals: A Narrative Review,” (2018),
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367114/
3 GBAO, “Healthcare Workers: Poll Analysis,” (2021),
https://static1.squarespace.com/static/619c009fb3e63b1bb3d3684f/t/61b781ef3825d3535437a6e5/1639416303381/Health
care+Workers+Memo+121321.pdf
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 5
Findings
Barriers to accessing training
Both stakeholders and survey respondents identified common barriers to accessing FNE training for nurses
who want to provide those services. The most commonly reported barriers were:
Having to use vacation time to attend trainings
Health care facilities' costs to excuse nurses for training
Total out-of-pocket cost (including program fees, travel, lodging, child care and lost wages)
Insufficient opportunities for mentorship, which are particularly impactful for nurses in smaller or rural
health care facilities
Incompatible times/locations for currently available trainings
Having to use vacation time to attend trainings
FNE trainings require varying amounts of time depending on their content, but core SANE training, one of the
most common FNE trainings offered in Washington, requires a minimum of 40 course hours. For example, the
Harborview Abuse and Trauma Center's core SANE training occurs over five days. This means that nurses
must be able to leave their jobs for at least five days to attend, not including the potential required travel time.
In addition, stakeholders reported that nurses have had to use vacation days to attend forensic nursing training
because they are not typically paid to attend this training. This is not the case for required trainings.
When a nurse is assigned to a unit, that unit has required trainings. For the unit's required trainings, health care
facilities pay the registration fees, all associated attendance costs, and nurses' training time. However,
stakeholders reported most forensic nursing practitioners are not assigned to a forensic nursing unit because
of the irregular and unpredictable need for forensic medical exams. Instead, most nurses are assigned to a
different unit and must step away from their regular duties in their assigned unit to perform a forensic medical
exam on an ad-hoc basis. Because nurses are assigned to units other than forensic nursing units, hospitals do
not pay for forensic nursing training, even though that training is required to perform the forensic medical
exam.
Health care facilities' costs to excuse nurses for training
Health care facilities incur added staffing costs to excuse nurses from their regular duties to attend FNE
training. These costs include expenses like paying for overtime hours to cover shifts.
Stakeholders reported that health care facilities ensure that nurses are excused from clinical work to attend
trainings required for their assigned unit but that not all facilities make the same accommodations for nurses
to attend FNE training. Nurses face another barrier when health care facilities do not excuse nurses from their
regularly assigned duties. This forces them to use vacation time to attend FNE training.
Total out-of-pocket cost
In addition to time away from work, other costs are associated with FNE training. These include program fees,
potential lodging and travel costs, and child care costs for nurses who need that service.
Stakeholders reported that since FNE training is not required for most nurses to work in their assigned units,
nurses attending these trainings often pay these costs out of pocket, which is a significant barrier to access.
The Harborview Abuse and Trauma Center has observed that interest in attendance is stronger when it has
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 6
offered its core SANE training course for free. While this observation is anecdotal, it still illustrates that there
are Washington nurses who would like to get FNE training but choose not to because of the cost.
Insufficient opportunities for mentorship
While training courses provide nurses the knowledge and skills they need to perform a forensic medical
examination, stakeholders reported that opportunities to observe and learn from more experienced forensic
nursing practitioners are important to build confidence and keep those skills current.
Stakeholders reported that nurses might feel less confident conducting these exams because they have less
hands-on experience or lack the support of an experienced colleague, even if they have undergone FNE
training. This is especially true in smaller and more rural facilities that may see fewer patients requiring
forensic medical services. The need for more mentorship or continuing education opportunities for forensic
nursing practitioners was echoed by survey respondents, who listed a lack of mentorship opportunities as one
of the top training barriers.
Incompatible times or locations for currently available training
A final common barrier was that currently available forensic nursing trainings are offered at times and
locations incompatible with enough nurses’ schedules and geographic locations.
Traveling to another part of the state to attend training can add to the cost barrier discussed above. One
stakeholder reported that they traveled to Colorado to receive their SANE training. The Harborview Abuse and
Trauma Center has tried to eliminate the travel cost barrier by offering a regional core SANE training that can
be delivered in a community where nurses request it, but for many nurses in Washington, there are still not
enough locally available training courses.
Stakeholders also reported that having more trainings available during different times of the week would make
it easier for more nurses to attend FNE training because there would be overlap with more nurses' days off.
Missing fewer days of regularly assigned duties would reduce staffing costs for health care facilities and costs
like lost wages or vacation time for nurses. Currently, stakeholders said there is not sufficient variety in the
times when FNE training is available in Washington. While the barriers above were the most commonly
reported, the list below reflects all stakeholder-identified barriers to accessing FNE training:
Table 2: All barriers to accessing FNE training identified by stakeholders
Health care facility
Nurses' barriers barriers Legislative barriers Program barriers
Limited clinical training Staffing shortage No state-level standards of Costly development of
times and opportunities Lack of hospital care for: FNE training
Limited mentorship standards of care for Health care facilities Costly clinical provision
opportunities FNE services Forensic nurse expenses
Limited continuing Cost to backfill staffing examinations Costly travel expenses
education opportunities Cost to adopt FNE training curriculum
Training schedules and standards of care
work schedules Cost to provide FNE
Training fees services
Lost wages
Travel costs
Hotel and food
expenses
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 7
Washington's need for forensically trained nurses
Nurses, victim advocates and survivors have long identified the need for more forensically trained nurses in
Washington.
The 2019 report that OCVA prepared in response to the requirements of Substitute House Bill 2101 (2018)
highlighted the fact that, in nine Washington counties, there are no hospitals that provide SANE services.4
SANE services are a subset of the larger category of forensic medical services, but stakeholders reported that
hospitals in these counties rarely provide other kinds of forensic medical services, such as in cases of nonfatal
strangulation assault, domestic violence or child abuse.
Survivors must seek care elsewhere if the first health care facility they visit does not provide forensic medical
services. This can take several hours, a delay that victim advocates report may dissuade survivors from
seeking care at a second location for various reasons. When they cannot access appropriate forensic medical
care, survivors may suffer serious health consequences and can have difficulty pursuing legal action against
their abuser if they so choose.
A survivor must be told within two hours of arrival at an emergency room if the ER does not offer SANE exams
or does not have the appropriate staff available to offer the exam. Typically, survivors wait two to four hours to
be seen, and there is no maximum amount of time a survivor may wait for a SANE exam. This exam is
extremely time sensitive, as physical and biological evidence is only available for up to 72 hours, and earlier is
better. Washington state guidelines encourage hospitals to see survivors sooner, but no laws currently require
a timeframe.
Timely access to forensic medical care is a crucial part of the response to interpersonal violence, but in
stakeholder meetings, victim advocates stressed that the medical response to these crimes is just one link in a
chain of care, and all those links need to be coordinated to ensure survivor care is truly trauma-informed and
victim-centered. While it is outside the scope of this report, Commerce strongly endorses the continued pursuit
of a statewide, coordinated system of care for survivors of interpersonal violence that includes victim
advocates, law enforcement and other first responders, medical personnel, and members of the criminal
justice system including attorneys and judicial officers, among others.
According to Commerce's 2019 SANE report, we do not have an accurate count of SANE nurses because of
the high turnover rates and nomadic nature of SANEs.
4 Washington State Department of Commerce, “Sexual Assault Response,” (2019), https://www.commerce.wa.gov/wp-
content/uploads/2019/12/Report-SANE-Final.pdf
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 8
Recommended strategies
Training costs, quality and accessibility must be addressed to make FNE training available for nurses in all
regions of the state. This section offers recommendations in three parts. Part one outlines Commerce’s
recommendations for long-term, sustainable funding to make training available statewide. Part two outlines
Commerce’s recommendations for a one-year workgroup and its recommended responsibilities. Part three
outlines Commerce’s recommendations for statewide standards for forensic medical services that could
increase training accessibility and ensure training quality.
Part 1: Establish a comprehensive FNE training fund
To make FNE training uniformly available across the state, stakeholders recommend establishing a long-term,
sustainable funding program for comprehensive FNE training. The program would fund:
Nurses’ costs to attend state-approved FNE trainings
Backfilling costs to cover staffing needs while nurses attend FNE training
Training programs’ costs to develop and facilitate expanded statewide FNE trainings
Costs to establish a telenursing center for ongoing training and mentorship
A new program at a state agency to implement this report’s recommendations
It is important to note that in conversations about SANE training (one kind of FNE training), the term
"certification" is often used. While there is a significant difference between a core-trained and an IAFN-certified
SANE-A or SANE-P, there is no shared definition of what "certification" means in Washington. The core SANE
training certificate requires the standard 40-hour SANE training plus a clinical component. Becoming a certified
SANE requires the standard 40-hour SANE training, 300 practice hours after training, and a passing score on an
industry-wide exam.
Stakeholders emphasized that fulfilling the requirement for 300 practice hours is unrealistic for many nurses,
especially rural nurses. In addition, several stakeholders reported that most nurses who deliver SANE exams
have completed a core training but are not certified because of the high threshold for practice certification
requires. Therefore, stakeholders recommend that any future legislation dealing specifically with funding SANE
training not require obtaining certification as a condition for reimbursement.
Robust, reliable state-level training funding will amplify training quality, quantity and accessibility. Stakeholders
recommend that this funding pay for the following:
Cover nurses' training costs
More than 80% of subject matter experts who completed the FNE training survey identified covering all of the
financial costs for nurses to attend FNE training as the most helpful change to make FNE training available
statewide. Accordingly, stakeholders recommend the state pay for all of nurses’ FNE training costs, including
but not limited to initial, ongoing and continuing education costs, travel, and registration fees.
Stakeholders agree nurses should be paid their regular wage to attend FNE training. However, continued work
is needed to determine whether health care facilities or the state government should be responsible for paying
nurses while attending FNE training.
Funding FNE training expenses would increase accessibility by ensuring nurses from all regions of the state
and all economic backgrounds could take time off work, travel to and participate in FNE training without paying
out of pocket. This is especially true for rural nurses, who incur greater travel expenses and may need extra
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 9
days off from work because they must travel farther to a training location. According to stakeholders, covering
training costs would increase equitable access to FNE training statewide and help recruit nurses from across
the nation to relocate permanently to Washington to take advantage of the state’s supportive FNE training
program. This is particularly important given the ongoing challenges mentioned across the nursing profession.
Reimburse health care facilities' costs to excuse nurses for training
More than 92% of nurses with forensic training reported in the FNE training survey that the number one barrier
to attaining FNE training is that health care facilities will not give nurses time off work to attend the training.
When a nurse requests time off to attend FNE training, health care facilities may not have staff available to
provide coverage while the nurse is absent or may be unable to afford to pay overtime for nurses that provide
coverage.
Stakeholders recommend state funding for health care facilities’ back-staffing costs. This recommendation
will not address all financial barriers health care facilities face when offering FNE programs or address staffing
shortages, but it would mitigate their costs to excuse nurses for FNE trainings, a key financial aspect of health
care facilities' staffing barriers.
Develop and provide statewide FNE training
FNE training programs that participated in stakeholder meetings identified cost as the main barrier that
prevents them from offering more mobile and onsite FNE training. These programs need additional funding to
develop innovative training opportunities and cover the travel costs of training programs so FNE trainings can
be offered statewide.
Rural nurses are disproportionately affected by fewer training opportunities because of their distance from
existing training sites and lack of local access to the required clinical component of FNE training. Although
Harborview Abuse and Trauma Center and the International Association of Forensic Nurses began offering
virtual trainings over the past several years, they do not provide the hands-on practice nurses need to perform
a forensic nurse examination competently.
Recognizing these challenges, Harborview Medical Center, Washington’s predominant SANE training program,
received federal grants to expand its training offerings to include travel across the state to provide in-person
trainings. These grants were not a long-term, sustainable solution and did not provide enough funding to meet
demand. Washington State University was authorized to provide FNE trainings in 2021, but the university
reported that its budget will not allow for delivering mobile training or developing online training opportunities.
To make access to FNE training more equitable across the state, stakeholders recommend long-term,
sustainable state funding for developing and providing mobile, onsite FNE training opportunities.
Long-term, sustainable funding for training development could also expand the variety of trainings offered. For
example, programs could offer opportunities like hybrid training, mobile simulation labs, mobile live-model
labs, and one- and two-day clinical trainings. The state’s long-term investment in FNE training programs will
ensure various, frequent and geographically diverse trainings are offered statewide.
Fund a telenursing program for forensic nurse exam mentorship
After initial FNE training, one of the most pressing needs stakeholders reported was ongoing mentorship and
continuing education. Once again, rural nurses experience an even greater lack of access to mentorship due to
their remote locations, infrequent practice opportunities, and reduced likelihood of having an experienced FNE
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 10
on staff from whom to receive mentorship. Stakeholders reported that too often, this lack of support and
feeling of isolation results in early burnout or leaves nurses with forensic training apprehensive about
conducting exams, which reduces survivors’ access to this critical service.
To address the lack of ongoing mentorship and continuing education opportunities, stakeholders recommend
the state fund a new forensic medical center that would include a forensic medical telenursing program. The
telenursing program would be based on the workgroup's recommendations in part two of the recommended
strategies in this report.
The telenursing program would provide ongoing training, consultation services, guidance, technical assistance,
continuing education and mentorship to FNEs across the state via video conferencing. The program would
need to be available 24 hours per day, seven days per week, so that any FNE from any part of the state could
access mentorship at any time. By connecting with the telenursing program, nurses in rural and urban
communities could equitably access ongoing mentorship opportunities.
Establish a forensic nursing coordination center
Stakeholders recommend establishing a new administrative center at a state agency to implement the
recommendations of this report, including overseeing and managing funding distributions to health care
facilities, training programs, and the forensic medical telenursing program.
The center could be responsible for the implementation, administration and management of:
Annual health care facility plans for providing FNE services
FNE curriculum requirements
FNE training program approvals
Posting relevant information online, including a list of health care facilities with FNE services and FNE
training offerings
Application and distribution of applicable federal, state and private grants
The forensic nursing coordination center would provide the foundation that ensures survivors requesting
forensic medical exams receive care that meets a uniform state standard from health care facilities and
nurses. The health care facility and nursing protocols and procedures could eventually expand to other arenas
affecting survivors of domestic violence and sexual assault. Eventually, the center could also manage multi-
disciplinary protocols and procedures for all first responders interacting with survivors, including emergency
dispatchers, law enforcement officers, emergency medical personnel and victim advocates. These expanded
protocols could ensure the availability of comprehensive, victim-centered and trauma-informed care to sexual
assault, intimate partner violence and nonfatal strangulation survivors across the state.
Part 2: Form a forensic nursing workgroup
Establishing statewide FNE curriculum requirements, FNE protocols and determining the standards of care for
forensic medical exams in Washington is a complex but necessary process requiring the knowledge of many
different subject matter experts. For that reason, stakeholders recommend the Legislature direct and fund the
Office of Crime Victims Advocacy to create and manage a one-year workgroup, costing approximately $50,000.
Workgroup composition
Stakeholders recommend the organizations invited to participate in the workgroup include but not be limited
to:
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 11
University of Washington's Harborview Abuse and Trauma Center
Washington State University
A tribal representative
A law enforcement representative
Crime Victims Compensation Program
SAFE Best Practices Advisory Group
The Children's Advocacy Centers of Washington
The Washington State Hospital Association
The Washington State Nurses Association
Victim advocates
Workgroup responsibilities
Make recommendations to the Legislature
Make recommendations about where to house the forensic nursing coordination center
The Legislature should direct the workgroup to recommend where the forensic nursing coordination center
would be housed and provide an estimate of the cost of establishing the center.
Make recommendations on state standards of care
Make recommendations on state health care facilities' minimum standards of care for emergency assault
services, including the content, implementation and requirements. Stakeholders recommend:
The workgroup make recommendations to the Legislature on defining emergency assault services'
minimum care requirements for all health care facilities. Facilities' required minimum care for survivors of
sexual assault, nonfatal strangulation, intimate partner violence and child abuse should include access or
transportation to a forensic medical exam performed by a registered nurse or doctor who has completed
the appropriate state-approved forensic nurse examiner training course or equivalent.
The workgroup's minimum care recommendations include requiring all health care facilities to create and
submit a plan to provide access or transportation to emergency assault services.
The workgroup make recommendations on the content, implementation and requirements for state health
care facilities' plans to provide emergency assault services. The facilities' plans to provide emergency
assault services must:
Be approved and documented annually by Washington’s forensic nursing coordination center
Include protocols and procedures for providing transportation to an FNE provider if an FNE is
unavailable onsite
Include protocols and procedures for contacting local victim advocates, if available
Make recommendations on standardizing forensic nurse examiners' procedures:
Standardize statewide FNE protocols, forms and evidence collection procedures, including training on
contacting local victim advocates
Create free, brief virtual trainings for currently practicing FNEs or FNEs trained out of state on the
protocols, procedures and required forms
Make recommendations on standardizing state FNE training curriculum requirements:
Establishing state FNE course curriculum requirements informed by but not limited to the new statewide
protocols and procedures for health care facilities and FNEs
Using curriculum requirements to approve future FNE training programs to assure consistent training
quality across the state
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 12
Make recommendations for a statewide telenursing program for forensic medical exams
The program shall provide mentorship, continuing education, ongoing training, consultation services, guidance
and technical assistance for forensic medical exams across the state via video conferencing.
Make recommendations on access to timely forensic medical exams
Consider and make recommendations on ensuring access to timely forensic medical exams, especially for
smaller and rural health care facilities.
Collaborate on training
The workgroup would collaborate with statewide training programs to establish educational opportunities and
prepare additional trainers.
Collaborate to coordinate innovative training schedules based on nurses’ schedules with
clinical/preceptorship training opportunities, including mobile clinical/preceptorship trainings in rural areas
Ensure clinical/preceptorship trainings are offered multiple times throughout the year in all regions of the
state
Create a website with all state-approved FNE training offerings
Part 3: Require state standards
Some health care facilities report hesitancy to grant nurses time off to attend FNE training because they do not
have the requisite standards of care to allow nurses to provide FNE services. Helping health care facilities
adopt standards of care could lead to more facilities offering FNE services and granting nurses time off to
attend FNE training. Stakeholders recommend the Legislature require minimum standards of care for health
care facilities that provide emergency assault services on site and standards of care for health care facilities
that do not offer emergency assault services. The workgroup recommended above could make
recommendations on the content and requirements for these standards and approved plans.
Establishing state standards of care could yield additional benefits, including laying the foundation from which
all other standards would be derived. Once statewide health care facility standards of care are created,
statewide FNE protocols, procedures and standardized forms could be established. Once FNE protocols,
procedures and forms are standardized, training curriculum requirements could be developed to ensure nurses
in all regions receive consistent, quality training that prepares them to meet Washington's standards of care.
State health care facilities’ minimum standards of care for providing
emergency assault services
Health care facilities do not offer forensic medical services for multiple reasons, including that they report few
patients seeking forensic medical exams. Health care facilities are less likely to offer this service with
infrequent demand. This is particularly true of rural health care facilities, as evidenced by a 2019 study on
SANE access that surveyed all hospitals in Washington. Nine counties in Washington do not offer SANE
services to survivors;5 all nine of those counties are rural, as identified by the Washington State Department of
Health.6
5 Washington State Department of Commerce, “Sexual Assault Response,” (2019), https://www.commerce.wa.gov/wp-
content/uploads/2019/12/Report-SANE-Final.pdf
6 Washington State Department of Health, "Rural and Urban Counties," (2017),
https://doh.wa.gov/sites/default/files/legacy/Documents/Pubs//609003.pdf
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 13
Health care facilities that do not provide FNE services are far less likely to have policies that define standards
of care for emergency assault services or enable health care facilities to assess the competency of trained
nurses to deliver forensic exams. Without the appropriate health care facility policies, FNEs cannot provide
forensic nurse exams even if they have the training. As a result, these facilities have no reason to approve a
nurse's time off to attend FNE training, making it especially hard for nurses in rural areas to access training.
Stakeholders also report that adopting health care facility standards of care is typically an arduous and
expensive process. To address these challenges facing nurses and health care facilities, particularly in rural
areas, stakeholders recommend the Legislature require minimum standards of care for emergency assault
services at all Washington health care facilities.
The two types of recommended minimum standards of care for emergency assault services in this report are
discussed below.
1. State standards for health care facilities providing 24/7 emergency assault
services onsite
The first type of state standard would be for health care facilities willing to offer 24/7 forensic medical exams
on site. Stakeholders recommend that the Legislature adopt the work group's recommendations for minimum
standards of care for emergency assault services. The standards of care would require forensic medical
exams to be performed by a registered nurse or doctor who has completed an appropriate Washington state-
approved FNE training course or equivalent. Standards would further address protocols and procedures for
contacting local victim advocates. Only health care facilities that choose to offer emergency assault services
on site would be required to adopt the appropriate standards of care to allow them to provide forensic medical
services, including forensic nurse exams.
The existence of state minimum standards of care for emergency assault services would make it simple for
health care facilities to incorporate these standards into their policies. As a result, more health care facilities
may adopt the standards, especially in rural areas, and thus would have the policies needed to offer FNE
services. These policies would incentivize health care facilities to grant nurses time off to attend FNE training.
Establishing state standards of care would also provide a foundation to develop more specific protocols and
procedures.
2. State standards for health care facilities not providing 24/7 onsite emergency
assault services
Commerce recognizes that not all health care facilities can provide 24/7 on-site FNE services for financial,
practical or other reasons. For these facilities, stakeholders recommend the Legislature require separate
standards of care based on the workgroup's recommendations. Health care facilities that do not offer forensic
medical exams on site, or do not provide them 24/7, could be required to develop a plan to provide access to
emergency assault services. Health care facilities could plan to partner with a nonprofit FNE provider, if
available in the region. If a nonprofit FNE provider is not available, the facility could be required to establish a
plan to transport the survivor to a facility offering services. The Legislature could require health care facilities
to submit their plans annually to the appropriate agency. Several states, including Illinois, have similar
legislation.
Health care facilities with a nonprofit FNE provider in their region could be required to coordinate partnerships
with the local provider to establish a per-patient billing program. This would allow health care facilities to pay
for FNE services on an ad-hoc basis rather than incurring the annual expense of staffing FNEs around the
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 14
clock. The opportunity to participate in a per-patient billing program could significantly increase the number of
health care facilities that can afford to offer forensic medical examinations, which could increase the number
of facilities willing to adopt emergency assault services standards of care. This could increase survivors’
access to forensic medical services, and it could increase the number of nurses granted time off work to
attend training – rural nurses especially – because the relevant health care facility standards of care would be
in place.
Any health care facility without a nonprofit FNE provider in its region could be required to transport the survivor
to a facility that provides FNE services, a requirement that would build on the precedent established by current
legislative requirements. RCW 70.41.367 requires hospitals that do not perform sexual assault evidence kit
collection or do not have appropriate providers to notify individuals who present in an emergency department
and request a sexual assault evidence kit collection of this fact. Such hospitals are further required to
"coordinate care with the local community sexual assault agency and assist the patient in finding a facility with
an appropriate provider available."
Washington could enact legislation similar to Illinois’ Sexual Assault Survivors Emergency Treatment Act to
ensure survivors receive services if they are transferred to another health care facility. Through this act, Illinois
requires regional coordination amongst health care facilities. Hospitals that do not provide forensic medical
services must establish a relationship with a local provider of forensic medical exams. Then the hospital must
establish a plan for transferring survivors to the facility providing forensic medical services. The transferring
hospital must also get consent from the treatment facility before transferring a survivor to ensure services will
be available when the survivor arrives.
Washington health care facilities' plans would need to include protocols and procedures for contacting FNE
providers and victim advocates, if locally available, as well as protocols and procedures for transporting the
survivor. This would not directly increase FNE training, but it would recognize and accommodate the unique
challenges some health care facilities in rural areas experience without requiring them to incur unreasonable
expenses. It could also increase access to FNE services for survivors.
Establish statewide FNE protocols and training requirements based on
Washington state standards of care
Stakeholders emphasized the need to assess and ensure the quality of FNE trainings and services. While the
number of statewide trainings could be increased by offering virtual FNE trainings, entirely virtual options
would not provide the requisite clinical learning opportunities that FNEs need to provide proper forensic
medical examinations. If the state pays for nurses’ FNE training, then the state would want to ensure those
trainings meet a standard of quality that will prepare nurses to provide the highest standards of care.
Washington would need state standards of care to measure a training’s quality from which statewide FNE
protocols, procedures and standardized forms could be developed. Once statewide FNE protocols, procedures
and forms are standardized, FNE training curriculum requirements could be derived based on the statewide
FNE protocols, evidence collection procedures and standardized forms.
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 15
Table 3: Findings, recommendations and anticipated outcomes
Findings Recommendations Anticipated outcomes
Establishing long-term, sustainable funding for
Stakeholders identified State to provide long-term, nurses’ FNE training expenses will:
Increase statewide, equitable training access for:
the most helpful action sustainable funding for:
Nurses in all regions, including rural areas
to increase statewide Initial, ongoing and continuing
Nurses from all economic backgrounds
education fees
FNE training is to pay for Travel expenses
Increase the total number of FNE-trained nurses.
FNE training costs Potentially incentivize out-of-state nurses to relocate to
Compensation for lost wages
Washington for this supportive training program, according
to stakeholders
Providing health care facilities the financial support
Stakeholders identified they need to backstaff will:
the greatest barrier to State to provide long-term, Address the financial barriers health care facilities face that
accessing statewide prevent them from granting nurses time off to attend
sustainable funding for:
training
FNE training is not Hospitals' costs to backstaff while
Increase the number of health care facilities that grant
getting time off work to nurses are absent for FNE training
nurses time off to attend FNE training
attend training Increase the statewide number of nurses granted time off to
attend FNE training
FNE training programs
Establishing training programs’ long-term,
identified a lack of long- State to provide long-term, sustainable funding to develop and provide
term, sustainable sustainable funding to: statewide FNE trainings will:
funding as the main Develop diverse and innovative FNE Increase the number of mobile FNE trainings offered
barrier that prevents trainings statewide
them from offering more Provide additional statewide mobile Increase the number of clinical trainings offered statewide
and onsite FNE training opportunities Increase the variety, frequency and geographic diversity of
mobile and onsite FNE
FNE training offerings
training
State to adopt emergency assault Enacting state standards of care will:
service standards of care for: Establish the foundation for all other FNE standards
No state standards of Facilities that provide forensic Increase health care facility adoption of FNE standards
medical exams Increase the number of health care facilities providing FNE
care for emergency
Facilities that do not provide forensic services
assault survivors medical exams Increase the number of health care facilities granting nurses
Forensic nurse examiners (protocols, time off to attend FNE training
procedures and forms) Support statewide quality and consistency of FNE services
State to use FNE standards of Establishing state standards for FNE training
care to: curriculum will:
Establish state FNE training program Ensure consistent FNE training quality statewide
No state standards for requirements Provide a discretionary tool to determine which FNE
FNE training Create a process to become a state- trainings the state will fund
requirements approved FNE training program Increase opportunities for more training programs to be
Determine which FNE training state-approved while ensuring training quality standards are
programs the state will fund (only met
approved programs) Potentially increase the number of FNE trainings offered
Establish a statewide forensic Establishing a statewide FNE telenursing center will:
Stakeholders identify medical exam telenursing Increase statewide, equitable access 24/7 to:
limited access to Mentorship and ongoing education
program to provide: Technical assistance
mentorship and Mentorship via video conferencing Professional FNE support to reduce FNE burnout and
continuing education Technical assistance via video turnover
opportunities conferencing Potentially increase the number of nurses continuing to
Access to ongoing education offer FNE services
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 16
Recommended strategies out of scope
Throughout this work, stakeholders made recommendations that fell outside the scope defined in the enabling
legislation but remain worthwhile, as they would increase survivors’ access to victim-centered, trauma-
informed care. These recommendations are categorized by subject below.
Address the nursing staff shortage
Stakeholders recommend long-term, sustainable funding to increase pay or create bonuses for nurses
performing forensic nurse examinations to incentivize nurses to become forensic nurse examiners.
Such bonuses may also attract nurses from other states, which could help with staffing shortages by
increasing the number of FNEs in Washington.
Establish satellite or mobile FNE teams to deliver forensic nurse services to underserved areas. Mobile
FNE teams could provide services to multiple health care facilities in a region, rather than each facility
staffing FNEs around the clock. A team of mobile FNEs would ultimately result in fewer FNEs needed to
serve a broader area.
Identify health care facility barriers
Audit health care facilities to identify where FNE services are available and where they are needed. This
would establish which health care facilities most need FNE support.
Support multi-disciplinary coordination and consistency
Standardize protocols, procedures and forms for sexual assault, intimate partner violence, nonfatal
strangulation and child abuse for all people who may interact with a survivor, including emergency
dispatchers, police officers, emergency medical personnel, and administrative staff in emergency
departments. Statewide, multi-disciplinary coordination and consistency would ensure that survivors are
treated with the highest standards of care in all regions of the state and at every stage following
interpersonal trauma.
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 17
Appendix A: Stakeholder meetings and training survey
Consultation with subject matter experts and key stakeholders named in statute was critical to understanding
the major barriers preventing nurses from getting forensic nursing training in Washington and creating
recommendations to address those barriers.
At the core of this process was a series of three stakeholder meetings, held in April, May and July 2022. The
required stakeholders by Chapter 269, Laws of 2021 (SSB 5183):
Harborview Abuse and Trauma Center
Department of Health
Nursing Care Quality Assurance Commission
Washington State Nurses Association
Washington State Hospital Association
Schools of nursing at Washington State University and the University of Washington
Forensic nurse practitioners
Other organizations deemed appropriate by the Office of Crime Victims Advocacy
Among stakeholder meeting participants not specifically named in statute was a representative from Lutheran
Community Services Northwest, who brought a survivor-centric lens to the issue of access to forensic nursing
training. See Table 1 for a full list of participating stakeholders.
After the first stakeholder meeting, Commerce prepared a survey to collect more perspectives on barriers to
accessing forensic nursing training, strategies that could address those barriers, and what the state's most
significant forensic nursing training needs are. Stakeholders assisted by distributing this survey through their
networks. Commerce received 40 responses, the majority from people who identified themselves as nurses
with forensic training.
At the second stakeholder meeting, Commerce presented the survey results and preliminary recommended
strategies for increasing access to forensic nursing training, soliciting feedback from stakeholders. Commerce
used that feedback to continue shaping its recommendations, presenting its final strategies at the third
stakeholder meeting and gathering a final round of stakeholder feedback.
First meeting purpose and discussion
The main objective of the first stakeholder meeting was to gather information from stakeholders on the
barriers that prevent nurses from getting forensic nursing training and what changes to the status quo could
help overcome those barriers.
This meeting began with a summary of the authorizing statute and Commerce’s scope of work. Following that
introduction, the bulk of the meeting was a guided discussion of four questions Commerce prepared:
1. Ignoring financing and time, what training would the “best” forensic nurse have?
2. What do “reasonable travel” and “reasonable expense” mean?
3. What challenges are folks currently encountering with attending training?
4. What is one thing that would make attending forensic nurse examiner training easier for you or other staff?
Commerce received valuable insights from the discussion of these questions. These included challenges with
taking time away from work to attend training, sometimes forcing nurses to use vacation time and creating
backfilling challenges for health care facilities. One piece of feedback echoed by many stakeholders at the first
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 18
meeting was that, in an ideal world, nurses should not have to pay for any costs related to attending forensic
nursing training.
During the discussion, a stakeholder also suggested surveying additional forensic nurse practitioners not
present at the meeting to gather more perspectives on the barriers preventing nurses from attending trainings
and strategies that could address these barriers. Commerce committed to conducting this survey before the
next meeting.
Following the first stakeholder meeting, Commerce used the comments from the guided discussion to inform
its preliminary list of recommended strategies to improve access to forensic nursing training and the
questions it included in its supplementary survey. Upon receiving the survey results, Commerce analyzed the
responses and prepared a short presentation about them to deliver to stakeholders at the second meeting.
Training survey and summary of results
The survey that Commerce distributed after the first stakeholder meeting contained 10 questions concerning
appropriate definitions of reasonable expense and travel, the challenges preventing nurses from accessing
forensic nursing training, and changes that could help overcome those challenges. Of 40 survey respondents,
23 identified themselves as nurses with forensic training and eight as hospital administrative staff, reflecting a
range of relevant perspectives.
Figure 1: Profession of respondents
1
60.53%
1
Nurse with forensic training
1 Hospital administrative staff
Nonprofit organization staff
0
Association or representative organization
staff
0 Nurse without forensic training
21.05% Other hospital staff
0 18.42%
15.79%
Other
0
5.26%
2.63% 2.63%
0
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 19
Questions two and three of the survey asked respondents about their definitions of reasonable travel and
expenses. For both questions, a plurality of respondents indicated that nurses should not have to pay out of
pocket for training-related expenses or travel.
Figure 2: What does 'reasonable travel' look like to you?
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
1 hour or less. 2 hours or more 2 hours or more 2 hours or more Any travel is Other
No overnights. 1-2 overnights. 2-3 overnights. 3-4 overnights. reasonable if it is
paid in full by the
hospital or state
Figure 3: What FNE expenses do you think are reasonable for a nurse to pay for?
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Registration Fees Travel Expenses Family/Childcare Use Vacation Time No Expenses are Other
for FNE Training Expenses to Attend Reasonable
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 20
Question four asked respondents what challenges they observe people encountering when seeking forensic
nursing training. The most common response was an inability to get time off, followed closely by total costs, a
lack of mentorship opportunities and inconvenient training times or locations.
Figure 4: What challenges are folks currently encountering with attending trainings?
5
4.5 Can't Get Time Off
4
Total Costs (fees, travel, time off)
3.5
3 Inconvenient Times/Locations
2.5
Score No Mentorship Opportunities
2
1.5 No FNE Program at Hospital, so not
inclined to Support FNE Training
1 Other
0.5
0
Question five asked respondents about a change that would make it easier to attend forensic nursing training.
The most common response was paying for all training-related expenses so that nurses did not have to,
followed by offering training at in-person, virtual and hybrid venues and health care facilities and excusing staff
who want to attend forensic nursing training.
Figure 5: What is one change that would make attending forensic nurse examiner
training easier for you or other staff?
5
4.5
4
3.5
3 Pay FNE Training Expenses
2.5 Virtual, Hybrid & In-Person Venues
Score
2
Hospitals Excuse Nurse for FNE Training
1.5
Innovative Training Schedules
1
Training Agencies Partner
0.5
0 Other
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 21
Second meeting purpose and discussion
At the second stakeholder meeting, Commerce presented the survey results and sought feedback on
preliminary recommended strategies for increasing access to forensic nursing training.
Based on the information gathered from the first meeting and its survey, Commerce observed that the most
common ask of the state government was to provide long-term, sustainable funding for all costs associated
with attending forensic nursing training. Participants at the second stakeholder meeting responded positively
to this strategy, endorsing it as one of the most important recommendations Commerce could make.
Another topic of discussion at this meeting was how to address the issue of inadequate mentorship
opportunities for nurses who have received forensic training. While the conversation on this point initially
focused on the feasibility of having forensic nurse practitioners in every health care facility in the state or
having a mobile team that could provide regional coverage for facilities without a forensic nurse practitioner, it
eventually landed on a virtual program as a promising option.
The Harborview Abuse and Trauma Center pointed out that having a forensic nurse practitioner in every health
care facility might not be practical, and the availability of mobile teams would not reduce wait times for
patients in cases where providers needed to travel an extended distance. Stakeholders agreed that a program
where experienced forensic nurse practitioners could virtually assist less experienced nurse practitioners
could be a valuable means of increasing access to mentorship and empowering trained nurses who may not
see many patients requiring forensic services. Harborview reported that it is already exploring this kind of
program.
Participants' final major topic at the second stakeholder meeting was standards of training and care for
forensic nursing. While standards of practice fall outside the scope of this report, stakeholders supported
statewide training standards, which could give the state government criteria to assess which forensic nursing
training programs a future funding program might fund. Both care and training standards could also mitigate
the liability concerns that one stakeholder reported prevented her from being allowed to perform forensic
exams at the facility where she works, despite having completed a forensic nursing training program.
Following the second meeting, Commerce prepared the final recommended strategies to share with
stakeholders for feedback and approval at the third meeting.
Third meeting purpose and discussion
Commerce’s goal for the third stakeholder meeting was to present its final recommended strategies for
increasing access to FNE training to stakeholders for feedback. In addition, Commerce discussed the
$680,000 allocation in the 2022 Washington state supplemental operating budget for the Department of Health
to create a stipend program for nurses seeking SANE training and sought input from stakeholders on which
eligible expenses that program should reimburse.
Several stakeholders expressed concern over the language in the budget proviso specifying that
reimbursements will “cover eligible expenses incurred to complete the training necessary to become a certified
sexual assault nurse examiner.” These stakeholders pointed out that full certification per International
Association of Forensic Nursing standards requires 300 hours of clinical practice after receiving training,
which makes becoming a certified Sexual Assault Nurse Examiner (SANE) nearly impossible in practice for
nurses in rural areas. As a result, a stipend program that required nurses to become certified SANEs would
likely have limited and inequitable utility.
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 22
In addition, stakeholders expressed concern over the fact that one of the nearest training programs for nurses
in southwest Washington that offers a pathway to SANE certification per International Association of Forensic
Nursing standards is in Oregon, so requiring that reimbursable training culminates in certification might result
in state dollars leaving Washington. Stakeholders agreed that it is important for state resources to support
training programs in Washington.
The Department of Health communicated that it would convene a stakeholder group to consult on the
implementation of this stipend program in July or August 2022, and it was looking forward to gathering more
input from subject matter experts.
Stakeholders provided several suggestions for changes to the recommended strategies that Commerce
presented. The first of these suggestions was to change the language concerning covering the costs of lost
wages for nurses attending FNE training to reflect stakeholders’ position that health care facilities should pay
for some of these costs, not just the state government.
The second suggestion was to use the term “training program” as opposed to “trainer” or “training provider” to
emphasize the fact that a high quality, supportive training program incurs more costs than just the direct costs
of delivering a 40-hour core training. The Harborview Abuse and Trauma Center said it gives nurses who
complete its core SANE training a phone number they can call if they need guidance while delivering an exam,
which demonstrates that training should not be considered a one-off experience and encompasses more than
just classroom time.
The third suggestion stakeholders provided was to stipulate that health care facilities planning to provide
access to FNE services must be required to have FNE services available 24/7. When discussing the possibility
of requiring health care facilities that do not provide FNE services to contract with nearby facilities that do
provide those services, stakeholders pointed out that some facilities that do provide FNE services cannot
provide them around the clock. In cases like this, a facility may need to enter into agreements with multiple
other facilities to transfer patients seeking FNE services to a provider 24/7.
The fourth recommendation stakeholders made was emphasizing the need for any future state standards of
training or care to require nurses who received forensic nursing training outside of Washington to receive
supplementary education on procedures unique to our state, like appropriate evidence collection. Stakeholders
said that the quality of patient care would suffer without this requirement.
Finally, stakeholders recommended including a tribal representative and representatives from other
organizations that provide FNE services to the list of recommended members of the workgroup Commerce is
proposing.
INCREASING ACCESS TO FORENSIC NURSE EXAMINER TRAINING 23
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