PATIENT-CENTERED CARE

It is important for healthcare practitioners to recognize that sexual assault is a traumatic event and, therefore, to provide patient-centered care. When conducting an exam, obtaining the history, and collecting evidence, a trauma-informed approach is essential because violence and abuse can cause psychological distress. Trauma-informed care restores safety, security, and control to patients.

1. Begin the interview by offering the patient the services of an advocate. Texas law requires that the survivor be offered the support of a certified sexual assault advocate. This person has been trained to support the patient through the exam and future involvement with the criminal justice system. Advocates can also assist patients with access to counseling and reimbursement through the criminal justice system for out-of-pocket costs. A survivor also has the legal right to the presence of an additional support person of their choice (e.g., family member, friend) (Texas A&M, 2022).
2. Obtain consent. Patients must consent to the evidence collection process. This consent should allow both the collection of evidence and the release of evidence to law enforcement. It is recommended that the consent form also include consent for photographs if they will be taken. Specific statutes address child or nonparental consent as well as consent for adults with cognitive disabilities (see also “Resources” at the end of this course).
3. Offer the option of a nonreport exam. Offer adult patients ages 18–64 without a disability the choice to undergo a forensic exam with or without law enforcement involvement. A patient who reports a sexual assault within 120 hours has the right to a forensic examination without making a report to law enforcement. Evidence may be collected and stored, and the patient can decide up to five years later whether or not to have the evidence processed and engage with the criminal justice system.

Survivor Response to Trauma

Individuals respond to trauma in various ways based on their own background, developmental phase, and the type of trauma inflicted. Each survivor’s response to trauma is unique and self-defined. Approximately 30% of posttraumatic stress disorder (PTSD) cases in the United States are attributed to sexual violence. Typically, the physical injuries that survivors sustain during a sexual assault are minor and do not require treatment, but psychological injuries are common and may negatively impact the survivor’s life.

Common symptoms of survivors of sexual assault include:

• Depression
• Anxiety
• Flashbacks or hypersensitivity to reminders of the traumatic event
• Intrusive thoughts
• Avoidance of thoughts, people, and places that may trigger memories of the trauma
• Easily triggered emotions
• Negative effect on daily life

It is important for healthcare professionals to address the patient’s mental and physical needs. Persons who have experienced trauma should be made aware of resources to seek help, since early intervention may prevent long-term conditions such as PTSD, chronic pain, depression, chemical dependency, and suicidality (Texas A&M, 2022).

Elements of Trauma-Informed Care

Trauma can impact a patient’s ability to think, remember, and relay the history of the event in chronological order. The clinician therefore considers the vulnerabilities and experiences of the patient as well as acknowledges the impact of the traumatic event. The following practices can improve the patient’s ability to recall information accurately. These methods are based on an understanding of the neurobiology of trauma.

• Build rapport and establish trust with the patient.
• Let everyone know what actions will be taken in advance of the occurrence.
• Acknowledge the patient’s distress.
• Provide an environment that encourages a feeling of safety both physically and emotionally by asking the patient what they need to feel safe.
• Offer choices.
• Use nonleading, open-ended questions that allow for narrative responses.
• Minimize interruptions.
• Focus on what the patient can remember thinking and feeling during the event.
• Begin by asking general health information and explain why the questions are asked.
• Focus on sensory details of the assault, such as colors, smells, sensations, or features of the assailant.
• Maintain patience and express empathy and understanding.
• Expect that information may be relayed out of chronological order.
• Give the patient permission to say “I don’t know” rather than guess.
• Refrain from asking the patient “why” questions and maintain a nonjudgmental attitude.
• Speak slowly and clearly and allow the patient to take breaks as needed.
• Be mindful of the patient’s developmental stage.
  (Texas A&M, 2022)

Language and Cultural Awareness

Patients have the right to choose the language and format that information is given to them. It is not appropriate to utilize family or support persons as interpreters. Most facilities have access to interpreters as well as other resources to assist the clinician in ensuring that the patient fully understands and can give informed consent (see “Resources” at the end of this course) (Texas A&M, 2022).

In addition to addressing the patient’s English-language proficiency, the nurse must respond sensitively to patients in matters of race, ethnicity, gender and gender identity, religion, disability, immigration status, socioeconomic status, sexual orientation, and developmental stage. Any of these factors may influence how a patient experiences the exam. Each patient is an individual and may have different beliefs from the clinician, which should be respected (Texas A&M, 2022).

It is best practice to ask patients about how they identify their own gender rather than to make assumptions (IAFN, 2020). Patients should be asked their pronouns (e.g., he, her, they, etc.), and the nurse should replace heteronormative language with gender-neutral terms when caring for patients who identify as LGBTQ+ (lesbian, gay, bisexual, transgender, or queer/questioning). As of 2021, the state of Texas has the second highest number of people (1.8 million) who identify as lesbian, gay, bisexual, and transgender in the United States (PPIC, 2022).