Paco Alvarez: Alright, just to get us started, could you explain what sexual assault nurse examiners are and how they differ from regular nurses?
Drew Hawkins: Sexual assault nurse examiners are nurses. They are RNs, nursing school certified nurses. And then these are nurses who seek additional specialty training to work with survivors of sexual assault. So they are trauma-informed is what the training really refers to. That’s the terminology. And the idea is that they’re constantly seeking consent, they are explaining the process ad nauseum to the survivor, they connect survivors to advocates. As soon as a survivor comes to a hospital, the SANE will have had an advocate there ready to meet them so that that person can be with them throughout the process. So the short answer is these are nurses who have decided to pursue this really challenging work and get specialized training in order to be able to do that.
Alvarez: What were the main findings of your investigation?
Hawkins: Yeah, it’s a good question, because this investigation really changed throughout. When I was talking with my editors at Type, we compared it to a snake sometimes, where it kept slithering and bobbing and weaving. And with each check-in, we would go, whoa, what about this, or what about that?
So I would say that the big findings are the scale of the impact of a shortage of SANEs and at the same time, what one SANE for the story called a double-edged sword. So this unforeseen and I think unintended consequence of SANEs, which were a group of nurses who started this, they got together, they wanted to improve quality of care for patients and they also wanted to prove the quality of evidence collection for prosecution. So they created SANEs, this specialized training program. So what happens is if a survivor goes to a hospital that does not have a SANE, it’s very common or possible that they will then be either transferred to a hospital that does have a SANE or maybe told that they need to go to a hospital that has a SANE if they want a forensic medical exam, which is commonly called a rape kit.
So the biggest finding was that that transfer, that barrier that that imposes, after talking with survivors and advocates and really coming to understand how significant that is where this person has had maybe the worst thing that’s ever happened to them. And then they made the difficult decision that’s already hard to go to a hospital for that care. And then, they have that initial examination because everyone who goes to a hospital is guaranteed by law an initial examination, which is pretty invasive if you’ve just been assaulted, right? You’re being prodded, poked, and it takes time. And then to be told, oh, you actually need to go to this other place if you want this forensic medical exam, which also, by the way, takes a few hours. Obviously you could, when I first heard about it, talking with nurses, I was like, well, that’s gotta be a huge deterrent that we’re not thinking of. So the biggest finding was this double edged sword where you’ve got SANEs who are there to help people, but when there isn’t one available because there aren’t enough of them, now you have patients who have this extra barrier to get this care. So this double-edged sword idea was pretty striking to me.
And also, you know, from an investigative reporting aspect, the challenge to this was getting the data, you always want your numbers, you want your spreadsheets, you want your data. With this case, though, that actually was not possible, because – I was looking at this in the Gulf South, Louisiana, Mississippi, Alabama. And I think this is pretty common across the country. But I can really only speak to these three states that I was into, where there’s not data that’s collected from the origin. So if someone goes to the hospital and that hospital says, OK, well, you need to go to this other hospital. And so starting that transfer process and then that receiving hospital completing that transfer process – that stuff isn’t captured. So the closest that came to it when I was talking to a SANE at a hospital in New Orleans is she said, I’ll get a call from a hospital somewhere and they will give me some basic information like a name, a date of birth. I’ll write that on a sticky note. I’ll stick that on my computer screen. And if that patient doesn’t come, you know, eventually, I’ve got to throw that sticky note away. That is the extent of this data that’s collected. So the scale of how many survivors may not get this care because of that transfer process was tough as a journalist to prove that. So I had to talk to so many people and kind of show that that’s there in the absence of hard data.
Alvarez: You kind of talked a bit about this, but what inspired you to look at SANEs in the Gulf region?
Hawkins: I know that there is a shortage of nurses. This is not a radical finding, right? This is something we’ve been dealing with for a while now. And then as a result of not having enough nurses, that also means you don’t have enough specialty nurses. So that’s SANEs, that’s also special trauma nurses. There are a lot of specialty nurses and that means there are fewer of them in general. And I had seen some reporting out of Alabama that talked about, this was a long project that a reporter had done where she was following a specific woman who had to drive herself across county lines to get a forensic exam. And so I saw that and I was like, I wonder how common that is. I wonder many SANEs we have in our region. And then kind of looking into the registrations, the certificates of certified SANE’s, I pretty quickly saw that Mississippi had less than 10 for the whole state. And I thought, well, that’s pretty nuts. So I wonder what’s deeper from there. So it kept going from there, and I went to SANE Training. Well, I talked to nurses, and that’s when I talked about the snake earlier. And I was looking into it, and it kind of pivoted as I had more and more conversations with nurses and advocates, legal experts, talking to people through it. But it started with this idea of, oh, wow, some people might have to drive themselves to go get this care, that’s got to be a pretty big deterrent. And that’s where it all started.
Alvarez: I guess you’ve mentioned a couple of them, but what are some of the underlying reasons behind the same shortage?
Hawkins: Yeah, you know, broadly, it’s the nurse shortage. And you know it’s interesting too, and I’m glad you asked this, because talking with a lot of nurses during more than a year that I was working on this, who are just remarkable people. I think everyone who has a nurse in their life, you know what kind of person there is. And then you’ve got these nurses who also are the type of person who goes, yeah, I want to work with sexual assault survivors. That’s a job that means, you know, sexual assaults often don’t happen between 9 and 5. So these are generally often in the middle of the night, you get a call and someone who’s just had the worst thing that’s ever happened to them needs you. And that’s all the time. So these particular people, they’re really tough, right? And so they gave me pretty hard conversations. Like they were not pulling any punches.
And one of the things they said was that there’s not a shortage of registered nurses. There’s not a shortage of trained nurses. There is a shortage of working nurses. Because so many nurses are choosing to leave the profession because of different reasons. Some of them that have been described to me by nurses are obviously first and foremost would be pay, right? They don’t feel that they’re being compensated for the amount of work that they are having to do, especially as more nurses leave and that more work gets filed on the ones that stay. Another one is working conditions. You can see this with like there’s a big, there’s an ongoing strike with the nurses at University Medical Center in New Orleans and a lot of the things that they talk about are safety, whether that’s, you know, patients coming in and the hospital not having proper security procedures, whether it’s workplace safety, as well as compensation for additional certifications.
When it comes to SANEs, they have to get this extra training. They may not necessarily be compensated for having that additional training, although they may be the one who has to do that extra difficult work because they’ve been trained. And at the same time, that training may not be free itself. In Mississippi, there’s a program that was giving free trainings, which is great. But the trainings don’t involve lodging, food, if you’re a mom, child care. You have to forego maybe a week’s worth of pay to get that training. So there are these additional barriers that make it harder to get this same certification, this same training. Also this course varies too by region, by facility, by health care system because every hospital, every system, they’ve all got their different quirks and approaches and funding models and challenges. But those are some of maybe the larger, broader issues that some of the nurses I’ve talked to have told me about.
Alvarez: You mentioned patients having to go to other counties if they can’t find a SANE in their own county. Are there other ways that hospitals are trying to adapt to the SANE shortage?
Hawkins: Yes, been a couple of different ways. And actually, some of those different ways were, as I mentioned earlier, the struggle of finding data. Some of these solutions, if you will, or attempts to meet these challenges were helpful for me, as a reporter, to illustrate the underlying problem that those proposed solutions are trying to address.
So two of them would be, the first one would be TeleSANE, which is exactly what it sounds like. It is a a SANE, a sexual assault nurse examiner, will zoom into an emergency room, an emergency department, and they will guide a nurse there through a forensic exam. And, you know, there’s pros and cons to that. One, the pro being that you’ve got a Sane there for a survivor, which can make a difference. The con being, obviously, you know, a traumatic experience like that, someone talking to you through a computer screen may not be the connection that you need. There’s also too, nurses criticize that as hospital systems and facilities going with the cheaper option rather than investing in the infrastructure and the workforce to have more sayings on staff, whereas they can essentially outsource tell us sayings to come in as needed. So, there’s some criticism there from nurses. And there’s also investment in hospital buy-in that it would take to make that happen. So that’s TeleSANE, that’s one.
The other one is what’s called, they have different terms for it, but the common way of putting it is traveling SANE. And Louisiana has this in some regions, it’s not statewide. So this was helpful for me, again, to be able to point to and look at data from areas. Traveling saints are, they are what they sound like. They go to the hospital, a survivor goes to a hospital, the traveling SANE comes to them. So the way they’ve done this in Louisiana in some places is the SANE will be employed by the coroner’s office. And there’s a whole different, there’s lot of reasons why that is, but that just sometimes happen to be the simplest government body to employ them. So they’re employed by their coroner’s office and they go to the hospital to meet the patient. In the areas where that has been implemented, the number of forensic exams have gone up. So that was one way for me to show, okay, if you remove the travel barrier and there’s more forensic exams, but there hasn’t at the same time been exponentially more sexual assaults, like that’s relatively stable, then obviously, or not obviously, you know, we’re investigative journalists, right? But that could indicate, I would say, that travel and that transfer is potentially a barrier to people. But also at the same time, traveling SANE, like in Jefferson parish in Louisiana, for example, there are two full-time traveling SANEs that covered 19 hospitals and these are again, I can’t really over hype or overstate how tough these nurses are as human beings. But they all talk about burnout and fatigue and, and being exhausted, but it also feeling like a duty because if they’re not going to do it, who will, right? So. These solutions aren’t perfect, but those have been some of the attempts to address the the issue.
Alvarez: Zooming in on the survivor level, you featured a source who had experienced a deeply traumatic sexual assault – what was it like to work with her to tell the story?
Hawkins: It’s interesting, and I’m glad that you asked that, because initially, as we were working on this project, I actually wanted to approach this story without having the survivor anecdotal lead open. I feel like that was the go-to, and like that’s not, and I don’t mean it’s overwrought or overdone, and so therefore, as a journalist, it’s not as interesting or important. That’s not what I mean. What I meant was I was focused on the nurses. That was the point of the story. And of course, it includes the survivor impacts, but I was really interested in SANE nurses and what’s making this happen
But as I was going through this, the thing about sexual assault is it touches all of us, whether it’s you have experienced it, someone in your life has. And so in this instance, this was someone from my community that I knew. I knew that this had happened to her when it happened. And as I was talking to sources here in New Orleans, advocates and nurse sources, I don’t know if you’re aware of this, but New Orleans is the smallest city on the planet. Everybody knows everybody. And at one point, her name came up because she now volunteers and does some advocacy work. And I was like, oh, OK, you know, actually, I’d like to talk to her in general to hear about her advocacy work and get some insight into that. And as we were starting those conversations, I was, like, you know, I feel like your experience actually might be helpful for this, because she expressed struggling with the idea of if she had to make the choice between getting her physical injuries treated or getting the forensic exam, then she would have struggled to make that choice. And that was something we were talking about as I was going through this reporting. And so it kind of came up as like, your experience actually might be really illustrative of this larger problem. And so she was open to that idea.
I wanted to approach it extremely carefully and if at any moment that she could totally back out of it. I shared her sections, the draft versions of them with her. I shared the audio script, I did a podcast episode, a 14 minute radio story for this. And I shared the Instagram reel, I did a social media reel, which ended up not using any of her perspective, but I shared anything that would be relevant to her experience and her story, I shared with her and wanted some feedback for it, which was great because one, of course, like it was trusting. I felt like this was her story to tell at a certain point anyway. And also like she flagged stuff and was like, actually this, you know, it’s actually not quite this way. So it was actually helpful. So you know I think keeping that relationship, that dialogue and that trusting back and forth communication open, texting throughout, having calls to double check things, keeping her updated with the story was, was really, really critical.
And we did a listening session for the end of this project, and she was actually on the panel and talked about reporting, and someone asked her a question about what it was like to work with a reporter, and it was really wonderful to hear from her point of view, as the way she put it, which was that she felt comfortable, she felt safe sharing her story with me, and she felt like that I was always keeping her in the loop and being open and honest about what the status of things were and sharing things with her.
That was my approach from the beginning was like, you know, keeping that trust there. And if at any moment she wanted to back out, I would have totally respected that. And there were some moments, too. You know, there were sometimes where she’s like, I’m not sure, and I’m like, listen, no problem. Why don’t you sit on it? We’ll talk about it. No problem. And then ultimately she thought about it and came back to it. So yeah, I’ve kind of been meandering there a little bit, but I initially didn’t want to necessarily use a survivor anecdote as an open, but in this case, it really was illustrative and it’s a small community. One of the prosecutors that I interviewed worked on her case. You know, one of the advocacy organizations worked with her because everything was just, again, New Orleans is a small city, but also, like, it’s just a small space, too, the advocacy space there. So it ended up just being, I think, the right decision. And it just came about from conversations with her.
Alvarez: And then you’ve talked about this a bit, but, um, how has the SANE shortage affected the nurses themselves? What did the SANEs tell you about their experiences?
Hawkins: Yeah, I mean this could take an hour to talk about, but I would say for sure, for sure is burnout. That always comes up. And there’s no way it can’t come up. I mean, I think if I just describe to you their workload, you would go, they must get burnt out. I mean these are late, hard, long hours. And again, you know, every single person that they work with has just had the worst thing in the world that’s ever happened to them. So, they’re gonna be affected by that. And they also have to provide this trauma-informed care and be extra patient and work with survivors who can sometimes be in really difficult positions and be experiencing a lot of trauma. And they feel like because there aren’t more nurses getting SANE training or coming out of nursing school even aware of it. You know, one SANE I talked to at a training called it the best kept secret in nursing. And all of the nurses who were there at that training, none of them had heard about SANE training in nursing school. So they also feel this sense of obligation that like, if I don’t do it, nobody else will, but those hours are brutal, and the work is brutal. So burnout is for sure, I would say, the largest impact that comes up in conversations with SANEs, who again, are some of the toughest human beings that you’ll ever meet. And so if they’re talking about burnout, then it’s gotta be real, you know what I mean?
Alvarez: So my last question is what is the response to your investigation been like?
Hawkins: I would say really, really good, across a broad spectrum. I think sexual assault impacts everyone in a certain extent. You either know someone or you yourself have experienced it, I think. For this story, I talked to a lot of different people. I talked to legal experts, prosecutors. I talked to survivors. I talked to advocates. And I also went to a lot of official meetings, the Louisiana Sexual Assault Response Committee, which includes people from the governor’s office, state legislators, police, coroner’s offices, SANEs, advocacy groups, you name it, they’re all on there. And I would say while they have very, very different backgrounds and where they’re coming from, nobody thinks that we should be not doing more for sexual assault, right? Everyone believes that. I think how to make that happen, there’s debate and argument there, but nobody is against making things better and more access for sexual-assault survivors.
One of the first things I did was when this published, I shared it with every single possible person I could that had gone to those state committee meetings. Of course, all of my sources, obviously, but we were gonna host a listening session too. So I really wanted to get this out there. So we had Louisiana state senators and representatives come, advocacy groups. And the reception has been great because one thing that I would say too is when you talk to advocates and nurses and even officials who work in this space – they will tell you that sexual assault is one of those things and the sexual assault response plans is one those things that normal people just do not think about until they need it.
And so the public at large doesn’t necessarily realize what problems, if any, there are with the sexual response plans until maybe they actually are a survivor themselves and need it. And then they go, oh, wow, this is an issue. And so having it laid out in the way we did with this story, with survivor impact, advocate perspective, legal perspective, all of that, it was a helpful tool for them, I think, to use that to illustrate to people why this is important. And there has been some legislation that came in this last session, at least in Louisiana. And there’s also been discussions about it in Mississippi, about expanding that access and having hospitals have to give forensic exams. A lot of that stuff is still in its infancy, but the people who are supporting those measures have to express that they will be using this report as part of their efforts, right? So if it ends up affecting in any way some sort of policy change, and then for me, that would be the biggest W, but generally the reception has been really great. It’s not a fun story to read, right, but it really does in a pretty undeniable way lay out how this could affect survivors of sexual assault, which nobody wants to see happen, right? So you know, the response has been really great is the short answer to that.