Program for Aid to Victims of Sexual Assault CI Report – Interim

What has been most instrumental to your progress?

One critical aspect of our work this year was listening and responding to the needs articulated by stakeholders in Northern St. Louis County. We coordinated a series of listening sessions with law enforcement officers, Sexual Assault Nurse Examiners (SANEs), advocates, and prosecutors in the northern part of Minnesota to better understand what they identified as the critical needs for victims of sexual assault in their communities. Centering the experiences and voices of those living and working in Northeastern Minnesota communities clarified what is currently working well for victims of sexual assault and where gaps in service remain. Choosing to listen and allowing what we learned to drive and shape our work also helped open a door to develop more positive working relationships with our colleagues in Northeastern Minnesota. By asking open-ended questions and truly listening to the answers we received, we communicated our intention to collaborate with openness and integrity. This is an important first step to building strong, collaborative relationships between partners and regions.

Convening our SANE (Sexual Assault Nurse Examiner) Team in Duluth with SANEs from across the region has been very beneficial for both the rural SANEs, but also our SANE Program. We have been partnering very actively with the hospital-based SANE Program at Fairview Range Memorial Hospital located in Hibbing, Minnesota. The Hibbing SANE Program is a very rural program without a set budget for recruitment, training, call time, or continuing education. In April, PAVSA SANE Program staff visited their bi-monthly staff meeting to learn more about their program structure and the operating challenges that both SANE Programs share. Then, in June, the PAVSA SANE Program invited the Hibbing SANEs to come to one of our monthly meetings to do extensive case review. Our Lead SANE, Alisha Blazevic, also provided continuing education on strangulation and charting to the four nurses from the Hibbing SANE Program who joined us. We’ve continued to be in contact via email about future plans to meet. Several of the Hibbing SANEs will be attending a clinical workshop in Duluth in October, and there is interest in a regional SANE Summit this winter. This collaboration has definitely been impactful.

A significant activity that has been made possible by the Bush Foundation grant is the PAVSA SANE Program being involved in statewide efforts to standardize and improve medical forensic services for survivors of sexual assault across the state. The work that PAVSA is doing through our Bush Foundation grant to improve access to medical forensic exams in Northeastern Minnesota is very much aligned with the work being led by MNCASA (Minnesota Coalition Against Sexual Assault) through the Medical Forensic Exam Access Project (MFEAP), funded by the MN Office of Justice Programs. We have been able to send Em Westerlund, PAVSA SANE Coordinator to the bimonthly meetings hosted by MNCASA that are providing insights about access and quality of medical forensic exams across the state to the Minnesota Legislature. MFEAP provides a platform to amplify the concerns of outstate and rural SANE programs and hospitals that are tasked with providing these exams. Having a seat at the MFEAP table also ensures that as important policy decisions are being made about exam payment, exam components, and statewide SANE program coordination, communities in Northeastern Minnesota are not left behind.

Key lessons learned

It became clear early on that there are longstanding and unresolved divides between Duluth and Range communities. Over the course of several months as we tried to set meetings to discuss this grant with co-signing partners, we encountered unexpected resistance and waning communication, particularly from the Northern St. Louis County Sexual Assault Program. Despite efforts to communicate about the scope of this grant and the allowable expenses within it, the Northern St. Louis County Sexual Assault Program articulated that they felt that ‘Duluth gets everything.’ We had many difficult conversations with staff from the program to try to draw out what exactly that meant. These conversations were not easy. Much of the resentment and distrust that is present is based on past disagreements and competition for grant funding between the programs. We continue these conversations and efforts to involve the Northern St. Louis County Sexual Assault Program by co-facilitating listening sessions with them, requesting their ideas for next steps in this work, providing the medical staff and SANEs in the region with extensive continuing education opportunities, and continuing to listen.

Another difficult part of this work, which may in part be characterized as ‘failure,’ is the observation that our stated goal of improved access to forensic medical exams in Northeastern Minnesota may not look exactly how we imagined it would. In Duluth, the PAVSA SANE Program is viewed as a critical, victim-centered part of a sexual assault survivor’s journey to healing. Our multidisciplinary team of partners including law enforcement, advocates, and prosecution have emphatically stated that SANE is the best-practice model and non-negotiable part of our community response to sexual assault. That viewpoint is not shared by all our neighbors in Northeastern Minnesota. There is a lot of diversity from community to community. Through the listening sessions, we drew out stark contrasts between those who view the Hibbing SANE Program as an anomaly, or an experiment of sorts, while others strongly insisted that exams conducted by Emergency Room nurses were of a comparable quality to those conducted by a trained SANE. This diversity of opinions about what best practice is in Northeastern Minnesota changes the direction of our work, and ultimately the direction of this grant.

Reflections on inclusive, collaborative or resourceful problem-solving

The ability to be resourceful has been critical to our success during this grant period. Despite our best efforts to collaborate effectively, we have struggled to build trusting working relationships with some of our partners in Range communities. That being said, we continue to strive for inclusivity and engage in dialogue with all stakeholders in this work, even when those conversations are strained. We have been resourceful in seeking collaborative relationships with partners in other systems and communities and have built strong collaborative relationships with MNCASA and the Hibbing SANE Program, two programs we hadn’t considered to be critical partners when we wrote this grant proposal but who have proven themselves to be indispensable allies. We have been comfortable acknowledging that ‘success’ or ‘improvement’ with regards to medical forensic exams is not a singular concept to our partners on the Range, and we have sought innovative ways to incorporate the diversity of opinions about this issue into the solutions we propose. Loosening our grip on what we assumed was the answer to this problem has enabled us to be more flexible, responsive, and adaptable in this work.

Other key elements of Community Innovation

Understanding the problem

What we have learned so far about the need we identified in our initial grant application is that there is no singular ‘Range’ community nor is there consensus about the need for a coordinated medical response to sexual assault. From our listening sessions, we have heard that law enforcement from two different jurisdictions are satisfied with the mosaic of medical responses ranging from SANE exams to medical forensic exams conducted by emergency room nurses. Having a regional SANE model or expecting a SANE program at every medical facility across the region is unrealistic and unwanted. What there is consensus about is the need for increased training for all medical providers, including RNs, physicians, and SANE nurses. We are working to connect each facility with the resources and training that they are asking for. In this way, we are understanding that each community and sector wants different things from this grant and understanding that variation has enabled us to be more responsive to the expressed needs in each community. This work is much more specific and varied than the singular approach to medical forensic exams that we had envisioned in our initial grant proposal.

If you could do it all over again…

One piece of advice would be that our prerogative going in, that there was consensus about forensic medical exams for sexual assault victims on the Range, was not necessarily true even though meetings during the grant development process had led us to believe this was true. A better approach to begin, even before the grant proposal was submitted, would have been to broaden our goals for this grant from a singular approach to accommodate the fact that every Range community has different resources, politics, history, and priorities – and to be okay with this diversity. Another bit of useful advice would be to allow the grant to look different than we envisioned it. Just because we have found very positive outcomes from SANE in the greater Duluth community doesn’t mean that every community wants access to SANE. It would have been helpful if we’d realized sooner that it’s okay that what we envisioned wasn’t shared with all communities across the region — and that we could be adaptable and meet each community we were working with where they were at.

One last thought

We did feel reassurance through this process from staff at the Bush Foundation as we realized that the ‘turf wars’ of the past were negatively impacting our ability to collaborative effectively with some partners including the Northern St. Louis County Sexual Assault Program. As we engaged in deep listening and invested resources to build relationships with other disciplines and communities on the Range, we became more aware of the fact that there is no singular Range or cohesive vision held by community members on the Range for what a medical forensic exam should look like for victims of sexual assault. Through the frustration of trying to have open, honest dialogue and failing with some partners, we felt very supported by Aya and others that our efforts to communicate effectively were positive, and that the new relationships and collaborations we were forging were just as impactful as those relationships that were marked by tension and distrust. We continue to strive to be responsive to all our grant partners and include them in whatever capacity they wish to be involved at.