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AFN Impact: Providing Services to Rural Appalachia

Written by Dr. Kathleen Thimsen, AFN Treasurer

Ashleigh McMahan, BSN, RN, CEN, SANE-A, is the project coordinator for the Health Education Learning Program for Sexual Assault in Rural Appalachia (Help-Sara). She began her journey in serving vulnerable individuals with health disparities and social determinants of health (SDoH) with a personal drive. “It was this passion that led me to join East Tennessee State University in 2022, after graduating with my BSN in 2016,” said McMahan. “My aim was to find a way to support nurses in rural Appalachia, who often face limited educational and healthcare resources.”

East Tennessee State University (ETSU) was first awarded a three-year, $1.4 million Health Resources & Services Administration (HRSA) grant in fall 2018. Over the first three years, progress with Help-Sara created the opportunity for the university to be re-awarded a SANE training grant for an additional three-year period (2021-2024).

The intention of the SANE education grant is to increase the number of practicing sexual assault nurses who serve in areas currently under-resourced and under-served. ETSU focuses on a remote, 21-county service area spanning northeastern Tennessee and southwestern Virginia. The region is comprised of five hub-hospitals representing a total of 18 care-access points. The SANE nurses work closely with the area’s family-justice and child-advocacy centers. The current staffing of the hub’s critical-access hospitals comprises three full-time RNs, with two in Tennessee and one in Virginia. The other positions are filled by part-time and per diem SANE nurses.  

ETSU began its mission to provide education and training for work in the forensic nursing specialty in 2019 as a post-graduate certificate program. The program identified that many nurses didn’t have a graduate degree, and the availability of resources to support advanced education didn’t have a deep enough reach. As a result, the HRSA grant was a mechanism to meet the educational needs of the nursing communities. Still, it had limitations on the availability of local institutions of nursing curriculum. As the HRSA grant was intended, the curricular design of the ETSU program was developed and implemented as an online training program that is now augmented by Wednesday webinars provided through the Academy of Forensic Nursing and other educational offerings through the International Association of Forensic Nurses.

The online training is comprised of the 40-hour SANE training, along with additional topics and courses needed by forensic nurses—including in-person skills lab training and competency validation, which is offered as an inter-professional model with the colleges of nursing and medicine and College of Pharmacy at ETSU. The simulation course offers each participant three to six exams in the training series.  All the curriculum focuses on adult care, while additional training in pediatric care is offered through collaborative partnerships with organizations especially focused on pediatric and adolescent populations.

McMahan shared some of the barriers and obstacles the ETSU program has encountered. Those barriers include limited access to care for people living in small communities, where they perceive social barriers associated with community norms and personal bias experienced in small-town life. Additionally, when an assault occurs, there are complex situations for reporting, such as where to report a crime, due to the campus being primarily a “commuter campus.” Additionally, follow-up post-examination is a complex dilemma due to small-town living and people traveling great distances for specialized care. Services are significantly challenged by long drives to access care, which average four hours across the 21 counties. Also, serving people who must drive an hour and a half into the mountain terrain and an additional two to 2.5 hours west is challenging.

To solve the challenges, ETSU is engaged in a one-year, no-cost grant extension employing forensic tele-SANE services. Training and coordinating competent SANE and forensic nurses at both ends of the patient encounter are key. Having all the nursing specialists trained in trauma-informed care, which has been the cornerstone of the partnerships, has been greatly impacted by the addition of 66 forensically trained nurses in the last year and a half. This is merely a start to replace the sexual assault nurses who, before COVID-19, numbered 174. The impact of the pandemic significantly reduced access and services.

McMahan’s dedication and commitment to Help-Sara is evident in her drive to continue the work that ETSU began and continues to offer to improve access and expertise for nurses interested in being trained and providing specialized forensic nursing care and services to an underserved region.

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