Victim Advocate Collaboration

International Association of Forensic Nurses

National Sexual Violence Resource Center, a division of Respect Together

Problem Statement

Violence is a public health problem of epidemic proportions. Globally, violence-related injuries result in the death of 1.25 million people every year. One in three women experience physical and/or sexual violence in their lifetime, and 120 million girls and young women less than 20 years of age have experienced some sort of forced sexual contact (WHO, 2022). In the United States alone, nearly 25,000 people were victims of homicide in 2020 and more than 1.4 million were treated in hospital emergency departments for assault related injuries (CDC, 2022).

Violence erodes communities by reducing productivity, decreasing access to safe and stable homes, and disrupting social services, which further perpetuates health inequities for vulnerable populations (CDC, 2022). In the U.S., expenditures related to violence cost hospitals and healthcare systems approximately $2.7 billion annually (American Hospital Association, 2017). Many individuals who survive violence have ongoing physical and emotional sequelae that may impact them, their ability to work, and their overall quality of life. Victim advocates are trained  to support victims of violent crime. These professionals are paid and unpaid individuals working in a variety of settings to respond to the mental, physical, financial, social, emotional, and spiritual needs of victims (Office for Victims of Crime, n.d.). Victim advocates are vital to the provision of comprehensive services for survivors of violence and can positively impact their short- and long-term outcomes (Mihelicova et al., 2021). Whenever possible, a multi-disciplinary team responding to individuals who have experienced violence should include both a forensic nurse and a victim advocate.

Conversations around violent crime and criminal justice reform often leave out the victims of crime. Victim advocates place the holistic needs of crime victims at the forefront of their work, which results in improved outcomes for victims and society by decreasing health care costs and increasing access to mental health services (De La Rue et al., 2023). Victims of violence interact with multiple systems including healthcare, criminal justice, child protection, educational institutions, military, and others. As a result, many agencies offer advocacy services or may even have an advocate on staff, but it is important to recognize there are different types of victim advocates who provide a variety of services.

Community-based advocates are employees or volunteers of independent (typically nonprofit) organizations whose mission is to provide support to victims. These advocates serve victims of violence regardless of whether the victim chooses to engage with the legal system. In many  cases, community-based advocates have a level of legal privilege and confidentiality not  afforded to other members of the multidisciplinary team. Confidentiality is important to establish in an effective therapeutic relationship and for the safety of victims (Javorka & Campbell, 2019). Community-based advocacy services include crisis intervention, legal and medical advocacy, individual and group support, and community awareness. In many communities, these advocates are available 24-hours a day. Community-based victim advocates play a crucial role in lessening the negative impact of violence on individual patients and ultimately communities (Kometiani & Farmer, 2022; Zweig et al., 2021). When community-based victim advocates are present following a sexual assault, victims are more likely to receive helpful information, referrals, services, and experience less secondary trauma from the medical and legal systems (Campbell, 2006; Zweig et al., 2021). Receiving counseling and support services helps reduce the overall economic hardship experienced by victims of violence by decreasing long-term consequences and linking them with available crime victims’ compensation funding (Mihelicova et al., 2021). Community-based victim advocates play a vital role in the healing of individuals who experience violence. Timely inclusion of community-based advocate support to victims of violence can improve patient outcomes (Henninger et al., 2020). The creation of strong collaborative relationships between forensic nurses and community-based advocates to provide trauma- informed, evidence- based care to violence victims is essential for individuals, communities, and society to support victims on their healing journey (Henninger et al., 2020).

System-based advocacy services can be provided via a variety of offices: community-based programs, criminal justice system offices, patient advocate programs at healthcare facilities, educational institutions or military advocacy programs, tribal social services, child or adult protective services, and others (United States Department of Justice, 2017). System-based advocates address victims’ needs within the confines of their specific system, but some may be less able to address a victim’s holistic needs outside the facility. Many communities have their own unique system-based advocates, particularly healthcare-based advocates affiliated with forensic nursing programs, who provide comprehensive holistic advocacy to patients impacted by violence. However, legal protection of victim-advocate communication is often not afforded to system-based advocates, which may prevent open discussion and limit the content shared.

Position

The International Association of Forensic Nurses (IAFN), in collaboration with the National Sexual Violence Resource Center (NSVRC), acknowledges the importance of the role of the victim advocate, recognizes the benefits of the timely inclusion of advocate support, and encourages the creation of strong collaborative relationships between forensic nurses and advocates to provide trauma-informed, evidence-based care to reduce the consequences of violence on individuals and communities. The IAFN and NSVRC assert that:

1. Victim advocates should be involved as non-medical first-responders in any multidisciplinary
2. All patients reporting violence should be offered in-person accompaniment by a victim advocate for their medical forensic exam, whenever
3. When in-person accompaniment is not available, remote/virtual accompaniment or introductions should be offered, whenever
4. The patient should be given time alone with the victim This is especially important in jurisdictions where community-based advocates have legally protected privileged communication.
5. In all instances where the patient chooses not to receive in-person advocacy services, forensic nurses and healthcare institutions should provide the patient with information on advocacy program services before
6. Advocacy services must be culturally competent and inclusive of individuals of diverse ethnic, religious, sexual, and gender
7. Advocacy services should disclose the limits of their confidentiality to any victims being

In addition, IAFN and NSVRC encourage healthcare personnel, including forensic nurses, to work closely with advocates to ensure best practices and holistic care for patients experiencing violence through the following:

1. To provide informed consent, forensic nurses need to understand the role of the advocate who provides services in their This understanding should include whether, and under what circumstances, an advocate can provide confidential care. This understanding should include differences between various community-based or system- based victim advocates, their roles, and when referrals are appropriate.
2. Forensic nurses, and all other team members, should collaborate closely with advocates in the development and implementation of community protocols to provide timely access to

Furthermore, IAFN and NSVRC acknowledge additional research on hospital accompaniment or referral to community-based advocates for patients experiencing intimate partner violence,  sexual assault, stalking, and trafficking is crucial to determine evidence-based best practices.

Rationale

Patients experiencing violence must have access to support systems, specifically advocacy services. Healthcare, particularly the forensic nurse, is often the first point of contact with formal systems after the individual who has experienced violence presents (Dunston et al., 2018). Healthcare providers are in a unique position to advocate for and introduce resources that impact patients’ long-term health outcomes. All patients should be offered advocacy services, as this practice demonstrates the promotion of equitable distribution of services that positively affect patients’ physical, emotional, and psychosocial health (Matwick & Woodgate, 2017). The National Protocol for Sexual Assault Medical Forensic Examinations states, “Advocates can  offer a tangible and personal connection to a long-term source of support” (Department of Justice, 2013, p.39). The protocol also recommends healthcare personnel recognize the importance of advocacy services within the exam process in order to facilitate a patient-centered, coordinated, multidisciplinary approach.

Victims of violence interact with multiple systems including healthcare, criminal justice, child and adult protection, educational institutions, military, and others. Many agencies offer some advocacy services or may even have an advocate on staff. Each office in every community is unique, and it is important for the forensic nurse to understand the purpose of each advocates’ specific role. Not all advocacy services are available or appropriate for hospital accompaniment.

Community-based advocates are unique among service providers as they provide immediate and long-term support to victims of violence, including interactions with other service providers, such as healthcare, legal, criminal justice, etc. (OVC, n.d.). Community-based advocates are associated with providing more emotional support and tangible aid than other service providers. The presence of community-based advocates fosters increased access to medical services, increases the likelihood for patients to create a police report, and decreases emotional distress. (Campbell, 2006). For patients who elect to report to law enforcement, victim advocates play key roles in reducing barriers to participation in the criminal justice system (Patterson & Tringali, 2015).

IAFN and NSVRC are dedicated to ensuring patients have access to forensic nurses and that forensic nurses are referring patients to both community- and system-based advocates who can contribute to positive short- and long-term health outcomes. Early introduction to victim advocates can be a critical component of a patient’s recovery from violence.

References

 American Hospital Association (2017). Cost of community violence to hospitals and health systems. Retrieved from https://www.aha.org/system/files/2018-01/community-violence-  report.pdf

Campbell, R. (2006). Rape survivors’ experience with the legal and medical systems: Do rape victim advocates make a difference? Violence Against Women, 12, 30-45.

Centers for Disease Control and Prevention (2022). Violence Prevention. Retrieved from  https://www.cdc.gov/violenceprevention/communityviolence/index.html

De La Rue, L., Ortega, L., & Castro Rodrigues, G. (2023). System-based victim advocates identify resources and barriers to support crime victims. International Review of Victimology, 29(1), 16-26.

Dunston, S.K., Vickers, B., Jamoo, E., Titos, A., & Massey, M. (2018). Cognitive evaluation of the national survey of hospital-based victim services. Atlanta, GA: Center for Questionnaire Design & Evaluation Research, National Center for Health Statistics, Centers for Disease Control & Prevention. Retrieved from  https://wwwn.cdc.gov/qbank/report/Dunston_2018_NCHS_NSHVS.pdf

Javorka, M. & Campbell, R. (2019). Advocacy services for college victims of sexual assault: Navigating complicated confidentiality concerns. Journal of Trauma Dissociation, 20(3), 304-323.

Kometiani, M. & Farmer, K. (2022). Exploring resilience through case studies of art therapy with trafficking survivors and their advocates. The Arts in Psychotherapy, 67, 1-13.

Matwick, A.L. & Woodgate, R.L. (2017). Social justice: A concept analysis. Public Health Nursing, 34(2), 176-184.

Mihelicova, M., Wegrzyn, A., Brown, M., & Greeson, M. (2021). Stressors of rape crisis work from the perspective of advocates with and without sexual victimization history. Journal of Interpersonal Violence, 36(19-20), 1-24.

Office of Victims of Crime (n.d.) Victim advocate training, Retrieved from  https://www.ovcttac.gov/views/TrainingMaterials/dspOnline_VATOnline.cfm

United States Department of Justice, Office on Violence Against Women (2017). Reflections from the field on victim/survivor advocacy. Washington DC: US Department of Justice. Retrieved from https://www.justice.gov/ovw/page/file/936746/download

United States Department of Justice, Office on Violence Against Women (2013). A National Protocol for sexual assault medical forensic examinations: Adult/Adolescent, 2nd edition. Washington DC: US Department of Justice. Retrieved from  https://www.ojp.gov/pdffiles1/ovw/228119.pdf

World Health Organization (2022). Injuries and Violence. Retrieved from  https://www.who.int/teams/social-determinants-of-health/injuries-and-violence

Zweig, J., Farrell, L., Walsh, K., & Yu, L. (2021). Community approaches to sexual assault: VAWA’s role and survivors’ experiences. Violence Against Women, 27(1), 30-51.