How the nursing shortage may lead to gaps in sexual assault care

How the nursing shortage may lead to gaps in sexual assault care

Missoula, Montana

KFF Health News


Jacqueline Towarnicki received a text message as she was finishing her day at a local medical clinic. She was assigned a case involving a patient who had bruises all over her body but couldn't recall how they got there.

Towarnicki caught her breath, a feeling she was familiar with after working four years as a nurse examiner for sexual assault in this city located in northwestern Montana.

Towarnicki said, 'You want to curse almost'. 'You're like, 'Oh, no, it's happening.''

Towarnicki is a second-job. She is on call every weekend and once a week. The survivor might need to be protected against sexually transmitted diseases, take medicine to prevent pregnancy, or collect evidence to prosecute the attacker. Or, all of the above.

When her phone rings in the middle night, it is usually a ringing. Towarnicki sways down the stairs to avoid waking up her son as her husband, who is half asleep, whispers encouraging words into the darkness.

She is able to breathe normally by the time she puts on the clothes that she had laid out near her back door. A clinic that provides round-the clock care to people who have suffered assault.

She wants to make sure her patients are safe.

Towarnicki stated that 'you meet people at their darkest and most terrifying moments'. You don't see that in any other health care job.

Towarnicki, a former travel nurse and van dweller for many years, is comfortable with the uncertainty of being a sexual abuse nurse examiner.

Many examiners also work full-time and on call shifts. They work at odd times and often alone. They are trained in trauma recognition and response, can gather evidence that may be used as evidence in court and offer care to prevent the body from long-lasting effects of sexual abuse.

They are few in number.

They can't always afford or find them. Some sexual assault survivors will have to travel to another town or state in order to consult an examiner.

In rural areas, gaps in sexual assault treatment can extend hundreds of miles. This spring, a program in Glendive (Montana), whose population is around 5,000 and which is located 35 miles away from the border with North Dakota, stopped accepting patients for examinations. The program didn't have the nurses necessary to handle all cases.

Teresea, 56, a part-time town mayor who also took on-call duty, said: 'These nurses are the same ones working in the ER where a patient with a heart condition could be admitted.' The staff were exhausted.

Miles City is the next option, 75 miles away, and adds at least one hour of travel time to patients who already traveled hours to get to Glendive.

Across the country, there has been a slow response from policymakers to provide training, funding and support. Some states and hospitals are working to increase access to sexual abuse response programs.

To hire a coordinator for sexual assaults in the state who will be responsible for expanding training and recruiting new workers. Montana's new law, which takes effect on July 1, will create the Sexual Assault Response Network within the Montana Department of Justice. The new program will set standards for this care, provide training in-state, and connect examiners across the state. South Dakota and Colorado

A national list of nurses trained to respond sexually assaulted is not available. This means that a victim may not be aware they need to travel to get treatment until they are in the emergency room or at the police station.

Sarah Wangerin is a former examiner and nursing instructor at Montana State University. She said that patients who are still in shock after an attack might prefer to go home. Some people can't leave town.

Wangerin called sheriffs' offices and county hospitals to map the locations of sexual assault nurse examiners in Montana. She found 55. In more than half the counties, there were no examiners. Only seven counties had nurses who were trained to deal with cases involving children.

We're re-traumatizing people by not knowing what we should do.

First Step in Missoula is one of only a few programs that respond to sexual assaults full-time in the state. The facility is operated by Providence St. Patrick Hospital, but it's separate from the main hospital.

The walls of the clinic are decorated with pictures by children and landscapes. Staff members choose to use softer lamps instead of the harsh fluorescent overhead lights. There are couches and rocking chairs in the lobby. Always available are heated blankets, snacks and drinks.

First Step is distinguished by its nurses' loyalty. Kate Harrison, who waited a little over a year before joining the clinic, is still working there today. This is in part due to the support of the staff.

A specially-trained team will work together to ensure that no one is carrying too much. Staff can discuss difficult cases while on the night shift. They go to group therapy for secondary trauma.

Harrison works as a cardiac nurse in a hospital during the day. It can feel like a job where you are always on time.

She can play any role that her patient requires for as long they require. One patient spent hours crying and talking on the floor of the clinic lobby. Harrison also acted as a DJ during an examination for a patient who was nervous, selecting music from her phone.

Harrison said, 'It was in the middle night and she had just experienced this sexual assault, and we just laughed and sang to Shaggy.' You have the freedom and grace to say that.

She knows that a colleague will be happy to assist when the work becomes overwhelming, or if she has had a lot of cases in a row and needs a rest.

Harrison stated that 'this work can sometimes take you into the undercurrents of society and its underbelly'. It takes a team.

This includes coworkers such as Towarnicki who reduced her hours in her day job to allow her son, a sexual abuse nurse examiner, to continue working. This meant that her repayment plan for student loans was extended by three years. She said that even though she is pregnant with her second baby, the work feels worthwhile.

Towarnicki, alone in her clinic one night, was clicking through the photos of her last patients. Towarnicki was alone in the clinic when she clicked through photos of her last patient.

Towarnicki counted quietly out loud how many bruises there were, and took note of their size and location. She tells those with gaps in their memory that she cannot speculate on how the marks got there, or give them all of the answers they deserve.

It was difficult to resist ruminating as she sat at her computer in the blue glow of its screen, long after her patient had left.

Towarnicki shook her heads and said loudly, 'Totally looks like a mark on a hand'.

The evidence and the patient's story had been sealed and locked up, only a few feet away from a wall full of thank-you notes from patients and sticky note encouragements among nurses.

Towarnicki relaxes with a cup of pudding from the clinic snacks on the tougher evenings. She can usually let go of the patient's story when she closes her clinic. She said that part of her healing involves'seeing light return to people's faces, and seeing them breathe deeper'. This happens 19 times out of 20.

Towarnicki explained, 'There's that one in 20 times when I get home and my head is spinning.' It takes her hearing her son speak and some time to think about it to bring her back. I feel that if you don't find it difficult at times, then maybe you shouldn’t be doing the work.

Towarnicki was on her way home at 11:15 p.m., a very early night. She knew that her phone might ring again.

Eight additional hours of call-out.

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