Missoula, Montana
KFF Health News
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Jacqueline Towarnicki received a text message as she was finishing her day shift at a local clinic. She had a new case, a patient covered in bruises who couldn’t remember how the wounds got there.
Towarnicki gasped, a familiar sentiment after four years of working night shifts as a sexual assault nurse examiner in this northwestern Montana town.
“You almost want to swear,” said Towarnicki, 38. “You’re like, ‘Oh no, it’s happening.'”
These nights of service are Towarnicki’s second job. He is on call once a week and one weekend a month. A survivor may need protection against sexually transmitted infections, medication to prevent pregnancy, or tests to prosecute her attacker. Or all of the above.
When your phone rings, it’s usually in the middle of the night. Towarnicki tiptoes down the stairs of her house to avoid waking her young son, while her half-asleep husband whispers encouragement in the dark.
Her breathing is steady as she changes into the clothes she placed near the back door before going to bed. She grabs her nurse badge and drives up. First Step Resource Centera clinic that offers 24-hour care to people who have been assaulted.
You want your patients to know they are out of danger.
“You meet people in some of their most horrific, darkest, scariest moments,” Towarnicki said. “Being with them and then seeing who they are when they’re gone, you don’t get doing any other job in health care.”
A former traveling nurse who lived out of a van for years, Towarnicki is fine with the uncertainty that comes with being a sexual assault nurse examiner.
Most examiners work on-call shifts in addition to full-time jobs. They often work alone and at odd hours. They can collect evidence that could be used in court, are trained to recognize and respond to trauma, and provide care to protect their patients’ bodies from the lasting effects of sexual assault.
But their numbers are few.
Up to 80% of US hospitals not having sexual assault nurse examiners, often because they can’t find them or can’t afford them. Nurses struggle to find time for shifts, especially when there are staff shortages means covering many hours. Survivors of sexual assault may have to leave their town or even their state to see an examiner.
Gaps in sexual assault care can span hundreds of miles in rural areas. A program in Glendive, Montana, a city of nearly 5,000 residents 35 miles from the North Dakota border, stopped taking patients for exams this spring. It did not have enough nurses to respond to cases.
“These are the same nurses that work in the emergency room, where a heart attack patient might come in,” said Teresea Olson, 56, who is the city’s part-time mayor and also manned shifts guard. “The staff was exhausted.”
The next closest option is 75 miles away in Miles City, adding at least an hour to travel time for patients, some of whom already had to drive hours to reach Glendive.
Nationally, lawmakers have been slow to offer training, funding and support for the job. Some states and health facilities are trying to expand access to sexual assault response programs.
oklahoma legislators are considering a bill hire a state sexual assault coordinator tasked with expanding training and recruiting workers. A Montana law that takes effect July 1 will create a sexual assault response network within the Montana Department of Justice. The new program aims to set standards for that care, provide statewide training and connect examiners across the state. It will also look at telehealth to fill the gaps, following the lead of hospitals in South Dakota and Colorado.
There is no national tally of where nurses have been trained to respond to sexual assault, which means a survivor may not know they have to travel for treatment until they are sitting in an emergency room or at the hospital. Police department.
Sarah Wangerin, a Montana State University nursing instructor and former examiner, said patients who recover from a seizure can simply go home. For some, leaving the city is not an option.
This spring, Wangerin called county hospitals and sheriff’s offices to map where sexual assault nurse examiners operate in Montana. He found only 55. More than half of the 45 responding counties had no examiners. Only seven counties reported having nurses trained to respond to cases involving children.
“We are failing the people,” Wangerin said. “We are re-traumatising them by not knowing what to do.”
First Step, in Missoula, is one of the few full-time sexual assault response programs in the state. It is operated by Providence St. Patrick Hospital but is separate from the main building.
The walls of the clinic are adorned with children’s drawings and mountain landscapes. The staff do not turn on the harsh fluorescent overhead lights, instead choosing to light the space with softer fixtures. The lobby includes sofas and a rocking chair. There are always warm blankets and snacks on hand.
First Step stands out for having nurses who stay. Kate Harrison waited about a year to join the clinic and is still there three years later, thanks in part to the support of the staff.
The specially trained team works together so that no one carries too heavy a load. While being on the night shift means opening the clinic alone, staff members can report difficult cases together. They attend group therapy for secondhand trauma.
Harrison is a cardiac hospital nurse by day, a job that sometimes feels too attached to a clock.
At First Step, you can switch to whatever role your patient needs for as long as they need to. In the past, that meant sitting for hours on the floor of the clinic lobby while a patient cried and talked. On another occasion, Harrison doubled as a DJ for a nervous patient during an exam, blasting music from his cell phone.
“It’s in the middle of the night, she’s just been sexually assaulted, and we’re laughing and singing to Shaggy,” Harrison said. “You have this freedom and grace to do that.”
When working alone is overwhelming or you’ve had back-to-back cases and need a break, you know a co-worker would be willing to help.
“This job can sometimes take you into the undercurrents and underbelly of society,” Harrison said. “It takes a team.”
That includes coworkers like Towarnicki, who cut back on hours at her day job after having her son to continue working as a sexual assault nurse examiner. That meant adding three years to her student loan repayment schedule. Now pregnant with her second child, she still feels the work pays off, she said.
On a recent night, Towarnicki was alone in the clinic, clicking through photos she took of her latest patient. The patient chose not to file a police report, but asked Towarnicki to record all the evidence just in case.
Towarnicki silently counted aloud the number of bruises, their sizes and locations, while taking notes. She tells patients who have memory gaps that she can’t speculate how each mark got there or give them all the answers they deserve.
But as she sat in the blue light of her computer screen long after her patient had left, it was hard to help but reflect.
“It totally looks like a hand mark,” Towarnicki said, suddenly out loud, shaking her head.
All the evidence and his patient’s story were sealed and locked away, just feet from a wall of thank you cards from patients and sticky notes of encouragement between nurses.
On the toughest nights, Towarnicki takes a moment to relax with a cup of pudding from the clinic’s snacks. Most of the time, he can put his patient’s history aside when he closes the clinic. Part of his healing is “seeing the light return to people’s eyes, seeing them able to breathe more deeply,” which, she said, happens 19 out of 20 times.
“There’s one of 20 where I go home and I’m hanging around,” Towarnicki said. In those cases, it takes hearing the voice of her son and time to process, to make her back off. “I feel like if it’s not hard sometimes, maybe you shouldn’t be doing this job.”
It was a little after 11 p.m. when Towarnicki headed home, early in the evening. He knew his phone might ring again.
Eight more hours on call.
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