Regions Hospital readies rural nurses to help sexual assault victims

Nurse Emily Smelcer had seen this before: Her patient at Regions Hospital in St. Paul, a sexual assault victim, was too scared or too traumatized or too unprepared to recall simple details.

What was new was the question that unlocked those answers.

The Mauston, Wis., nurse was at Regions recently as part of a new residency program to give sexual assault nurse examiners, called SANEs, more practical skills and more practice screening victims than they would experience at their small or rural hospitals. That included lessons on trauma-informed questions to help victims think back to their attacks.

"What did you hear?" Smelcer asked the woman.

There was a train horn, the woman recalled, which meant it must have been near the train station in St. Paul, which meant it must have been in a nearby housing complex. And suddenly details were pouring out.

Regions started the training program last year in partnership with the University of Minnesota, seizing on the reality that the urban trauma hospital treats more sexual assault victims than the average rural hospital. Smelcer figured her hospital in central Wisconsin does a dozen evaluations a year, but she witnessed or led four screenings in her week at Regions.

An effective screening can reduce mental and physical health problems in victims after their sexual assaults, but examiners need the "competence and confidence" to do them, said Ellen Johnson, Regions' SANE program educator.

Nurses in remote locations "are practicing essentially in a vacuum by themselves, figuring it out as they go," Johnson said. "So, it's a huge benefit for them to be able to work with a program that is well-established and be able to learn some new skills."

Sensory questions unlock memory

Rural Minnesota is not immune to the rising problem of sexual violence. Rates of hospital care for interpersonal violence, a broader category that includes sexual abuse, were as high or higher in some parts of rural Minnesota as they were in the Twin Cities, according to the Minnesota Injury Data Access System.

Emergency department visits for sexual abuse increased among adults from 690 in 2016 to 1,175 in 2022, the data showed, but many more visits likely occurred without being properly coded in medical records.

Smelcer sought the Regions training to refresh her skills after taking a year off from sexual assault screening at the Mile Bluff Medical Center in Mauston. Prior screenings had involved victims assaulted by strangers, but Smelcer said she encountered women at Regions who knew their attackers and struggled with homelessness, mental illness or drug abuse.

Sensory questions about sounds, sights and smells cut across different situations and helped victims open up, she said.

"It's kind of drawing [information] out," Smelcer said. "It was a game-changer for me."

The U received a three-year federal grant to support the Regions residency, which pays for lodging and travel so nurses from across the country can afford the training in Minnesota. Seven nurses have completed the residency, and another four are scheduled this spring. The funding also covers a mentorship program, allowing experienced examiners at Regions and other metro hospitals to work remotely with rural nurses and provide them support.

Training in effective interviews is key, because trauma "changes the way we store and encode memory," said Sarah Hoffman, a U associate professor of nursing involved with the residency program. The portion of the brain responsible for reasoning and emotional processing takes a back seat to the portion governed by emotion and physical sensation.

"The neurochemicals that are active essentially shine a spotlight on what would seem like random or bizarre sensory memories," she said. "So, the questions are meant to reflect that. We ask initially, 'Tell me what you remember about the event.' And then we go into the five senses. We say, 'Do you remember anything you saw? Do you remember anything you heard?' "

'It gets to our hearts'

Nurses and other clinicians earn SANE designations by completing 40 hours of classroom training and then observing real-life or simulated screenings.

The Regions residency is another level of training, giving examiners practical tips on how to testify in court cases and how to cope with the emotional stress of sexual violence screenings that can last four to eight hours.

Nurses often only interact with victims during the initial exams and never get to know if or how they recover, Johnson said.

"It gets to our hearts," she said. "It can be hard work."

Smelcer in the past took long, random drives in the Wisconsin heartland and listened to music after working with sexual assault victims. It wasn't quite the same during her week in the busy Twin Cities, but a few random turns of her car led her to a shopping mall to decompress.

"It can be very taxing with the emotions," she said, "because you kind of live through them."