Last year, when Frances LaRae Morgan visited St. Paul from South Dakota’s Pine Ridge Indian Reservation, she was busy. An Indian Health Service sexual assault nurse examiner (SANE) at Four Directions Clinic in Kyle, South Dakota, Morgan was taking part in a new residency program developed by Regions Hospital’s SANE program and the University of Minnesota School of Nursing focused on supporting nurse examiners who serve rural and Indigenous communities around the country.
For 10 days, residents shadow working nurse examiners as they treat patients who are seeking medical care after a sexual assault. Morgan’s schedule was full for her entire visit. “I didn’t spend a lot of time in my hotel room,” she said. “When I was there, I saw nine patients. I only had one day where I didn’t get a call.”
The grant-supported residency is focused on building nurses’ confidence and competence with sexual assault exam skills, providing trauma-informed and healing-centered care for survivors of sexual assault and developing self-care skills to prevent burnout and help nurse examiners build resilience and sustainability.
Morgan, who completed her training in 2020, applied for the Twin Cities residency program after reading about it in an email. She said that many residents in her community of around 30,000 have experienced sexual assault.
“If you put three people — men, women, anybody — in a room on our reservation, one of them was probably assaulted,” Morgan said. “Our rates are extraordinarily high.”
Before she became a sexual assault nurse examiner, Morgan said that her clinic was referring sexual assault patients to a hospital in Rapid City, about 90 miles away. “They didn’t always have the transportation or the motivation to go there for treatment,” she explained of her patients. “That motivated me to become a SANE so I could provide help to my people.”
The SANE residency is the first of its kind in Minnesota, and one of only a few in the United States. It is coordinated through a three-year grant administered by the University of Minnesota called Strengthening Forensic Nursing. Grant funding helps to pay for participants’ transportation and lodging. The group has applied for funding for an additional cycle.
Ellen Johnson, Regions Hospital SANE program educator, said that the residency program focuses on nurse examiners with little or no experience. “Perhaps they work in an area where they are not going to see many patients every year, and it would benefit them to come to us and participate in care,” Johnson said.
The program aims to help nurse examiners from more rural areas learn from urban counterparts with deep experience working on sexual assault cases. In their own, more isolated, communities, Johnson explained, residents often “aren’t likely to get the kind of real-life orientation that our nurses get in the city. They may have nobody to buddy with. They have few mentors. This program is meant to give them patient experience in a condensed period of time so they can hit the ground running in their location.”
Because in-person learning is key to the residency program, during their visit to the Twin Cities, participants stay tethered to their nurse mentors, ready to respond whenever they get the call to travel to one of four East Metro hospitals — Regions in St. Paul, St. John’s in Maplewood, Woodwinds in Woodbury and Lakeview in Stillwater.
During her residency, Morgan recalled, “I would get a call from one of the SANE nurses that was my preceptor. I would meet them in the lobby at either hospital. We would go over what was told to them and come up with a plan. Then we would go in, see the patient and do what we had to do.”
Johnson said that she and her colleagues see any patient who comes into one of these hospitals and would like an exam for sexual assault. “We will come and see any patient who reports being sexually assaulted within 10 days of their sexual assault. We respond and partner with advocacy organizations to support the patient.” While SANEs provide emotional support during an exam, she said that staff from advocacy organizations, like Ramsey County’s SOS Sexual Violence Services, are there to provide short-term counseling, advocacy and safety planning: elements that are key to the process. “Because we are nurses, we have a health focus.”
Beyond the residency program, Johnson, with her colleague Linda Walther, leads a 40-hour SANE training course and a 16-hour skills lab throughout the year. “There is also orientation on the job where you buddy with an experienced SANE to see a few patients together and then you are on your own,” she said.
At Regions, Johnson said, “We have six nurses that serve as mentors. There are a couple more throughout the state that serve as mentors for newer SANEs, so whenever they see a patient they can schedule a meeting with their mentor and debrief. It is ongoing support.”
These real-life connections are key for working SANEs, Morgan said. “One thing that I found very beneficial was having an advocate that knew the process and what you have to do. They were there beside you in real time, showing you how they do it, and giving you confidence that you can do it, too.”
‘We want them to have better outcomes’
Because there are clear connections between mental illness and sexual assault, Johnson said that nurse examiners are trained to go into their work with an understanding of the many different ways those connections can manifest themselves.
“Forty percent of our patients have a history of mental illness,” Johnson said. “It is hard to know what came first — the mental illness or the history of trauma and abuse. Ongoing abuse leads to forms of mental illness like depression, suicide, overdose.”
While it makes sense that sexual assault could lead to some forms of mental illness, Johnson explained that sometimes addiction or mental illness can actually play a role in a sexual assault.
“Somebody with mental illness may exhibit behaviors that make them more vulnerable to sexual assault,” she said, adding, “A sexual assault is not their fault. It is the fault of the person who decides to take advantage of that vulnerability.”
Johnson said that perpetrators of sexual assault often seek out people who are, “vulnerable, like the young college student who is away from home for the first time and wants to have fun and meet people. A sexual assailant could say, ‘Come to this party with me.’ Then they take them up to their dorm room and sexually assault them.” She said that most people know their sexual assailants, and most do not tell others they were sexually assaulted. “Even though we saw more than 400 patients last year, we should have seen 2,000. They are out there.”
Not seeking help after a sexual assault can lead to further victimization and trauma. Some people find unhealthy ways to cope with their pain, Johnson said. “They do harmful things to themselves because those harmful things give them temporary relief. They eat too much, they smoke too much, they drink too much, they do drugs, withdraw from society, have too many sexual relationships,” Johnson said. “All of these lead to long-term health effects like heart disease, diabetes, respiratory illness, cancer, early death.”
Because of the long-term health impacts of untreated trauma, SANEs are trained to step in early. “We as nurses want to stop the progression,” Johnson said. “We want people to know they are more than their trauma. I don’t want this trauma to define you. It can shape you, but it does not need to define you. Our whole goal is to put patients on a trajectory for help, not a spiral downhill. We want them to have better outcomes.”
It’s important to remember that being immersed in their patients’ trauma can take a toll on nurses’ mental health. “We give so much of ourselves in this work,” Johnson said, explaining that exams can take up to four hours. “I want to take a nap each time I do an exam. We call that vicarious trauma.”
At home in South Dakota, Morgan said that many of the people she sees are so worn down by multiple traumas that they believe they are at fault for their sexual assault.
“A lot of our patients are easy targets, for lack of a better word,” she said. “They say, ‘I was drunk,’ so they think they can’t report it. I tell them, ‘You can be walking around naked on the street and you still have a right to report a sexual assault.’”
A sexual assault examination is mentally exhausting for the patient and the provider. Because most of her patients are Native just like she is, Morgan likes to suggest that they participate in a powerful Indigenous purification ritual.
“After we’re done doing what we have to do,” she said, “I offer our patients the opportunity to come and participate in a sweat. I like to participate with them so they are comfortable, so they aren’t like, ‘I am going to a random place with a bunch of random people.’” While it’s not a required part of her job, Morgan said she sees the ritual as an important part of the healing process for everyone: “I find it very helpful in the mental health of our patients. And I feel like it also helps my own mental health.”