To Nurse and Protect
As more victims of sexual assault seek treatment, E.R. staff must figure out how to best care for them
As more victims of sexual assault seek treatment, E.R. staff must figure out how to best care for them. KATHERINE LAIDLAW
FROM THE LOCAL
FOR ABIDA DHUKAI, a nurse practitioner, preparing to see a female patient always starts the same way. First, she puts up an emotional wall. “I need to protect myself because I don’t know what I’m going to hear,” she says.
Then she mentally runs through the many questions she will ask if there’s abuse involved. “How safe do you feel?” “Do you have children?” “Are you financially independent?” “Does your abuser know where you work?” She goes through these checkboxes, and more, so as not to get too close to the rising tide of anger swelling within her.
Dhukai is a wiry woman of Indian descent, with long, dark curly hair tied back in a bun. She speaks at the quick pace of a person who has places to be, and she usually does. For nine years,
she has worked in Toronto’s Mount Sinai Hospital emergency department, seeing patients with ailments and injuries that range from twisted ankles to heart attacks. After a few years, she began to focus most on women’s health and became especially interested in tackling what she considered a less-than-empathetic response to the women who reported they’d been sexually assaulted.
In 2009, Dhukai began taking notes on her phone about her thoughts and feelings after seeing each of those cases. Her file is now hundreds of thousands of words long. When women reported that police officers had victim-blamed them, she wrote it down. When women blamed themselves, suggesting maybe they’d had too much to drink, she wrote it down. “As I saw more and more violence, I felt more angry,” she says. “How can somebody do this to another human being?”
Reflecting on her experiences made her realize that the hospital needed stronger protocols for dealing with patients suffering from abuse. She approached Christine Bradshaw, a social worker and the chair of the hospital’s Violence Against Women Awareness Committee, and the two worked together to implement changes in how the emergency department receives these patients.
OVER TIME, DHUKAI and Bradshaw have innovated. They’ve put into place precautions to protect a patient’s identity, are providing them with better resources and they now ask every woman who is admitted into the hospital’s department for women and infants whether anybody close to them is hurting them physically, sexually, emotionally or financially.
Universal screening—the practice of asking every person who enters the emergency department whether or not they’re being abused—isn’t mandatory. Instead, it’s left to individual clinicians to determine when someone’s story and symptoms don’t match. Or, as Dhukai does, they can simply put the question to everyone.
“When I first started out, I’d see one or two women a week who’d been sexually assaulted,” Dhukai says. Lately she feels that this number has increased and suggests the rise, which she first noticed around four years ago, is a result of increased public conversations around the issue.
For Dhukai, that uptick has taken a toll. One weekend in February 2017,
DHUKAI REALIZED THE HOSPITAL NEEDED STRONGER PROTOCOLS FOR DEALING WITH PATIENTS SUFFERING
surrounded by the emergency department’s frenzy—people coughing, yelling, drunk—the nurse processed multiple rape cases during one shift. Something in her tipped following the last one. “I can still remember her face,” Dhukai says.
For weeks after, Dhukai was quiet and withdrawn. She took two weeks off work—she knew she needed space. But it’s not being haunted by faces that makes her worry about herself. It’s when they start to blend, when a patchwork of bruises on one patient reminds her of another.
“They mesh together sometimes,” she says. “It’s disturbing.”
ACCORDING TO DATA released by Statistics Canada in July, there was a 13 per cent increase in police-reported sexual assaults nationwide in just one year, to 24,672 incidents in total. “The MeToo movement has significantly raised people’s awareness,” says Bradshaw. “And nobody wants to sit with this anymore. They want to talk.” In turn, an already overburdened health system must determine how to best care for these traumatized patients.
The emergency department plays a unique role in the societal response to sexual assault: it’s often the only place where nurses, social workers and police officers converge to ensure that a victim is safe. It’s also sometimes the only place where someone who has experienced abuse will be alone with another person long enough to talk about it.
When someone discloses abuse to her, Dhukai begins by asking them how safe they feel. From there, the conversation can take a number of paths. If there are children involved, healthcare professionals run an intensive assessment and call the Children’s Aid Society if necessary. After that, Dhukai will carefully elicit the exact details of the abuse and whether or not the victim has ever considered pressing charges. She’ll ask if her patient wants to be examined by a sexual-assault nurse or, if it’s between the hours of 8 a.m. and 10 p.m., if she wants to speak to the hospital’s social worker. Finally, Dhukai offers information about shelters and a list of resources.
THE UNIQUE CHALLENGES of working as a sexual-assault nurse come with a number of occupational hazards. Because they hear graphic narratives every day, these workers can experience disturbances with intimacy, safety, trust and control—in some instances as significantly as the victims they treat, according to a 2015 Journal of Forensic Nursing study.
They’re also more susceptible to vicarious trauma—the emotional residue that comes from empathetically engaging with people’s pain or fear—than most other kinds of nurses. This can lead to social withdrawal, emotional numbing, nightmares and
a decline in sexual enjoyment. Following that, they may experience burnout, compassion fatigue and even posttraumatic stress disorder.
Attrition rates are high among sexual-health nurses, which can create disruptions in continuity of service. One 2016 report from the United States Government Accountability Office noted that the state of Wisconsin had a .08 per cent retention rate, with only 42 of 540 examiners still practising at the end of two years.
Although Canadian statistics aren’t available, former sexual-assault nurse Amanda Pyper knows first-hand why burnout happens here. When Pyper started working at Women’s College Hospital, she was 23 and just out of school. Right away, she was administering forensic exams and offering crisis counselling to women, many of whom appeared at the hospital because they’d been sexually assaulted. “I was very stressed out,” she says. “I was constantly anxious about making mistakes. I was the only health-care professional many of those people had contact with. I had a lot of autonomy in terms of decisionmaking and changing the course of people’s care and lives.”
Over time, Pyper grew more comfortable in the role, but some parts of the job never grew easier. Overnight shifts were especially gruelling, when sexualassault nurses from Women’s College travel across the city, answering pages from hospitals such as Sunnybrook, St. Michael’s and Mount Sinai, as violated and vulnerable patients wait for them to arrive.
Pyper says the hardest part of that job, which she did on the side of her full-time position at Mount Sinai’s emergency department, was talking with women searching for answers she couldn’t provide. “A lot of people want to know, ‘Was I sexually assaulted?’ People come in wanting an answer, yes or no,” she says. “I don’t think people fully appreciate that there is no test for that.”
In the last few years, the demands of treating sexual assault have increased dramatically. Previously, situations ranged from stranger rape to daterape drugs, but the cases tended to be clear-cut. Now, as education around consent and sexual assault has changed—in school, at home and in the media—reporting tends to be less straightforward. Pyper saw a greater number of situations involving people the victims considered friends or exes. And as more patients come in with
WHEN DHUKAI GETS HOME FROM A DIFFICULT SHIFT, SHE SINKS INTO BED AND SPEAKS TO NO ONE.
cases involving alcohol and ambiguity, it makes following a methodical medical protocol difficult because those cases require so much more than a forensic test. “The biggest thing people want is trauma counselling,” Pyper says. “I’m not trained in how to do that, so I was finding that I wasn’t providing them with the best care.”
Eventually, the demands of the job grew too great. Pyper left her role as a sexual-assault-centre nurse last October, returning to working solely at Mount Sinai.
WHEN DHUKAI GETS home from a particularly difficult shift, she sinks into bed and speaks to no one, letting the phone ring if someone calls. After almost a decade of this work, she has developed rituals that help her offer care at the standard she expects of herself. She doesn’t watch the news. She exercises regularly, spending an hour a day biking or doing yoga, and practises meditation. All this helps dispel the flashes of anger that rise up within her daily, anger at a society that doesn’t protect women before they become her patients.
When their job feels overwhelming, the nurses talk to each other, checking in to make sure they’re taking care of themselves. They can access the services of the hospital’s social workers, Dhukai says, but those colleagues are overworked, too. She has yet to find an outside resource who understands how overwhelming the convergence of sexual-assault narratives and an emergency department that operates at a breakneck pace can be.
Sometimes the greatest challenge of the job is quieting the voice inside that compels Dhukai to save every woman who walks through the doors. “I wish I could just wrap them up in my arms and say, ‘Everything’s going to be okay. Just come with me, my little ducklings. I will take care of you,’” she says. “But I can’t.”