ACFEI Articles

Forensic Nursing: Investigating the Career Potential in this Emerging Graduate Specialty

Article Publisher: American Journal of Nursing - Date: Mar. 2004

Source: American Journal of Nursing, Mar. 2004, Vol. 104, No. 3

Citation: Burgess, A. W., Berger, A. D., & Boersma, R. R. (2004, March). Forensic nursing: Investigating the career potential in this emerging graduate specialty. American Journal of Nursing, 104 (3), 58-64.

James Byrd, 48, was angry. There were still pieces of pulp in the orange juice container after his girlfriend washed it. In a rage, he hit her and stamped on her stomach. She was ill that night, and for the next four days, but Mr. Byrd wouldn't let her leave the house to seek health care. Finally, when he left the house with their 10-year-old daughter, the victim dragged herself outside, hailed a cab, and went to the hospital. She couldn't walk into the ED. Taken directly to surgery, she was found to have a lacerated pancreas.

Surgeons removed her spleen and sutured her pancreas. During her recovery in the hospital, a prosecutor and a nurse recorded her statement and her appearance on videotape. She told of the years of domestic violence (primarily psychological) she'd endured. Mr. Byrd was arrested and jailed and she returned home.

When Mr. Byrd's trial began a year later, a surgeon and an ED nurse testified to their documentation of the victim's injuries, surgery, and recovery. But when the victim took the stand she refused to testify against her boyfriend. How could the prosecution convince a jury of the defendant's guilt without the victim's testimony? Would the jury understand that it's common for victims of domestic violence to refuse to testify against their abusers? A forensic nurse with a well-established reputation in the field of domestic violence was brought in to explain the victim's refusal.

Mr. Byrd was convicted of two counts of assault in the first degree and faced a sentence of 25 years in prison.

Forensic nursing, one of the newest specialty areas recognized by the ANA, is gaining momentum nationally and internationally. Forensic nursing practice is, according to the International Association of Forensic Nursing (IAFN), the "application of nursing science to public or legal proceedings."¹ Forensic nurses investigate real and potential causes of morbidity and mortality in a variety of settings. Responsibilities range from collecting evidence from perpetrators and survivors of violent crime to testifying in court as a fact witness (someone who saw a situation firsthand) or an expert witness (someone who offers an opinion of a particular situation). Forensic nurses understand evidence collection (such as forensic photography) for subsequent legal and civil proceedings and are the "bridge between the criminal justice system and the health care system.”²

The American Board of Forensic Nursing is one of 13 executive advisory boards of the American College of Forensic Examiners International (ACFEI). The ACFEI publishes The Forensic Examiner®, a peer-reviewed journal, and offers certification programs to nurses and other health care professionals. For more information go to www.acfei.com.

THE HISTORY OF FORENSIC NURSING

Today, screening for violence is a minimum standard of care. Both the Centers for Disease Control and Prevention (CDC) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) recommend screening for family violence in hospitals and clinics. JCAHO's recommendations have been in place since 1992, and in 1998 the CDC backed efforts to improve the recognition and treatment of victims of domestic violence with the publication of Intimate Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Health Care Providers. Once considered a problem exclusively for the criminal justice system, violence is now regarded as a public health issue. Yet it's taken years for violence to reach this level in the public's awareness.

The efforts of the health care community to stem the tide of violence in America gained momentum in 1985, with the Surgeon General's Workshop on Violence and Public Health. In his opening remarks, U.S. surgeon general C. Everett Koop, MD, encouraged the 150 attendees to develop recommendations that could become the "stimuli of change and progress everywhere." He championed a multidisciplinary approach that could be embraced by professionals in medicine, nursing, psychology, and social services. "Our focus will be squarely on how the health professions might provide better care for victims of violence and also how they might contribute to the prevention of violence," he said.³

At the same time, nursing was enjoying new strength as a provider of health care services to victims. Nurses had volunteered at many of the rape crisis centers that opened in the 1970s and by the mid-1980s were widely acknowledged for the expertise they had developed as a result. In addition, scientific competence had become integral to the profession. This combination of factors opened doors for nurses to collaborate with other providers, initiate courses and programs of research on victimology and traumatology, influence legislation and health care policy, provide expert testimony in criminal and civil court cases, and ultimately, create a new specialty.

Forensic nursing has its roots in the 18th century, when midwives testified in court on matters such as virginity, pregnancy, and rape.⁴ (By contrast, the discipline of forensic medicine began early in the 16th century and focused on pathology and cause of death.⁴) The current model of forensic nursing evolved from the role of the police medical officer found in the United Kingdom and other countries.⁵

The skills of the forensic nurse - observation, documentation, and preservation of evidence-are critical in determining the legal outcome of violent crimes.⁶

THE NEED FOR FORENSIC NURSING EDUCATION

With training, health care providers can identify both victims and perpetrators of crime.^7,8 In its recent publication, Violence as a Public Health Problem, the American Association of Colleges of Nursing states that "as members of the largest group of health care providers, nurses should be aware of assessment methods and nursing interventions that will interrupt and prevent the cycle of violence."⁹ Such efforts may focus on the ED, where most seriously injured people are treated."¹⁰ Results of a 1999 study underscore the value of instruction: after the ED nursing staff in an urban, level l trauma center underwent a four-hour session an screening for intimate-partner violence, 18% of women ages 18 and older visiting the ED were identified as victims of violence and referred to social services.¹¹ Before the training, such identification and referral occurred in just 1% of the women presenting to the ED.

In October 2002 IAFN Scientific Assembly, a group of forensic nursing faculty agreed that although continuing education in forensics (such as evidence collection and violence prevention) can provide an overview of the field, it's inadequate for practice. Thus, many nurses are pursuing education through college and university programs. (See Forensic Nursing Programs, page 63, for a list of university programs.) Others are seeking education in forensics outside of nursing.

FORENSIC NURSING PROGRAMS

There are four primary routes for obtaining training in forensic nursing.

Continuing education courses supplement nursing degree programs and are used for professional education and to fulfill renewal criteria for state licensure.

Certification programs have specific content, entrance requirements, and often a written examination. Clinical internships may be required.

A minor or concentration in forensics is available in some university undergraduate and graduate nursing programs.

Formal graduate study builds on the foundation of the baccalaureate.

In 1997 the ANA published The Scope and Standards of Forensic Nursing Practice, which calls for the synthesis of education and experience for forensic nursing proficiency. The ANA recommends that in addition to attending core graduate nursing courses, graduate students carry out a clinical internship and complete the forensic nursing curriculum required for the degree.

Graduate clinical internships may be completed in many settings, including a state forensics crime laboratory, a medical examiner's office, a victim advocate's office, a shelter for victims of domestic violence, a forensic psychiatry unit, or an ED.

Forensic nursing curriculums focus on victimology, perpetrator theory, forensic mental health, interpersonal violence, criminology, and criminal justice. Other areas of study include the following:

• The fundamentals of forensic nursing include evidence collection; documentation; interviewing skills; criminal, procedural, and constitutional law; scope of practice; interdisciplinary collaboration; identification of nursing roles; and testifying in court as an expert witness.

• Forensic law. Forensic nurses must understand the legal issues surrounding expert testimony in legal proceedings; issues such as culpability, burden of proof, rationale for punishment, and mitigating circumstances; and defenses such as justification, insanity, entrapment, and duress.

• Forensic science. Topics include the collection and preservation of evidence, the interpretation of DNA-laboratory reports, forensic chemistry, toxicology, cause of death, blood spatter interpretation, manner and mechanisms of injury, wound identification, and cause.

SPECIALTY ROLES IN FORENSIC NURSING

As their responsibilities evolve, forensic nurses are assuming increasingly diverse roles, in risk management, employee litigation, bioterrorism, and domestic and international investigations of human rights abuses. Newly proposed is the child abuse nurse examiner.¹² The most common roles are sexual assault nurse examiner (SANE), advanced practice forensic nurse or forensic clinical nurse specialist, and nurse death investigator and nurse coroner.

The SANE is the most common forensic nursing specialty. SANEs care for victims of sexual assault, collect and document forensic evidence needed to pursue a criminal case, and testify at trial. Programs that teach nurses to work with sexual assault victims have existed in the United States since 1976. They typically consist of more than 40 hours of classroom instruction followed by a number of hours of clinical practice.¹³ Initial requirements, training programs, continuing education, and competency requirements vary by state (see www.sane-sart.com for a list of existing SAT, programs and resources for the development of new educational programs).

Newer programs, such as those for the sexual assault forensic examiner (SAFE) or the forensic nurse examiner (FNE), have begun to replace SANE programs. These programs will expand the scope of forensic nursing to include not only sexual assault incidents but the gathering of forensic evidence in cases of domestic abuse or automobile accidents.

The IAFN (see "Who's Who in Forensic Nursing," page 60) recently published SANE education guidelines and is currently working with the U.S. Department of Justice Office on Violence against Women (OVW) to develop a national sexual assault forensic examination protocol. The OVW will also develop training standards to accompany the protocol. The IAFN offers a certification program for the sexual assault nurse examiner-adult and adolescent (SANE-A). The first SANE-A certification examination was given in April 2002 (certification is valid for three years).¹⁴ As of September 2003, there were 352 IAFN-certified SANE-A nurses.¹⁵ To be eligible for the examination, applicants must hold a valid U.S. RN license, have a minimum of two years of practice as an RN, have been "determined competent in current SANE practice" by an appropriate clinical authority, and have successfully completed an adult-adolescent SANE education program that includes either a minimum of 40 continuing education contact hours of classroom instruction or three semester hours (or the equivalent) of academic credit in an accredited school of nursing.

President Bush's proposed initiative, Advancing Justice through DNA Technology, includes $5 million allocated in 2004 to "support the development of training and educational materials for doctors and nurses involved in treating victims of sexual assault." HR 3214 was passed by the House of Representatives in October 2003 and read to the Senate in December.¹⁶ The initiative calls for more than $1 billion in five years, and if it's approved, some of the funds may be appropriated for SANE and SAFE programs.

Ciancone and colleagues published a survey of SANE programs in the United States in 2000.¹⁷ Of the programs that responded, 55% had been in existence for less than five years; 16% for more than 10 years. The median number of patients seen annually was 95. Roughly 75% of programs were affiliated with a hospital, police department, or rape crisis center; more than half of the examinations were conducted in a clinic, office, or hospital setting. Ninety percent offered prophylaxis and treatment for sexually-transmitted diseases (STDs), but STD cultures, HN testing, and screening for illegal drugs and alcohol were selectively performed. The authors suggested that a standardized protocol could reduce inconsistencies among programs and that further research be conducted.

Anecdotal evidence suggests that SANEs have made a profound difference in the quality of care provided to sexual assault victims and in the outcomes of investigations and prosecutions.¹³ Further, SANE training allows evidence to be collected more - quickly and in a manner that is compassionate and doesn't traumatize a victim further.

Advanced practice forensic nurse and forensic clinical nurse specialist. In addition to working with victims of crime and their families, advanced practice forensic nurses and forensic clinical nurse specialists may work with perpetrators, people involved in paternity disputes, and cases involving workplace related injuries, medical malpractice, automobile accidents, food or drug tampering, or medical equipment defects.⁴ They may be researchers or clinicians; in hospitals they may serve as consultants and educators. They can assess a patient's risk of being victimized (through intimate-partner abuse, for example) and help reduce that risk through patient education.

Nurse death investigators and nurse coroners are two roles discussed in the ANA's Scope and Standards of Forensic Nursing Practice; each role varies by state. Currently, 22 states have medical examiner systems, 11 states use the coroner system, and 18 states use a mixed medical examiner and coroner system.^18,19 (For detailed information, go to www.cdc.gov/epo/dphsi/mecisp/summaries.htm.) One key difference between the two is that coroners are elected to the position, while the governor appoints medical examiners (who must be physicians). Nurse death examiners work for the medical examiner and investigate the circumstances of a death before the body can be released. Nurse coroners can perform death investigations, as well as issue death certificates, a responsibility that differentiates them from nurse death investigators. Catherine O'Brien, a nurse death investigator, considers death "another point on the continuum of care.²⁰ She emphasizes that because the majority of cases referred to a medical examiner's office are natural deaths, nurse death investigators should be trained to handle natural death cases, which are not the focus of law enforcement personnel.

There are many death investigator programs available. One, the American Board of Medicolegal Death Investigators, located in the Division of Forensic Pathology- at St. Louis University School of Medicine, offers two levels of certification: the registry (or diplomate) level and the fellow (or advanced board certification) level. One approach to becoming a registry candidate is to have 30 hours of formal death investigation training and complete an examination and a performance evaluation. Candidates looking to become fellows must be certified at the registry level for at least six months, have at least 4,000 hours of death investigator experience, and currently be employed as a death investigator.

FORENSIC NURSING RESEARCH

The ANA's Scope and Standards of Forensic Nursing Practice encourages research to validate and improve forensic nursing practice.²¹ Research in recent decades has increased awareness of sexual trauma considerably; it has also identified the effects of such trauma on family members and the community.²² Yet sexual violence still affects hundreds of thousands of women and children each year. Nurses could be more influential in reversing this trend by identifying victims of sexual violence in their care, improving the treatment of trauma, and designing research protocols aimed at prevention.

An important research question is what difference the use of SANEs makes in the arrest and prosecution of rape and sexual assault cases. Another possible area of inquiry is the identification of signs consistent with consensual or nonconsensual sex, a critical issue in acquaintance-rape trials. Forensic nurses in the United Kingdom and Scandinavia have already conducted important research on the behavior specific to dangerous patients and on nurses' attitudes toward patients with personality disorders.^23-26

REFERENCES

1. International Association of Forensic Nurses. About IAFN. [Web site]. 2002. http://www.iafn.org/about/default.html.

2. Benak, Rose. Focus on Diane Stuart. On the edge 2003;9(4):21.

3. U.S. Public Health Service, Services. Surgeon General's workshop on violence and public health. Report. [Web site]. 1986. http://profiles.nlm.nih.gov/NN/B/C/F/X/_/nnbcfx.pdf.

4. Lynch VA. Forensic nursing. In: Burgess AW, editor. Advanced practice in psychiatric mental health nursing. Stanford, CT: Appleton-Lange; 1998.

5. Lynch VA. Clinical forensic nursing: a new perspective in the management of crime victims from trauma to trial. Crit Care Nurs Clin North Am 1995;7(3):489-507.

6. Malestic SL. Fight violence with forensic evidence. RN 1995;58(1):30-2.

7. Rollins JA. Nurses as gangbusters: a response to gang violence in America. Pediatr Nurs 1993;19(6):559-67.

8. Sullivan LW: Forum on youth violence in minority communities. The prevention of violence - a top HHS priority. Public Health Rep 1991;106(3):268-9.

9. American Association of Colleges of Nursing. Violence as a public health problem. (Web site]. 2002. http://www.aacn.nche.edu/Publications/positions/violence.htm.

10. Shepherd J. Violence as a public health problem. Combined approach is needed. BMJ 2003;326(7380):104.

11. Larkin GL, et al. Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors. Ann Emerg Med 1999;33(6):669-75.

12. Sinnee H. Slipping through the cracks. On The edge 2003;9(4):10-3.

13, Litrel K, U.S. Department of justice. Sexual Assault Nurse Examiner (SANE) programs. Improving the Community Response to Sexual Assault Victims. [Web site]. 2001, http://www.ojp.usdoj.gov/ovc/publications/bulletins/sane_4_2001/welcome.html.

14. International Association of Forensic Nurses. SANE-A certification exam, On the edge 2003;9(1):13-4.

15. Council report of the IAFN. On the edge 2003;9(4):24.

16. U.S. Department of Justice. Advancing justice through DNA technology. [Web site]. 2003. http://www.usdoj.gov/ag/dnapolicybook_cov.htm.

17. Ciancone AC, et al. Sexual Assault Nurse Examiner programs in the United States. Ann Emerg Med 2000;35(4):353-7.

18. Centers for Disease Control and Prevention. Death Investigation Summaries. [Web site]. 2003. http://www.cdc.gov/epo/dphsi/mecisp/summaries.htm.

19, Pyrek K. Nurse Coroners Slowly Gain Ground. [Web site]. http://www.forensicnursemag.com/articles/311feat2.html.

20. O'Brien C. Death: another point on the continuum of care. [Web site]. 2003. http://www.forensicnursemag.com/articles/311perspect.html.

21. American Nurses Association. Scope and standards of forensic nursing practice. Washington, DC: American Nurses Publishing; 1997.

22, Burgess AW, Frederich A. Sexual violence and trauma. Policy implications for nursing. Nursing and Health Policy Review, 2002;1(1):17-36.

23. Woods P. How nurses make assessments of patient dangerousness. Mental Health Nursing 1996;16:20-2.

24. Woods P. Twenty years of admission to special hospitals. Psychiatric Care 1997;4(1):22-5.

25. Almvik R. Woods P. Predicting inpatient violence using the Broset Violence Checklist (BVC). lnt J Psychiatr Nurs Res 1999;4(3):498-505.

26. Bowers L, et al. Factors underlying and maintaining nurses' attitudes to patients with severe personality disorder. [Web site]. 2000. http://www.city.ac.uk/barts/research/reports/pdf/bowers_1/sdp.pdf.

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