FORENSICSInNursingCurrent Trends in Forensic Science

Cherry, B. & Jacobs, S. (2008). Contemporary nursing: Issues, trends, and management. (4th ed.) St. Louis: Mosby.Martin, N. (2009). Forensic nursing: What, who, where. The Kansas Nurse, 84(3), 3-5.Pyrek, K. (2009). Forensic nursing pioneers ponder the future. Retrieved from http://www.forensicnursemag.com/articles/3b1cover.html (2009). Forensic nurse: Job outlook for forensic nursing. Retrieved from http://education-portal.com/articles/Forensic_Nurse:_Job_Outlook_for_Forensic_Nursing.html (2009). Forensic nursing. Retrieved from http://www.mynursingdegree.com/forensic-nursing-certificate-online/ (2009). The forensic nurse. Retrieved from http://www.theforensicnurse.com/ References

Nursing science applied to the lawInvestigation/treatment of:ViolenceAbuseCriminal activityTraumatic accidentsWhat is Forensic Nursing?

A nurse (RN) with specialized training in:Forensic evidence collectionCriminal proceduresLegal testimony expertiseSpecialty Roles:Clinical forensic nurse (CFN)Sexual assault nurse examiner (SANE)Legal nurse consultantForensic psychiatric nurseForensic correctional nurseForensic gerontology nurseNurse attorneyDeath investigator/Forensic nurse investigator Forensic nurse educatorThe Forensic Nurse

1992-1st national convention of sexual assault nursesInternational Association of Forensic Nurses (IAFN)1996-American Association of Nurses

History

New specialty area of interestEducation continuing to evolveColleges and universitiesHealthcare facilities, correctional facilities, county prosecutors, coroners offices, medical examiners offices, insurance companies, psychiatric facilitiesDisaster and emergency managementCurrent Status of Forensic Nursing

AdvantagesDisadvantagesImportant resourceChallenging and excitingDifferent specialty areasMake a differenceDemanding hrs Challenging Emotional cases

Forensic nursing will continue to advance and evolveNew roles and opportunities (increase in the next ten years)Increasing crime ratesFuture Trends

Forensics: Pertaining to the LawForensic Nursing: Application of Nursing to the Law

What is Forensic Nursing?The application of forensic science, combined with clinical nursing practice as they are applied to public or legal proceedings in the law enforcement arena. It is the application of forensic aspects of health care combined with biopsychosocial education of the registered nurse in the scientific investigation and treatment of trauma, death, violent or criminal activity, and traumatic accidents within the clinical or community institution (Lynch, 1991).

Forensic NursesTrauma/ERSANENurse Coroners/Forensic Nurse Death InvestigatorsNurse Attorneys/Legal Nurse Consultants Psychiatric & Mental HealthCorrectional HealthDomestic Violence

1. ER/Trauma

ER/TraumaWhy are they neededIdentificationCare for the SurvivorCare for the Perpetrator Identification & Collection of evidenceClothesInjury and patterns of injury

ER/TraumaDocumentationWhat we do v. the crime committedChain of custodyMeasurements in centimetersLocationDescriptionPhotography

2. SANE

SANEA registered nurse who has been specially trained to provide comprehensive care to sexual assault patients, who demonstrates competency in conducting a forensic exam and the ability to be an expert witness.

Benefits of a SANE TEAMWillingnessSpecialty trainingComprehensive careFact based documentation (drop all opinions)Forensic issueevidence collectionchain of custodycourtroom testimony

SART-Sexual Assault Response TeamLaw EnforcementRape CrisisMedical ResponseSANE/RNPhysicianANPCrime LabCounseling ServicesForensic ScientistProsecution

Together Everyone Accomplishes MoreDont tell other members of the TEAM how to do their jobs.Together we can make offenders want to relocate.

SART (sexual assault response team)Provide victim centered servicesProvide compassionate careProvide community awarenessWhere to comeHow we will treat you

Encourage reporting of Sexual AssaultsAid in the identifying of false reporting

Sexual AssaultEvery 45 seconds a women is Sexual Assaulted.1:5 Women1:10-20 MenScreen ALL Trauma Patients (LOC, clothing)

Sexual Assault ExamSexual Assault is rarely suspectedHistory from Patient (to diagnosis & treat)Head-to-toe Assessment Detailed Genital ExamCollection of forensic evidenceTreatment for injuries, STDs & pregnancy

Drug based sexual assaults1/3 offenders convicted-alcohol40% of 2,366 survivors urine-alcoholMultiple drugs: Ethanol, Benzos (valium, xanax, restoril, klonopin, rohypnol) Barbiturates, GHB, Ketamine, Chloral Hydrate, Muscle Relaxants, Opiates, Sedative AntidepressantsChallenges:Drugs usesReportingCollection of evidenceLab methodologiesDosages

3. Nurse Coroners/Forensic Nurse Death Investigators

Nurse Coroner/Death InvestigationThe coroner is a public official who is primarily charged with the duty of determining how and why people under the coroners jurisdiction die (these jurisdictions vary form state to state, but typically include sudden, unexpected, unexplained, or traumatic death).

Nurse Coroner/Death InvestigationA licensed nurse who carries out the duties of a death investigator in accordance with the performance standards and procedures established under the medical examiner or coroners system of death investigating and the jurisdictional standards of practice.

Nurse Coroner/Death InvestigationNurses have the educational background to understand exactly what causes death and what happens to a body after death occurs. Death may be a criminal event, but it is always a medical event. Unlike law enforcement who look at the deceased and want to know, Who killed you? nurses look at a dead body and ask, Why are you dead? If it is determined that the death was due to criminal cause then it is law enforcements job to determine who. Who better to determine the manner of death than medical personnel?

Nurse Coroner/Death InvestigationManner of death is the circumstances in which the cause of death arose, i.e. natural, accident, homicide, suicide, and undetermined. In some cases manner of death may be difficult to determine and may appear accidental (i.e. in a suicide without a note). Forensic nurses possess the skills necessary to complete a psychological autopsy and interpret the subtle nuances of medications, health history and circumstances surrounding suspicious deaths.

Nurse Coroner/Death InvestigationMechanism of death is the physiologic derangement or biochemical disturbance incompatible with life, which is initiated by the cause of death, e.g. cardiac arrest. Forensic nurses are well educated in physiology and are therefore prepared to accurately distinguish between the cause and the physiologic mechanism of death.

4. Nurse Attorneys/Legal Nurse Consultants

GoalsTo establish a leadership role in health care policy making.To influence health care social policy, health care legislation and nursing practice acts.To educate the public about health law issues.To educate the public about nurse attorneys.To educate nurses about the legal system.To represent the public; client advocate.

Nurse Attorneys/Legal Nurse ConsultantsNurses want to make fundamental change in the way healthcare is delivered, and recognizing that it needs to occur through legislation and political process is a big piece of it.Like nurses, attorneys must interact with people who are vulnerable, who have been injured or traumatized, and who need assistance to regain their wholeness.Client advocacy is the skill nurses bring to the profession.

5. Psychiatric and Mental Health

Issues and GoalsThe enhancement of appropriate care for the severe and persistently mentally ill.The integration of psychiatric and addictions treatment.Strategies for promotion of mental health and prevention of psychiatric disorders.The provision of appropriate care within the criminal justice system.The equitable provision of care for children and adolescents.

Issues and GoalsEnsuring access to care for older adults and members of minority groups.Advocacy for access to psychiatric-mental health services as readily as access to medical services.The development of an evidence-based approach to teaching nursing students about psychiatric-mental health nursing, at both the undergraduate and the graduate levels of education.

6. Correctional Health

Correctional Health NursesCorrectional healthcare is a unique specialty area.Goals:Facilitate an improved working relationship between the private sector and the correctional staff in jails, adult and juvenile detention centers, prisons to meet the needs of the inmate patient.Promote correctional healthcare as part of the public health continuum.

7. Domestic Violence

Intimate Partner Violenceis an Epidemic

The Surgeon General of the United States recently declared:Domestic Violence is the number one health issue facing the country today

Domestic Violence DV is the leading cause of injury to women in the world.DV is the leading nonobstetric cause of death to pregnant women.Every 9 seconds a women is battered.1:3 women are a victim of domestic violence

Cycle of Violence

Evas Top 5 Domestic Violence Myths/FactsMYTHSPoor/unemployedThe victim spends a lot of time running to the doctorHe would never hurt the childrenHe only does this when he drinks

He wouldnt kill her

FACTS

3-10 Million Children Witness DV Violence in Their Homes Each Year

63% of Young Men Ages 11 to 20 Who Are Serving Time for Homicide Have Killed Their Mothers Abusers

The Leading Cause of Injury to 14 Year Old Boys

More Facts.. DV kills as many women every 5 years as the total number of Americans killed in the Vietnam War54,000Approximately 50% of all homeless women and children in the U.S. are fleeing DV.There are 7 animal shelters for every 1 DV shelter.

DV & Healthcare Costs 3-5 billion dollars in health care claims100 million dollars in absenteeism, high turnover and lost productivityEmployees miss 1,175,000 days of work per year because of DV aloneDV in the US costs an estimated $67 billion/year13,000 acts of DV against women occur in the workplace every yearUp to 52% of victims of DV have lost their jobs because batterers typically engage in behavior that makes it difficult to work

Types of AbusePhysicalHitting, kicking, strangulation, weaponsEmotional/psychological Threats, destruction of self worth, isolationFinancialWork, advancement, access to finances, credit,

Lack of identifying victims of Domestic Violence is consistent in community hospitals and trauma centers.

8. The Role of the Forensic Nurse in the Medico-legal Death Investigation

Death Investigation Systems in the United States

Three TypesMedical ExaminerCoronerMixedDiMaio, (2001), p. 9-18

Medical Examiner vs. CoronerMedical Examiner A licensed physician in the state in which she/he practices forensic pathology and has been hired by the jurisdiction to investigate sudden and unexpected deaths

Coroner An elected official in the jurisdiction who investigates sudden and unexpected deaths. May or may not be a physician

DiMaio, (2001), p. 9-18

What is Forensic Nursing?

Forensic NursingApplication of the nursing process to public or legal proceedingsApplication of the forensic aspects of health care to the scientific investigation of trauma and/or death related to medicolegal issuesLynch, (1993)

Roles within Forensic NursingClinical Forensic NurseSexual Assault Nurse Examiner (SANE)Pediatric Forensic NurseForensic Psychiatric NurseNurse Death Investigator/CoronerCorrectional NurseLegal Nurse ConsultantNurse AttorneyLynch, (1993)

The Forensic Nurse Death Investigator

What is a Forensic Nurse Death Investigator?A Registered Nurse who: applies the nursing process to death investigation across the life spancollaborates with interdisciplinary agencies identifies trends conducts and/or participates in research promotes health and safety through community education.IAFN, FNDI Standards of Practice, 2004, (draft)

What can a nurse add to the death investigation?Apply nursing knowledge which includes anatomy, physiology, pharmacology and family interactionQuestions are formulated based on a medical knowledge baseAid families and survivors in terms of the grieving processVessier-Batchen, (2003)

Role of the Forensic Nurse Death Investigator at the Harris County Medical Examiners Office

Role in the ME OfficeObtain death reports per state codeAugment the natural death and infant/child death investigationConduct post mortem sexual assault/child abuse examinationsProvide case management for pathologistsCollaborate with organ/tissue procurement agenciesHarris County Medical Examiners Office, (2004)

Role in the ME OfficeProvide link between pathologists and lay investigative staffCommunicate COD and MOD with familiesEducate the community regarding death investigation and forensic issuesAssist with external examinationsHarris County Medical Examiners Office, (2004)

Augmenting the Natural Death InvestigationNormally, only uniformed officers attend the natural death sceneOther types of death may present as a natural deathConduct a more thorough investigationUnderstand subtle signs of abuse and neglect

Case ManagementCollaborate with pathologist to determine the appropriate medical recordsReview medical records once receivedObtain follow-up information Organize interagency meetings as necessary

External ExaminationsThorough physical examinationReview of medical recordsDescription via diagrams and dictationDocument pathological findings

Evolution of the Forensic Nursing Program at the Harris County Medical Examiners Office

Prior to Forensic NursingIn 2002, 80% of deaths that were reported were natural deathsInvestigators had limited medical knowledge80% of cases brought in to HCME were autopsiedRequests/receipt of medical records were inconsistent

Prior to Forensic NursingIncomplete records were received and multiple requests had to be madeMedication lists often did not correlate with the medical historyFew inquiries into circumstances that lead up to the deathInformation between pathologists and investigators was fragmented at times

Forensic Nursing Integrated in Harris County, TexasAfter extensive lobbying by Dr. Joye Carter, the Harris County Commissioners Court approved 1 Forensic Nurse positionJob description:Adjunct to pathologists and investigative staffOversee medical record aspect of the medicolegal examinationMember of Child Fatality Review Team

Community FocusImprove the natural and infant/child death investigations with better history gathering and assessmentsContact family members in order to provide information on cause and manner of deathDiscuss medical and familial implications of cause of death, if applicableProvide education regarding the medicolegal death investigation

Role Begins to ExpandThree positions approved by Commissioners Court at the end of 2002Expand coverage of nursing services to evening and night shiftAssist with review of organ/tissue procurement recovery requests with the pathologistAssist with natural death and infant/child death scene investigation

Expanding RoleProvide case management for infant/child deathsRespond to scenes and take reportsConduct the forensic gynecological examination and evidence collectionCommunity education

Increasing Nursing StaffBy end of 2003, identified that additional positions were necessaryConducted survey of selected medical examiner/ coroner offices throughout the United States regarding use of nurses in this settingProposal developed to justify additional positions

New Positions Are GrantedIn September 2003, Commissioners Court authorized nine (9) new nursing positions!Once all positions are filled, there will be twelve (12) nurses!

ReferencesCenters for Disease Control. (2004). Medical Examiner and Coroner Jurisdictions in the United States. Found at: http://www.cdc.gov.DiMaio, V.M. (2001). Forensic Pathology. (2nd ed). Boca Raton: CRC Press. Harris County Medical Examiners Office. (2004). Forensic nurse/ Physician assistant investigator II. Job description. Found at www.co.harris.tx.us.

ReferencesInternational Association of Forensic Nurses. (2004). Forensic Nurse Death Investigator Standards of Practice. Draft copy.Lynch, V. (1993). Forensic nursing: Diversity in education and practice. Journal of Psychosocial Nursing, 31(11), p. 7-14.Vessier-Batchen, M. (2003). Forensic nurse death investigators. The Web Mystery Magazine. Found at: www.lifeloom.com.

Justice will only be achieved when those who are not injured are just as indignant as those who are.King Solomon

Thank you !

Forensic nursing applies science to the law. It includes the investigation and treatment of: (read slide). *A forensic nurse is a registered nurse with specialized training in (read slide). There are many different career specialties to choose from. I will talk about a couple of them. The sexual assault nurse examiner (or SANE) responds to reported cases of sexual assault. The SANE will obtain history, conduct an interview and physical exam, and will also perform a pelvic exam for collection of evidence. The SANE also educated the victim on sexually transmitted diseases and pregnancy risks. The victim will be provided with referrals for follow-up care. The majority of forensic nursing takes place with sexual assault victims. A death investigator or forensic nurse investigator is the first person at the crime scene with a forensic background. This person really has to know forensics to make an accurate call on time of death. Forensic nurse investigators work with detectives, collect evidence, examine the body, collect tissue and blood samples, and photograph the body and crime scene. Some people may think that forensic nurses have to work with dead bodies, but they dont. It is just one of the options available for forensic nurses. *The first national convention of sexual assault nurses took place in 1992 in Minnesota. Seventy nurses attended this convention. Shortly after the convention the International Association of Forensic Nurses was developed. It wasnt until 1996 that the American Association of Nurses recognized forensic nurses. *Forensic nursing is one of the fastest growing specialty areas. This is most likely because violence is increasing and resulting in more traumatic cases. Colleges and universities recently added programs. Forensic nurses practice in a variety of different areas including (read slide). They have expanded their role to include disaster and emergency management. Disaster preparedness includes forensic issues such as sexual assault, mass fatality, disposal of human remains, and critical incident stress.*Forensic nurses are an important resource to health care and justice systems. The job is challenging which could be an advantage or disadvantage. A couple of disadvantages are demanding hours and emotional cases. One advantage that might outweigh the disadvantages is that forensic nurses make a difference in the lives of victims of sexual assault. *As crime rates continue to increase, forensic nursing will continue to advance. Their will be new roles and opportunities for nurses in forensics. Opportunities are expected to increase quickly in the next ten years. Police forces want to strengthen their cases against criminals and forensic nurses are able to collect evidence and testify in court.*