Forensic Nurse Examiner Training in NSW

Lessons Learnt - Dr. Maria Nittis -

maria.nittis@health.nsw.gov.au

SANE OR INSANE

BACKGROUND FOR THE SANE PROJECT

• Labor’s Public Safety Plan: Stage 5 for DV and SA announced

changes to enable nurses to perform forensic examinations

and appear as expert witnesses. (?2003)

BACKGROUND FOR THE SANE PROJECT

BACKGROUND FOR THE SANE PROJECT

• Background work for the project was undertaken by MoH

– based on a report produced by Churchill Fellow and

scholarship recipient - Jo Spangaro – 2004

REGIONAL HEALTH DISTRICTS

REGIONAL EXAMINATION SITES

BACKGROUND FOR THE SANE PROJECT

• Background work for the project was undertaken by MoH

– based on a report produced by Churchill Fellow and

scholarship recipient - Jo Spangaro – 2004

BACKGROUND FOR THE SANE PROJECT

• The Health Minister’s Office asked Primary Health and

Community Partnerships Branch to develop a funding

proposal for SANE in 2003. Department of Health provided

costings for 20 new positions across the state: $1.9

million

• Deputy Director-General operations committed seed

funding $200,000 in January 2003.

DoH ADVERTISEMENT FOR SANE

• See those aged 14 and above.

• Assess injury

• Objectively document health history and history of the

crime

• Collect forensic data

• Prevent psychological and physical health risks

• Facilitate client control over assault issues

• Facilitate healthy reorganisation and readaptation

following sexual assault.

Written by

policy

maker or

counsellor

or clinician

ESSENTIAL SELECTION CRITERIA - 2003

• 5 yrs or more experience clinical nursing

• Willingness to attend one week training in Sydney and if

necessary, an additional week placement

• Ability to be flexible and be placed on 24 hr on-call roster

DESIRABLE SELECTION CRITERIA

• Extensive experience in conducting pelvic examinations

on women

• Training in Midwifery, Sexual Health, Family Planning or

Women’s Health

• Experience of taking, handling and documenting

pathology samples

• An interest in working in the area of sexual assault.

TRAINING

• August 2005, 27 nurses commenced their SANE training

• One week of face to face training conducted by VIFM in

Sydney

• Requirement to observe 5 sexual assault examinations

and perform 5 supervised sexual assault examinations.

OUTCOME

26%

DAL (FASS) Results – Since Dec. 2010

Area Health Service Result

Sydney West 1 58

Sydney West 2 Never practised as Forensic Nurse Examiner

Sydney West 3 Never practised as Forensic Nurse Examiner

Sydney West 4 Never practised as Forensic Nurse Examiner

Taree 5 16

Newcastle 6 2

Newcastle 7 4

Newcastle 8 1

ACT 9 1

Nowra / Wollongong 10 5

Nowra / Wollongong 11 Never practised as Forensic Nurse Examiner

Nowra 12 Never practised as Forensic Nurse Examiner

Nowra / Wollongong 13 Never practised as Forensic Nurse Examiner

Albury 14 SANE - resigned

Tamworth 15 Never practised as Forensic Nurse Examiner

Bathurst 16 SANE - resigned

Broken Hill 17 Never practised as Forensic Nurse Examiner

Armidale 18 Never practised as Forensic Nurse Examiner

Port Macquarie 19 Never practised as Forensic Nurse Examiner

Greater West 20 Never practised as Forensic Nurse Examiner

Greater West 21 SANE - resigned

Cowra 22 Never practised as Forensic Nurse Examiner

Hunter New England 23 Never practised as Forensic Nurse Examiner

Greater South 24 SANE - resigned

Greater South 25 Never practised as Forensic Nurse Examiner

Lithgow 26 Never practised as Forensic Nurse Examiner

Wagga 27 SANE - resigned

WHAT WAS MISSING FROM CHURCHILL REPORT

2008

FUNDAMENTAL FLAWS

1500 km

LESSONS LEARNT FROM SANE

NSW

FUNDAMENTAL FLAWS

No forensic medical infrastructure:

i. No support

ii. No mentoring

iii. No review of Examination records or Certificates

iv. No training or supervision

FUNDAMENTAL FLAWS

No positions created:

i. No guaranteed award

ii. Did not necessarily have Health Services support

iii. Extensive delays because working another job

FUNDAMENTAL FLAWS – ESSENTIAL CRITERIA

Incorrect Selection Criteria:

• 5 yrs or more experience clinical nursing

• Willingness to attend one week training in Sydney

• and if necessary, an additional week placement

• Ability to be flexible and be placed on 24 hr on-call roster

SANE certification

• If you are asked to witness 5 examinations and do 5 examinations

• In a Unit that sees 40 adult examination per year

• And 70% of those patients presented after hours

• A Trainee Forensic Nurse Examiner would have to be placed at a unit

for 10 months – full time (if no on-call work)

OR

• On call for 4.25 months 24/7 – if only done in the after hours period.

OR

• Working 3 months permanently and on-call 24/7

SANE certification

• There are 50 Sexual Assault Units in NSW

• There are an average of 800 kits submitted to the forensic laboratory

for analysis per year

• Ratio of 2: 1 – exams performed for results returned

• Assumption: Each unit, on average, has 32 patients per year

FUNDAMENTAL FLAWS – DESIRABLE CRITERIA

• Extensive experience in conducting pelvic

examinations on women

FUNDAMENTAL FLAWS – DESIRABLE CRITERIA

• Extensive experience in conducting pelvic

examinations on women

FUNDAMENTAL FLAWS – DESIRABLE CRITERIA

• Extensive experience in conducting pelvic

examinations on women

• Training in Midwifery, Sexual Health, Family

Planning or Women’s Health

or ED or GP or Drug Alcohol or Mental Health

FUNDAMENTAL FLAWS – DESIRABLE CRITERIA

• Extensive experience in conducting pelvic

examinations on women

• Training in Midwifery, Sexual Health, Family

Planning or Women’s Health or ED or GP or Drug

Alcohol or Mental Health

• Experience of taking, handling and documenting

pathology samples

Immunisation Certificate or Venepuncture

FUNDAMENTAL FLAWS – DESIRABLE CRITERIA

• Extensive experience in conducting pelvic

examinations on women

• Training in Midwifery, Sexual Health, Family

Planning or Women’s Health or ED or GP or Drug

Alcohol or Mental Health

• Experience of taking, handling and documenting

pathology samples Immunisation Certificate or

Venepuncture

• An interest in working in the area of sexual assault.

FUNDAMENTAL FLAWS – DESIRABLE CRITERIA

• Extensive experience in conducting pelvic examinations on

women

“I think that stuff is over-rated” Dr. Christine Bassindale Perth SARC

THE WSLHD EXPERIENCE

Forensic Nurse Training from 2008

• We have trained three nurses and two more are in training or about

to be trained since 2008

1. Worked at Unit

since 2008; FTE

0.8; 2nd busiest

examiner in the

state; ED and SH

background; Grad

Cert Forensic

Nursing / SANE

2. Worked at Unit since 2012; FTE

0.4; 30 yrs nursing experience; ED

and Research background; Worked

independently with haemodialysis

patients

3. Worked at Unit for 9

months; FTE 0.4; Defence

force background; 2 yrs in

HDU. ICU. CCU -

Resigned

4. Worked at Unit since

January; FTE 0.4;

Extensive ED background

Know what the Nurse will be Required to Do

• See victims of sexual assault aged 14 or more;

• Assist with paediatric sexual assault examinations;

• See victims of domestic violence aged 16 or more.

• Consents

• Gather forensic and medical history

• Documentation of injuries including photography

• Collection forensic evidence

• Prophylactic meds e.g. HIV PEP, MAP, Hep B

• Expert Certificates with opinions

• Expert witness at Court

Our Selection Criteria

• Registered Nurse with APHRA and postgraduate qualifications in

forensic nursing or willingness to obtain same

• High level interpersonal skills, both verbal and written and

demonstrated ability to work independently

• Must be a NSW accredited vaccinator or willingness to obtain same

• Computer competency (including Microsoft Word, Power Point and

Email) and reasonable typing speed)

Job is for a

forensic nurse

Presenting

Expert Opinions

in Oral and

Written forms

Hepatitis B

Our Selection Criteria

• Current driver’s license and willingness to use same for work

• Demonstrated clinical experience with assessing immediate health

care needs of patients and the ability to determine need for referral

if appropriate

• Demonstrated ability in effective time management

• Experience with female genital examinations including speculum or

willingness to learn.

34km between

both units

Our Interview

• Typing test where we observe speed and ability to correct spelling

and grammer.

Our Interview

• Typing test where we observe speed and ability to correct spelling

and grammar.

• Observe their fluency skills and confidence levels – someone who is

easily flustered in an interview is likely to be easily flustered in court

• We get them to fill out, on a weekly chart, which evenings and days

they are free and which evenings and days they have commitments

If successful

We paid for the Family Planning Course – learn about female genital examinations,

speculum examinations, STIs and Contraception - $2,300

• Replacing this with a tailor made course for nurses where they are taught

speculum examinations and practice on a paid volunteer: $130

• Looking at in house teaching at the hospital gynaecology clinics

If successful

We paid for a unit of study at Sydney University in Sexual Assault - $3132.37

• Impact of sexual assault on health and community

• Anatomy of men and women

• Basic forensic science including DNA and Toxicology

• History and Examination

• Follow Up

• Counselling

• Medico Legal Issues: consent, chain of evidence and court reports

In Australia other courses include Flinders University new online course (in

association with John Hopkins): Fundamentals of Forensic Health Care available for

health care practitioners including nurses and paramedics:$1100

• Covers topics such as Legal Overview, When injuries speak, Sexual Assault, Details,

Documentations and Decisions, Evidence Collection

If successful

We paid for the Expert Witness Training Course - $1000

• ACLM runs Basic Law Intensive – 2 days - $880 or $680 if member

• ACLM runs Expert Witness programme – 2 days - $1175 or $950

• Unisearch run course with Hugh Selby – 1 day - $650

TRAINING COST: $6,432.37

In House training

• Provide Reference Material for Everything

In House training

• Provide Reference Material for Everything

In House training

• Provide Reference Material for Everything

FNE Competencies

• Drew up a list of competencies

• Stops the learning process from appearing overwhelming

Where to look Web address

AAFP www.forensicphysicians.org

National Occupational Standards http://www.colinwrightassociates.co.uk/pr

ojects/national-occupational-standards-

nos

IAFN www.iafn.org

In House training

Decontamination

Procedure

Consent

History Decide what

samples to collect

Speculum

examinations

Collect Samples

Injury

Interpretation

Injury

Documentation

Photography STI prophylaxis

Toxicology

Collections

Pack Up

Generate Expert

Certificate

How to Provide an

Opinion

• We broke examinations up into sections and as they became competent they would

complete that part of the examination.

• Learn nothing from observations after the first case if you are a pure observer

In House training

• If you are asked to do 5 examinations or 5 Expert Certificates with the

feedback at the end

WHAT SKILLS DOES A FORENSIC

NURSE EXAMINER TRAINEE

REQUIRE AT YOUR UNIT

Way Forward - Skills

• Need solid clinical judgement and knowledge of when to refer

• Emotional toughness and confidence

• Need to be able to collect blood and provide immunisations

• They need to be able to type quickly and ability to learn to use new software

systems

• Ability to participate in after hours’ roster – flexibility and a car

• Need to be able to perform genital examinations including speculum

• Need to have good verbal and written communication skills

Way Forward - Training

• Post Graduate Training

• Skill Fill e.g. imaging, vaccinations, speculum examinations etc – need a list of skill

fill opportunities

• In house training where trainee is involved in the examination from an early point and

made responsible (Placement in busy unit for a 6 month term)

• Training of nurses does not end once they are working independently – need a way of doing

this e.g. review case notes, expert certificates and images (e.g. photos of injury etc.) /

provision of training and updates / “phone a friend”

• Every now and then, once training completed, assist a graduate trainee in an examination ( 2

examples).

The Forensic Nurse Examiner – God’s Gift

maria.nittis@health.nsw.gov.au

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