FORENSICS In Nursing

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FORENSICSInNursing

• Current Trends in Forensic Science

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References

• 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.co
  m/articles/Forensic_Nurse_Job_Outlook_for_Forensi
  c_Nursing.html
• (2009). Forensic nursing. Retrieved from
  http//www.mynursingdegree.com/forensic-nursing-ce
  rtificate-online/
• (2009). The forensic nurse. Retrieved from
  http//www.theforensicnurse.com/

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What is Forensic Nursing?

• Nursing science applied to the law
• Investigation/treatment of
• Violence
• Abuse
• Criminal activity
• Traumatic accidents

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The Forensic Nurse

• A nurse (RN) with specialized training in
• Forensic evidence collection
• Criminal procedures
• Legal testimony expertise
• Specialty Roles
• Clinical forensic nurse (CFN)
• Sexual assault nurse examiner (SANE)
• Legal nurse consultant
• Forensic psychiatric nurse
• Forensic correctional nurse
• Forensic gerontology nurse
• Nurse attorney
• Death investigator/Forensic nurse investigator
• Forensic nurse educator

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History

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

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Current Status of Forensic Nursing

• New specialty area of interest
• Education continuing to evolve
• Colleges and universities
• Healthcare facilities, correctional facilities,
  county prosecutors, coroners offices, medical
  examiners offices, insurance companies,
  psychiatric facilities
• Disaster and emergency management

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• Advantages

• Disadvantages

• Important resource
• Challenging and exciting
• Different specialty areas
• Make a difference

• Demanding hrs
• Challenging
• Emotional cases

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Future Trends

• Forensic nursing will continue to advance and
  evolve
• New roles and opportunities (increase in the next
  ten years)
• Increasing crime rates

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Forensics Pertaining to the Law

• Forensic Nursing Application of Nursing to the
  Law

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Forensics is not about Dead People IT's about
the LAW
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Living Victims Deserve A Forensic Specialist
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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).

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Forensic Nurses

• Trauma/ER
• SANE
• Nurse Coroners/Forensic Nurse Death Investigators
• Nurse Attorneys/Legal Nurse Consultants
• Psychiatric Mental Health
• Correctional Health
• Domestic Violence

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1. ER/Trauma
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ER/Trauma

• Why are they needed
• Identification
• Care for the Survivor
• Care for the Perpetrator
• Identification Collection of evidence
• Clothes
• Injury and patterns of injury

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ER/Trauma

• Documentation
• What we do v. the crime committed
• Chain of custody
• Measurements in centimeters
• Location
• Description
• Photography

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2. SANE
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SANE

• A 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.

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Benefits of a SANE TEAM

• Willingness
• Specialty training
• Comprehensive care
• Fact based documentation (drop all opinions)
• Forensic issue
• evidence collection
• chain of custody
• courtroom testimony

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SART-Sexual Assault Response Team

• Law Enforcement
• Rape Crisis
• Medical Response
• SANE/RN
• Physician
• ANP

• Crime Lab
• Counseling Services
• Forensic Scientist
• Prosecution

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Together Everyone Accomplishes More

• Dont tell other members of the TEAM how to do
  their jobs.
• Together we can make offenders want to relocate.

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SART (sexual assault response team)

• Provide victim centered services
• Provide compassionate care
• Provide community awareness
• Where to come
• How we will treat you

• Encourage reporting of Sexual Assaults
• Aid in the identifying of false reporting

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Sexual Assault

• Every 45 seconds a women is Sexual Assaulted.
• 15 Women
• 110-20 Men
• Screen ALL Trauma Patients (LOC, clothing)

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Sexual Assault Exam

• Sexual Assault is rarely suspected
• History from Patient (to diagnosis treat)
• Head-to-toe Assessment
• Detailed Genital Exam
• Collection of forensic evidence
• Treatment for injuries, STDs pregnancy

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Drug based sexual assaults

• 1/3 offenders convicted-alcohol
• 40 of 2,366 survivors urine-alcohol
• Multiple drugs Ethanol, Benzos (valium, xanax,
  restoril, klonopin, rohypnol) Barbiturates, GHB,
  Ketamine, Chloral Hydrate, Muscle Relaxants,
  Opiates, Sedative Antidepressants
• Challenges
• Drugs uses
• Reporting
• Collection of evidence
• Lab methodologies
• Dosages

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1 hour 80 Women
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3. Nurse Coroners/Forensic Nurse Death
Investigators
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Nurse Coroner/Death Investigation

• The 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).

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Nurse Coroner/Death Investigation

• A 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.

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Nurse Coroner/Death Investigation

• Nurses 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?

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Nurse Coroner/Death Investigation

• Manner 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.

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Nurse Coroner/Death Investigation

• Mechanism 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.

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4. Nurse Attorneys/Legal Nurse Consultants

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Goals

• To 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.

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Nurse Attorneys/Legal Nurse Consultants

• Nurses 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.

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5. Psychiatric and Mental Health
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Issues and Goals

• The 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.

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Issues and Goals

• Ensuring 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.

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6. Correctional Health
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Correctional Health Nurses

• Correctional 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.

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7. Domestic Violence
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Intimate Partner Violenceis an Epidemic
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The Surgeon General of the United States recently
declared

• Domestic Violence is the number one health issue
  facing the country today

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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.
• 13 women are a victim of domestic violence

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Cycle of Violence
Intensity Frequency Severity
Physicial Assault
Abuse Severity
Emotional Abuse
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Evas Top 5 Domestic Violence Myths/Facts

• MYTHS
• Poor/unemployed
• The victim spends a lot of time running to the
  doctor
• He would never hurt the children
• He only does this when he drinks
• He wouldnt kill her

• FACTS
• lt15 unemployed
• Only 2/3 will seek medical assistance
• There is an increased incidence of child abuse
• 67 report alcohol abuse only 1/5 drinking at the
  time of abuse
• 2 women die each week at the hands of their
  husbands/Texas

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3-10 Million Children Witness DV Violence in
Their Homes Each Year
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63 of Young Men Ages 11 to 20 Who Are Serving
Time for Homicide Have Killed Their Mothers
Abusers
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The Leading Cause of Injury to 14 Year Old Boys
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More Facts..

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

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DV Healthcare Costs

• 3-5 billion dollars in health care claims
• 100 million dollars in absenteeism, high turnover
  and lost productivity
• Employees miss 1,175,000 days of work per year
  because of DV alone
• DV in the US costs an estimated 67 billion/year
• 13,000 acts of DV against women occur in the
  workplace every year
• Up to 52 of victims of DV have lost their jobs
  because batterers typically engage in behavior
  that makes it difficult to work

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Types of Abuse

• Physical
• Hitting, kicking, strangulation, weapons
• Emotional/psychological
• Threats, destruction of self worth, isolation
• Financial
• Work, advancement, access to finances, credit,

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Lack of identifying victims of Domestic Violence
is consistent in community hospitals and trauma
centers.
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1 hour 400 women
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8. The Role of the Forensic Nurse in the
Medico-legal Death Investigation
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Death Investigation Systems in the United States
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Three Types

• Medical Examiner
• Coroner
• Mixed

DiMaio, (2001), p. 9-18
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Medical Examiner vs. Coroner

• Medical 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
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What is Forensic Nursing?
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Forensic Nursing

• Application of the nursing process to public or
  legal proceedings
• Application of the forensic aspects of health
  care to the scientific investigation of trauma
  and/or death related to medicolegal issues

Lynch, (1993)
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Roles within Forensic Nursing

• Clinical Forensic Nurse
• Sexual Assault Nurse Examiner (SANE)
• Pediatric Forensic Nurse
• Forensic Psychiatric Nurse

• Nurse Death Investigator/Coroner
• Correctional Nurse
• Legal Nurse Consultant
• Nurse Attorney

Lynch, (1993)
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The Forensic Nurse Death Investigator
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What is a Forensic Nurse Death Investigator?

• A Registered Nurse who
• applies the nursing process to death
  investigation across the life span
• collaborates 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)
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What can a nurse add to the death investigation?

• Apply nursing knowledge which includes anatomy,
  physiology, pharmacology and family interaction
• Questions are formulated based on a medical
  knowledge base
• Aid families and survivors in terms of the
  grieving process

Vessier-Batchen, (2003)
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Role of the Forensic Nurse Death Investigator at
the Harris County Medical Examiners Office
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Role in the ME Office

• Obtain death reports per state code
• Augment the natural death and infant/child death
  investigation
• Conduct post mortem sexual assault/child abuse
  examinations
• Provide case management for pathologists
• Collaborate with organ/tissue procurement agencies

Harris County Medical Examiners Office, (2004)
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Role in the ME Office

• Provide link between pathologists and lay
  investigative staff
• Communicate COD and MOD with families
• Educate the community regarding death
  investigation and forensic issues
• Assist with external examinations

Harris County Medical Examiners Office, (2004)
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Augmenting the Natural Death Investigation

• Normally, only uniformed officers attend the
  natural death scene
• Other types of death may present as a natural
  death
• Conduct a more thorough investigation
• Understand subtle signs of abuse and neglect

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Case Management

• Collaborate with pathologist to determine the
  appropriate medical records
• Review medical records once received
• Obtain follow-up information
• Organize interagency meetings as necessary

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External Examinations

• Thorough physical examination
• Review of medical records
• Description via diagrams and dictation
• Document pathological findings

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

• In 2002, 80 of deaths that were reported were
  natural deaths
• Investigators had limited medical knowledge
• 80 of cases brought in to HCME were autopsied
• Requests/receipt of medical records were
  inconsistent

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Prior to Forensic Nursing

• Incomplete records were received and multiple
  requests had to be made
• Medication lists often did not correlate with the
  medical history
• Few inquiries into circumstances that lead up to
  the death
• Information between pathologists and
  investigators was fragmented at times

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Forensic Nursing Integrated in Harris County,
Texas

• After extensive lobbying by Dr. Joye Carter, the
  Harris County Commissioners Court approved 1
  Forensic Nurse position
• Job description
• Adjunct to pathologists and investigative staff
• Oversee medical record aspect of the medicolegal
  examination
• Member of Child Fatality Review Team

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Community Focus

• Improve the natural and infant/child death
  investigations with better history gathering and
  assessments
• Contact family members in order to provide
  information on cause and manner of death
• Discuss medical and familial implications of
  cause of death, if applicable
• Provide education regarding the medicolegal death
  investigation

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Role Begins to Expand

• Three positions approved by Commissioners Court
  at the end of 2002
• Expand coverage of nursing services to evening
  and night shift
• Assist with review of organ/tissue procurement
  recovery requests with the pathologist
• Assist with natural death and infant/child death
  scene investigation

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Expanding Role

• Provide case management for infant/child deaths
• Respond to scenes and take reports
• Conduct the forensic gynecological examination
  and evidence collection
• Community education

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Increasing Nursing Staff

• By end of 2003, identified that additional
  positions were necessary
• Conducted survey of selected medical examiner/
  coroner offices throughout the United States
  regarding use of nurses in this setting
• Proposal developed to justify additional positions

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New Positions Are Granted

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

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References

• Centers 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.

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References

• International 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.

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

• King Solomon

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Thank you !