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Title: FORENSICS In Nursing


1
FORENSICSInNursing
  • Current Trends in Forensic Science

2
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/

3
What is Forensic Nursing?
  • Nursing science applied to the law
  • Investigation/treatment of
  • Violence
  • Abuse
  • Criminal activity
  • Traumatic accidents

4
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

5
History
  • 1992-1st national convention of sexual assault
    nurses
  • International Association of Forensic Nurses
    (IAFN)
  • 1996-American Association of Nurses

6
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

7
  • Advantages
  • Disadvantages
  • Important resource
  • Challenging and exciting
  • Different specialty areas
  • Make a difference
  • Demanding hrs
  • Challenging
  • Emotional cases

8
Future Trends
  • Forensic nursing will continue to advance and
    evolve
  • New roles and opportunities (increase in the next
    ten years)
  • Increasing crime rates

9
Forensics Pertaining to the Law
  • Forensic Nursing Application of Nursing to the
    Law

10
Forensics is not about Dead People IT's about
the LAW
11
Living Victims Deserve A Forensic Specialist
12
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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).

14
Forensic Nurses
  • Trauma/ER
  • SANE
  • Nurse Coroners/Forensic Nurse Death Investigators
  • Nurse Attorneys/Legal Nurse Consultants
  • Psychiatric Mental Health
  • Correctional Health
  • Domestic Violence

15
1. ER/Trauma
16
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

17
ER/Trauma
  • Documentation
  • What we do v. the crime committed
  • Chain of custody
  • Measurements in centimeters
  • Location
  • Description
  • Photography

18
2. SANE
19
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.

20
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

21
SART-Sexual Assault Response Team
  • Law Enforcement
  • Rape Crisis
  • Medical Response
  • SANE/RN
  • Physician
  • ANP
  • Crime Lab
  • Counseling Services
  • Forensic Scientist
  • Prosecution

22
Together Everyone Accomplishes More
  • Dont tell other members of the TEAM how to do
    their jobs.
  • Together we can make offenders want to relocate.

23
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

24
Sexual Assault
  • Every 45 seconds a women is Sexual Assaulted.
  • 15 Women
  • 110-20 Men
  • Screen ALL Trauma Patients (LOC, clothing)

25
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

29
1 hour 80 Women
30
3. Nurse Coroners/Forensic Nurse Death
Investigators
31
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).

32
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.

33
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?

34
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.

35
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.

36
4. Nurse Attorneys/Legal Nurse Consultants

37
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.

38
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.

39
5. Psychiatric and Mental Health
40
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.

41
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.

42
6. Correctional Health
43
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.

44
7. Domestic Violence
45
Intimate Partner Violenceis an Epidemic
46
The Surgeon General of the United States recently
declared
  • Domestic Violence is the number one health issue
    facing the country today

47
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

48
Cycle of Violence
Intensity Frequency Severity
Physicial Assault
Abuse Severity
Emotional Abuse
49
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

50
3-10 Million Children Witness DV Violence in
Their Homes Each Year
51
63 of Young Men Ages 11 to 20 Who Are Serving
Time for Homicide Have Killed Their Mothers
Abusers
52
The Leading Cause of Injury to 14 Year Old Boys
53
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.

54
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

55
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.
61
1 hour 400 women
62
8. The Role of the Forensic Nurse in the
Medico-legal Death Investigation
63
Death Investigation Systems in the United States
64
Three Types
  • Medical Examiner
  • Coroner
  • Mixed

DiMaio, (2001), p. 9-18
65
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
66
What is Forensic Nursing?
67
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)
68
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)
69
The Forensic Nurse Death Investigator
70
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)
71
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)
72
Role of the Forensic Nurse Death Investigator at
the Harris County Medical Examiners Office
73
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)
74
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)
75
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

76
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

77
External Examinations
  • Thorough physical examination
  • Review of medical records
  • Description via diagrams and dictation
  • Document pathological findings

78
Evolution of the Forensic Nursing Program at the
Harris County Medical Examiners Office
79
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

80
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

81
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

82
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

83
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

84
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

85
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

86
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!

87
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.

88
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.

89
Justice will only be achieved when those who are
not injured are just as indignant as those who
are.
  • King Solomon

90
Thank you !
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