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FORENSICS
In
Nursing
“Current Trends in Forensic Science”
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://educationportal.com/articles/Forensic_Nurse:_Job_Outlook_for_Forensic_Nursing.htm
l
(2009). Forensic nursing. Retrieved from
http://www.mynursingdegree.com/forensic-nursing-certificate-online/
(2009). The forensic nurse. Retrieved from
http://www.theforensicnurse.com/
What is Forensic Nursing?
• Nursing science applied to the law
• Investigation/treatment of:
• Violence
• Abuse
• Criminal activity
• Traumatic accidents
The Forensic Nurse
 A nurse (RN) with specialized training in:
◦ Forensic evidence collection
◦ Criminal procedures
◦ Legal testimony expertise
 Specialty Roles:
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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
History
• 1992-1st national convention of sexual assault nurses
• International Association of Forensic Nurses (IAFN)
• 1996-American Association of Nurses
Current Status of Forensic Nursing
• New specialty area of interest
• Education continuing to evolve
• Colleges and universities
• Healthcare facilities, correctional facilities, county
prosecutors, coroner’s offices, medical examiner’s offices,
insurance companies, psychiatric facilities
• Disaster and emergency management
Advantages
Disadvantages
• Important resource
• Demanding hrs
• Challenging
• Emotional cases
• Challenging and exciting
• Different specialty areas
• Make a difference
Future Trends
• Forensic nursing will continue to advance and evolve
• New roles and opportunities (increase in the next ten years)
• Increasing crime rates
Forensics: Pertaining to the Law
Forensic 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 Nurses
1. Trauma/ER
2. SANE
3. Nurse Coroners/Forensic Nurse Death Investigators
4. Nurse Attorneys/Legal Nurse Consultants
5. Psychiatric & Mental Health
6. Correctional Health
7. Domestic Violence
1. ER/Trauma
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
ER/Trauma
• Documentation
• What we do v. the crime committed
• Chain of custody
• Measurements in centimeters
• Location
• Description
• Photography
2. SANE
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.
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
SART-Sexual Assault Response Team
• Law Enforcement
• Crime Lab
• Rape Crisis
• Counseling Services
• Medical Response
• Forensic Scientist
• SANE/RN
• Physician
• ANP
• Prosecution
Together Everyone
Accomplishes More
Don’t 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
services
• Encourage reporting of Sexual
Assaults
• Provide compassionate care
• Aid in the identifying of false
reporting
• Provide community awareness
• Where to come
• How we will treat you
Sexual Assault
• Every 45 seconds a women is Sexual Assaulted.
• 1:5 Women
• 1:10-20 Men
• Screen ALL Trauma Patients (LOC, clothing)
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, STD’s & pregnancy
Drug based sexual assaults
• 1/3 offenders convicted-alcohol
• 40% of 2,366 survivors urine-alcohol
• Multiple drugs: Ethanol, Benzo’s (valium, xanax,
restoril, klonopin, rohypnol) Barbiturates, GHB,
Ketamine, Chloral Hydrate, Muscle Relaxants,
Opiates, Sedative Antidepressants
• Challenges:
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Drugs uses
Reporting
Collection of evidence
Lab methodologies
Dosages
3. Nurse Coroners/
Forensic Nurse Death
Investigators
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
coroner’s jurisdiction die (these jurisdictions vary form state
to state, but typically include sudden, unexpected,
unexplained, or traumatic death).
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
coroner’s system of death investigating and the jurisdictional
standards of practice.
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 enforcement’s job to
determine who. Who better to determine the
manner of death than medical personnel?
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.
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.
4. Nurse Attorneys/
Legal Nurse
Consultants
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.
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.
5. Psychiatric and
Mental Health
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.
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.
6. Correctional
Health
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.
7. Domestic Violence
Intimate Partner Violence
is 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
Eva’s 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 wouldn’t kill her
• FACTS
• <15% 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
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 War…54,000
• 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.
DV & Healthcare Costs
• 3-5 billion dollars in health care claims
• 100 million dollars in absenteeism, high turnover and lost
productivity
• Employee’s 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
Types of Abuse
• Physical
• Hitting, kicking, strangulation, weapons
• Emotional/psychological
• Threats, destruction of self worth, isolation
• Financial
• Work, 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 Types
• Medical Examiner
• Coroner
• Mixed
DiMaio, (2001), p. 9-18
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
What is Forensic Nursing?
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)
Roles within Forensic Nursing
• Clinical Forensic Nurse
• Sexual Assault Nurse Examiner
(SANE)
• Nurse Death
Investigator/Coroner
• Correctional Nurse
• Pediatric Forensic Nurse
• Legal Nurse Consultant
• Forensic Psychiatric Nurse
• Nurse Attorney
Lynch, (1993)
The Forensic Nurse Death
Investigator
What is a Forensic Nurse Death
Investigator?
• A Registered Nurse who:
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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)
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)
Role of the Forensic Nurse Death
Investigator at the Harris County Medica
Examiner’s Office
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 Examiner’s Office, (2004)
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 Examiner’s Office, (2004)
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
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
External Examinations
• Thorough physical examination
• Review of medical records
• Description via diagrams and dictation
• Document pathological findings
Evolution of the Forensic Nursing Program at
the Harris County Medical Examiner’s Office
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
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
Forensic Nursing Integrated in Harris
County, Texas
• After extensive lobbying by Dr. Joye Carter, the
Harris County Commissioner’s 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
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
Role Begins to Expand
• Three positions approved by Commissioner’s 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
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
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
New Positions Are Granted
• In September 2003, Commissioner’s Court authorized nine
(9) new nursing positions!
• Once all positions are filled, there will be twelve (12) nurses!
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 Examiner’s Office. (2004).
Forensic nurse/ Physician assistant investigator II.
Job description. Found at www.co.harris.tx.us.
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.
“Justice will only be achieved when those who
are not injured are just as indignant as those
who are.”
King Solomon
Thank you !