FORENSIC NURSING

Forensic Nursing: Part 1. Evidence

Collection for Nurses
Laura A. Stokowski, RN, MS
http://www.medscape.org/viewprogram/8908

FORENSICS IN NURSING
Does your job ever include any of the following?

Screening a pregnant woman for domestic violence?

Trauma care for a hit-and-run victim in the emergency room?

Circulating in the operating room during a repair of a gunshot wound to the chest?

Caring for an elderly woman who fell at home?

If so, you are already using forensic nursing science in your practice. Forensics means
"pertaining to the law," and forensic nursing, "the application of nursing science to public or
legal proceedings."[1] Victims and perpetrators of abuse, neglect, and violence enter the
healthcare system not just via the emergency room but through many different doorways,
becoming patients of nurses in virtually all practice settings. The basic principles of
evidence collection, chain of custody, and documentation of forensic findings define the
forensic skills required by all nurses.

Why Nurses Need to Understand Forensics

Evidence can make or break a case in criminal proceedings. Identifying, collecting, and
safeguarding evidence are essential to buttress or refute any legal action that may follow
from a patient's injuries. The proper collection and preservation of evidence is the nurse's
legal, ethical, and professional responsibility.[2] Some practice settings have the luxury of
having a specialty certified nurse (such as a SANE, or sexual assault nurse examiner)
available 24 hours a day, 7 days a week to conduct comprehensive assessments and
forensic evidence collection, but this is not universal. In other facilities, evidence collection
responsibilities fall to the nurse caring for the patient. Without the proper education, these
responsibilities are perceived as a burden by front-line staff.
The Joint Commission has established 2 standards for the care of victims of abuse that
require nurses to identify abuse and neglect and assess patients within the context of the
requirements of the law to preserve evidentiary materials and support future legal actions.
Standards apply to victims of physical assault, rape, sexual molestation, domestic abuse,
child abuse or neglect, and elder abuse or neglect. [3] All nurses must also know how and
when to make appropriate referrals for the assessment or care of such victims.

But there is another, even more compelling reason for nurses to expand their knowledge of
forensic nursing science. The nurse, often the first healthcare professional to see the
patient, can have a profound effect on the injured person's experience with the regrettable
but necessary procedures to collect evidence when a crime might have occurred. Forensic
nurse Paul T. Clements, PhD, APRN, BC, DF-IAFN, eloquently explains, "When a person is
violated, someone has violated their trust. Nurses, the most trusted health professionals,
are the ones who are up close and personal with patients who are frightened, hurt, or
ashamed. The nurse who is knowledgeable about forensic procedures can establish and
maintain trust with the patient and collect important evidence that otherwise might be lost."

THE EVOLUTION OF
FORENSICS IN NURSING
Suzanne Brown, MSN, SANE-A, SANE-P, CFN, like many forensic nurses, started out as
an emergency department (ED) nurse, at a time when evidence collection was rarely a
methodical process. Years ago, a pair of trauma shears was often the ED nurse's most
valuable tool when a living accident or crime victim was brought in. Cutting clothes off,
using the bullet hole or stab wound as a starting point if necessary, was routine in trauma
care.[4] Paper evidence collection bags did not yet have a place in the trauma room. Prompt
cleaning of patients to remove blood and other substances often destroyed valuable
evidence.
Much has changed in the past 15 years. Advances in science and technology have
elevated the role of forensic evidence in the courts. [5] Nurses are increasingly working with
the police and other authorities to help identify and collect the evidence that will be used in
medicolegal cases.[2] Nurses in EDs and elsewhere must be familiar with victims' and
suspects' rights, referral agencies, and local, state, and federal laws pertaining to the
reporting of crimes and the collection of evidence.
The highest priority is life-saving intervention, which should not be delayed in order to
collect forensic evidence.[5]Nonetheless, when providing urgent care and treatment, the
nurse must be able to recognize, and not destroy or discard, what may be evidence of a
crime. The nurse does not determine whether a crime has occurred but collects all potential
evidence and maintains a chain of custody of that evidence. [6]

EVIDENCE COLLECTION
FOR NURSES
The situations that may require evidence collection by nurses are diverse and numerous.
"It is truly an epiphany," says Jamie Ferrell, BSN, RN, DABFN, CA/CP-SANE, SANE-A,
CMI-III, CFN, "when nurses realize that all practices of nursing have a forensic aspect."

Victims of violence may enter the healthcare system in primary care, community health
clinics, urgent care, or the emergency department. They might be identified in the pediatric
ICU, behavioral health, or even labor and delivery. Forensic evidence can come to light in
the operating room. Ferrell adds, "Every trauma patient should be considered a forensic
patient until proven otherwise."
Forensic evidence collection is a systematic process that follows state and federal
requirements.[5] Procedures for evidence collection should be readily available in each
setting for reference purposes. Most evidence collection kits contain instructions for using
the items contained within them. The following sections comprise a general overview of
forensic evidence collection for nurses who are not specially trained in this area; this
information is not intended to serve as a comprehensive evidence collection resource.

Consent
Written, informed consent from adults should be obtained prior to evidentiary examination.
[7]

This consent should inform the patient what evidence will be collected (including

photography, if planned) and who the recipient of the evidence will be (eg, law enforcement
agency). Consent forms should address confidentiality issues.

History
Initiating a diagnosis and treatment plan, along with considering what evidence to collect,
begins with taking a thorough history regarding how injuries were sustained and relevant
medical conditions. Knowing what happened (where on the body the victim was hit, the use
of restraints, etc.) will guide the examination and improve the accuracy of the evidence
retrieval.
Unless trained for special populations, the nurse is not performing a forensic interview;
rather, the nurse is documenting statements exactly as they are made, without bias,
alteration, or interpretation.[5] An open-ended question, such as "Tell me what happened to
you tonight?" elicits the most complete verbal history of the event. [8]

Photography
Photography is now common for documenting physical injuries during a medical/forensic
examination. Photography can be invaluable in reconstruction of events at a later time. It is
not, however, a substitute for written documentation. When possible, photographs should
be taken before wounds are treated.
Digital technology has facilitated the incorporation of photographs into computer-generated
reports. Photographs should be taken from different angles with a wide-angle lens. Closeups should be taken both with and without a scale (such as a ruler or scale tape) in the

picture to show size of the focal point (Figure 1).[2] In the examination of sexual assault
victims, a colposcope is commonly used to obtain photographic and video evidence.

Figure 1. Photographing a wound and scale with an X-am camera

Describing and Diagramming

A written description of assessment findings, including details about the patient's injuries,
must be made according to institutional policy. Precision is important; measure wounds in
centimeters and describe wound size, shape, appearance, and location using readily
recognized anatomic landmarks.[5] Sometimes, the results of abuse or neglect can be
subtle and not immediately recognized. On elderly patients, the examiner should note
burns, fractures, abrasions that might indicate restraints, decubiti, dehydration, hygiene
issues, and weight loss, any of which can be a forensic biomarker of abuse or neglect. [9]
Terminology to describe wounds is specific and accurate. For example, a laceration is not
the same thing as a cut.[5]A laceration is a tear of the skin or tissue that occurs when
external blunt force is applied. A laceration has marginal abrasion and tissue bridging,
whereas a cut severs the tissues cleanly and there is no bridging. [10] Ferrell cautions that
the color of bruises should not be depended upon to determine the age of a wound. When

bullet wounds are present, no attempt is made to differentiate between entrance and exit
wounds.
Body diagrams (body charts) are made to describe the exact anatomic location of a
person's injuries. Diagrams are visual supplements to written assessment findings.
[5]
[10]

Drawings are also important when a pattern or constellation of wounds is present.

Anatomic drawing templates are usually provided in evidence kits.

PHYSICAL EVIDENCE
COLLECTION
Any object (or part of an object) showing that a crime has occurred or establishing a link
between victim and perpetrator is physical evidence. Physical evidence can be tangible,
such as glass fragments in a sharp force injury; or transient, such as redness; or trace,
such as saliva.[11] A theory governing evidence was put forth by Dr. Edmond Locard, an
early 20th century French pathologist. In 1920 Locard wrote, "on the one hand, the criminal
leaves marks of his passage; on the other hand, by an inverse action, he takes with him,
on his body or on his clothing, evidence of his stay or his deed." [12] CalledLocard's principle
of exchange, it boils down to this: whenever there is contact between 2 objects, there is
mutual exchange of material between them. [11] Locard's theory is the basis for linking
victims, perpetrators, and crime scenes.
In clinical settings, the staff should be just as prepared to collect evidence as they are to
intubate a nonbreathing patient or start an emergency intravenous line. [11] Prepackaged
evidence collection kits containing the materials necessary to collect and preserve
evidence should be available.[11] Evidence collection kits for sexual assaults (sometimes
called rape kits) may be jurisdictional specific (Figure 2).

.Figure 2. A state-specific evidence kit

Physical evidence includes such items as clothing, footwear, hairs, fibers, stains, bullets,
sharp objects, physical injuries, and laboratory specimens. Gloves are worn during
handling of all physical evidence. Change gloves often during evidence collection. All
packages used to collect evidence are sealed and labeled with the date, time, patient's
name, description and source of the material (including anatomic location), name of the
healthcare provider, and names and initials of everyone who handled the material.
Collection procedures for some of the most common types of physical evidence follow.
[2,5,11]

Nurses should also consult their departmental policy and procedures manuals as

routine collection procedures vary in different hospitals and jurisdictions.

Clothing

Must be removed carefully because clothing can contain hair, fibers, or other trace
evidence. Ambulatory patients should remove one item of clothing at a time while
standing over a clean sheet (or paper) placed on the floor, covered with a second
clean sheet (or paper) to capture debris that may fall from the clothing or person.
Fold and package this top sheet (or paper) separately.

If clothing must be cut off, it is done without cutting through any tears, holes, or
other defects in the fabric.

Without shaking or excessive handling, bag each item upon removal. Each item is
placed in a separate paper bag to prevent cross-contamination. Plastic bags are not
used because moisture can collect within the bag and alter the evidence (Figure 3).

Do not remove attached hairs or fibers from clothing.

If clothing is wet, it is allowed to air dry before packaging.

Use protective paper to prevent stains from touching.

Include footwear in the collection of clothing.

.Figure 3. Bagging a victim's clothing

Hair, Fiber, Debris, and Solid Objects

Using forceps with plastic-coated tips, carefully remove hairs, fibers, or other debris
from the patient's body and place each item into paper envelopes. Surface debris that
is dry can be gently scraped onto a glass slide.

Place sharp objects (needles, blades, knives, glass fragments) in double peelpacks (heavy-gauge polyethylene pouch with tamper-evident adhesive closures) or in
plastic, glass, or cardboard containers.

Wrap bullets in gauze to preserve trace evidence and place in a peel-pack, cup, or
envelope. Do not touch bullets with metal instruments. Gunpowder residue can be
removed with tape that is then applied to a glass slide.

Preserve evidence on the victim's hands until collected by securing paper bags
over each hand.

Scrape or swab beneath fingernails or clip fingernails and package and label as
right or left hand (Figure 4). If envelopes are not available, fingernails, scrapings, and
the orange stick or swab used to collect them can be contained in the center of a
clean piece of paper which is then folded "druggist style" and sealed. (With evidence
in the center, fold paper in thirds. Turn 90 degrees and fold in thirds again. Tuck one
edge into the other to form a closed package).

Carefully comb the hair to remove evidence that may not be visible (Figure 5).

Figure 4. Scraping fingernails. A separate piece of paper is used to collect

scrapings or clippings from each hand.

Figure 5. Collecting a hair sample from the victim. Most states permit the use of
scissors rather than pulling hair for this purpose.

Body Fluids

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Use a high-intensity lamp to visualize stains or biological secretions (saliva, semen,

urine, blood, etc.).

Collect dried secretions or fluids with a slightly moistened sterile swab, and air dry

before packaging.

Swab bite marks (after photographing) for biological specimens.

In sexual assault cases, swab body orifices for biological specimens, collecting as
much as possible. If possible, biological samples are taken before further
contamination by drinking, eating, smoking, or voiding.
Collect laboratory specimens for toxicology screens and control, or reference,

samples to be used in DNA analysis (Figure 6).

Figure 6. Collecting evidence from a

victim.

CHAIN OF CUSTODY
Chain of custody is a legal process referring to the paper trail that assures the integrity and
security of the evidence. Chain of custody forms and labels document possession of the
evidence from the moment of collection until the moment it is introduced in court, where the
chain of custody will be closely scrutinized. If the chain of custody is broken, the evidence

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can be challenged in court and subject to allegations of mishandling or evidence

tampering.
The chain of custody begins as soon as the nurse locates or obtains physical evidence.
[11]

Whether or not the nurse has formal training in forensics, he or she must properly

establish and maintain the chain of custody for this evidence. [4] Clothing left piled in a
corner or recovered bullets sent to a pathology laboratory are common examples of
evidence for which the chain of custody might be questioned at a later time. [4] The more
people who handle a piece of evidence, the more likely it is that the chain of custody will be
compromised.
To properly initiate the chain of custody, labels are placed on each item of sealed evidence
indicating the patient's name, a description of the item, source of the material (including
anatomic location), the name of the person who sealed the evidence, the date and time it
was sealed, the names of those who release and receive the evidence, and the time it is
transferred. The chain of custody should be kept as short as possible. [5] Evidence chain of
custody forms are usually contained in evidence kits. When there are many items of
evidence for a single case, evidence disbursement forms can be used to document the
transfer of evidence.
Collected evidence must remain on the person of the nurse, in plain view, or in a secure
location to maintain the chain of custody. Evidence should never be left unattended or
handled by patients, parents, support persons, or caseworkers. Sealed and correctly
labeled evidence kits or bags may be stored in a secure location until they are transferred
to law enforcement officials (Figure 7). The best place to store evidence is in a locked drop
box and locked refrigerator, located in a limited access room that requires a key entry.
[4]

Wet evidence, such as wet clothing, cannot be placed in a drop box so it must be picked

up immediately by law enforcement officials.[4] The final transfer of evidence to law

enforcement is then documented in the patient's medical record.

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.Figure 7. Forensic nurse storing evidence box in a locked refrigerator

GOING TO COURT
The nurse who applies forensic principles by recognizing and preserving the evidence must
also be able to present him or herself at trial. Patients who have been victims of a violent
act deserve to have healthcare providers who are prepared and capable witnesses. One of
the purposes of their testimony is to authenticate evidence that was collected in the
healthcare setting and verify the chain of custody.[13]
Medicolegal testimony can be a stressful professional experience. [14] Juries are human and
are often quick to judge witnesses based on how they dress, how they speak, make eye
contact, and their perceived sincerity in the courtroom. [14] Cases can be decided on the
credibility of witnesses. Speaking directly to the jury in understandable language conveys
honesty to jurors. In addition, Cashman and Benak offer these tips to witnesses [14]:

Listen carefully to questions; answer only the questions that are asked.

Consider your response before speaking.

Avoid offering additional information unless clarification is needed.

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Preparation is extremely important and begins with a comprehensive assessment and

careful evidence collection because the evidence itself and how it was gathered and
preserved can be on trial.[15] Nurses work with their institutional risk management
departments and prosecuting attorneys to prepare for trial testimony. It is important for the
nurse witness and the prosecuting attorney to have the same understanding of the nurse's
role and responsibility, appreciation of the evidence, and what the jury needs to hear about
that evidence. Individual preparation involves reviewing the case record to avoid fumbling
for information during testimony.

New Careers
Nurses who are intrigued by the idea of forensic evidence collection might want to consider
a new role in this rapidly growing field. In Part 2 of this series, forensic nursing roles and
resources will be highlighted, allowing interested nurses to find out what forensic nursing
specialists are doing in a variety of settings.

Related Resource
International Association of Forensic Nurses

References
1. International Association of Forensic Nurses. About Forensic Nursing. Available at:
http://www.iafn.org/about/aboutWork.cfm. Accessed November 22, 2007.
2. Brown SL. Forensic nursing. In: Sheehy SB, Lenehan GP, eds. Manual of
Emergency Care, 5th edition. St. Louis, Mo: Mosby; 1999.
3. The Joint Commission. Standard PC.3.10. Comprehensive Accreditation Manual for
Hospitals. Joint Commission Resources; 2005.
4. Evans MM. Maintaining the chain of custody: evidence handling in forensic-cases.
AORN J. 2003;563-570.
5. Ferrell JJ. Forensic aspects of emergency nursing. In: Emergency Nurses
Association Emergency Nursing Core Curriculum, 6th edition. Philadelphia, Pa:
Saunders; 2007.
6. McCracken L. The forensic ABCs of trauma care. Can Nurse. 2001;97:30-33.
7. Emergency Nurses Association. Forensics: evidence collection and preservation.
Sheehy's Manual of Emergency Care. 6th edition. St. Louis, Mo: Mosby; 2005.
8. Emergency Nurses Association. Approach to the sexual assault patient. Sheehy's
Manual of Emergency Care. 6th edition. St. Louis, Mo: Mosby; 2005.
9. Pearsall C. Forensic biomarkers of elder abuse: what clinicians need to know. J
Forensic Nurs. 2005;1:182-186. Abstract

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10. McDonough ET. Death investigation. In: Hammer RM, Moynihan B, Pagliaro EM,
eds. Forensic Nursing. Sudbury, Mass: Jones & Bartlett; 2006.
11. Cabelus NB, Spangler K. Evidence collection and documentation. In: Hammer RM,
Moynihan B, Pagliaro EM, eds. Forensic Nursing. Sudbury, Mass: Jones & Bartlett;
2006.
12. Horswell J. The Practice of Crime Scene Investigation. London, UK: Taylor and
Francis; 2004.
13. Bentley Cewe BR. Overview of the American justice system. In: Hammer RM,
Moynihan B, Pagliaro EM, eds. Forensic Nursing. Sudbury, Mass: Jones & Bartlett;
2006.
14. Cashman DP, Benak LD. Preparing staff for testimony in sexual assault cases. J
Forensic Nurs. 2007;3:47-49.Abstract
15. Lynch VA. Forensic nursing science. In: Hammer RM, Moynihan B, Pagliaro EM,
eds. Forensic Nursing. Sudbury, Mass: Jones & Bartlett; 2006.

Forensic Nursing: Part 2. Inside Forensic

Nursing
Laura A. Stokowski, RN, MS

http://www.medscape.com/viewarticle/571555_1

Forensic nursing may well be the fastest growing nursing specialty in the
world, generating interest among both practicing and prospective nurses. [1] A
field with many subspecialties, forensic nursing has already spawned new
roles and careers for many nursing professionals with an interest in the law.
Educational opportunities in forensic nursing at many levels -- certificate,
Master's degree, doctoral, or nurse practitioner -- are also on the rise.
This good news for nurses is tempered by irony because the need for more
forensic nurses stems from an epidemic of global poverty, violence, and
crime.[2] The zone where healthcare needs intersect with the law is
expanding, and forensic nurses have stepped in to become leaders in the
healthcare response to violence.

The Blending of Nursing and Forensic Science

Long before holding the designation of forensic nurse, nurses provided care
to the victims and perpetrators of violence. History reveals that in the 14th

15

century, midwives performed gynecologic examinations for evidence of

pregnancy or virtue, and then testified before the King's court. [3] Fast forward
to 1984, when forensic nursing trailblazer Virginia Lynch conceived a
discipline based on forensic nursing science, to formally educate nurses to
provide the services they were already expected to provide. As the first
nurse (and first woman) death scene investigator in a rural Texas jurisdiction,
Lynch quickly realized that "every nurse I knew needed to be taught the
things I was learning." Like Lynch, most early forensic nurses had to forge
their own roles and educational experiences. In 1992, the newly
established International Association of Forensic Nurses brought forensic
nurses together under the leadership of founding President Virginia Lynch.

An early emphasis on the care and assessment of sexual assault victims

rapidly evolved to include almost every healthcare issue that had legal
implications. Forensic nurses do not replace other forensic professionals,
but instead bring a unique nursing perspective to the multidisciplinary
forensic team. Forensic nurses blend biomedical knowledge and critical
thinking skills with their understanding of the principles of law and human
behavior.[4] Forensic nurses recognize and meet physiological needs, while
acknowledging and addressing psychological trauma and the priority of legal
concerns.
Forensic nurses serve both the living and the dead -- those who are victims,
suspects, survivors, and those who are left behind. Their expertise combines
nursing science, forensic science, and criminal justice. Found in both
traditional and nontraditional roles and practice settings, forensic nurses
work in various locales including emergency departments, mental health
settings, correctional facilities, and coroners' offices. Forensic nurses may
collect evidence used by law enforcement or medical examiners, conduct
death investigations, or provide crisis intervention for the victims and families
of violence. Forensic nurses also know how to present themselves in court
and provide expert testimony as a fact witnesses or expert witnesses.

Forensic Nursing Roles

The term "forensic nurse" might not bring to mind bioterrorism, drug and
alcohol abuse, disasters, suicide, tissue and organ donation, medical error,
or arson. Yet these are among the health and medical issues that have legal
implications and, therefore, fall into the domain of the forensic nurse. As their

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skills are increasingly recognized, forensic nurses are rapidly branching out
into new legal arenas, such as risk management, employee litigation, and
human rights abuse.[5]
The following profiles of practicing forensic nurses are offered to illustrate
the tremendous potential of forensic nursing in an array of settings and
specialties. Resources and links to more information about these and other
forensic nursing roles, forensic nursing education, and forensic certification
opportunities can be found at the end of this article.

Forensic Nurse Examiner

Forensic nurse examiners (FNEs) are registered nurses who provide
comprehensive medicolegal care to forensic patients. The clinical FNE role
is a specialty unlike any seen before in nursing. [6] From infants to the elderly,
victims of all ages who have suffered physical or psychological abuse,
neglect, sexual assault, liability-related trauma, or other crime-associated
injuries may receive care from FNEs. The FNE may also be requested to
examine potential offenders and criminal suspects.
The special skills of the FNE include the ability to conduct and document a
thorough, unbiased, and objective clinical forensic history and assessment
(including digital imaging and laboratory specimens, as indicated), collect
and preserve evidence, and maintain the evidentiary chain of custody.
Patients of the FNE also receive crisis intervention, medical treatment,
education, and appropriate referrals for ongoing care.[7]

Sexual Assault Nurse Examiner

The medical care portal for many sexual assault victims is the hospital
emergency department.[7] Long waits, lack of privacy, unskilled examiners,
insensitivity, and improper collection or loss of evidence are factors in the
continued victimization, instead of the healing, of sexual assault survivors.
Turning to forensic nursing and the sexual assault nurse examiner (SANE)
role has dramatically improved this situation. Under the SANE model of
care, sexual assault victims consistently receive prompt, compassionate,
culturally sensitive and developmentally appropriate services from nurses
knowledgeable about victimization issues and expert in assessment and
evidence collection that will support future legal proceedings. The SANE
also attends to the assault victim's related medical needs, including

17

prevention of pregnancy and sexually transmitted disease, and the

evaluation and treatment of minor injuries.
The SANE is the only forensic nursing role to be validated through research
to any degree. Research shows that SANEs collect forensic evidence more
accurately than non-SANE trained nurses or physician colleagues. [8] Better
forensic evidence collection and documentation leads to more successful
sexual assault prosecution.[9] More consistent post-rape medical care is
provided with the SANE model than with the standard care model. [9]Perhaps
more important, however, is the SANE's unique contribution to the victim's
early psychological recovery, a result of the SANE's expertise in victimization
and trauma issues.[9]

Forensic Assessment and Consultation Team

Inova Fairfax Hospital in Falls Church, Virginia, is home to a 14-nurse sexual
assault and domestic violence response team known as the Forensic
Assessment and Consultation Team (FACT). Led by clinical manager
Suzanne Brown, MS, RN, an adult and pediatric SANE and certified forensic
nurse (CFN), FACT nurses are on call 24 hours a day to provide assessment
and care for patients in Fairfax County, Virginia. Sexual assault evidentiary
examinations of both victims and suspects are conducted at the request of
law enforcement or child protective service officials.
Exams are conducted in a completely private exam room designed to make
patients as comfortable as possible. The FACT exam room is outfitted with
all of the technology and tools needed for comprehensive examination,
evidence collection, and computer documentation, including the binocular
colposcope that illuminates, magnifies, and documents even the most
microscopic genital injuries during the forensic gynecologic exam.
Depressing a foot pedal sends digital images directly to the computer, where
they become part of the official report. An adjacent child-friendly waiting area
is well-used; a shocking 60% of FACT's sexual assault patients are under
the age of 16 years. For domestic violence patients, FACT's domestic
violence response nurses take portable equipment to other area hospitals or
to police departments to conduct examinations.
Brown's nurse examiners conduct more than 600 forensic exams yearly, and
a percentage of their time is also spent in court. To meet this demand,
Brown holds an in-house intensive training program in forensic nursing. She
finds that nurses from diverse clinical backgrounds can be successful FACT
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nurses. "We have nurses from women's health, obstetrics and gynecology,
mental health, and even endoscopy. They don't necessarily have to have an
ED background. With the right training, they develop a sophisticated
understanding of the importance of high-quality medicolegal evidence."
FACT is a regional program, serving adult and child clients from an area that
covers 20 jurisdictions. Regional programs are popular because they allow
the nurse examiners to see more clients and perform more examinations,
helping them to develop and maintain competence. It is also cost-effective,
particularly for rural and remote areas that do not see enough cases yearly
to maintain their own nurse examiner programs.

Nurse Death Investigator

It takes a certain type of nurse to be able to deal with death and dying all
day, every day. Stacey Mitchell, DNP, RN, Deputy Chief Forensic Nurse
Investigator in the Harris County, Texas Medical Examiner's Office has been
doing just that for nearly 6 years. "We see a lot of things that are sad and
disturbing, the worst of what people can do to other people," says Dr.
Mitchell.
Nurses who conduct medicolegal death investigation are known by different
titles, such as death investigator, forensic nurse investigator, deputy coroner,
or even coroner. Nurse death investigators (NDIs) have the authority to
confirm or pronounce death, establish decedent identification, and notify
next of kin.[6] Their skills enable them to perform the critical components of
death investigation -- ascertaining medical and social history of the
decedent, examining the body, and investigating the scene -- all with the
compassion characteristic of the nursing profession. The NDI's findings
assist the medical examiner or coroner to determine the cause and manner
of death.
Nurse death investigators from the Harris County Medical Examiner's Office
receive more than 15,000 death reports annually. On call 24 hours a day,
during 2007 the office's 9 nurses responded to the scenes of more than
2000 unnatural or unexpected deaths to determine what type of investigation
was indicated. At each scene, the nurse death investigator takes
photographs, examines the body, and interviews family members in order to
establish a preliminary manner of death.

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Nurse death investigators work closely with law enforcement, social

services, organ and tissue procurement agencies, and the community. A
large part of their work is educating families: explaining procedures and test
results and interpreting autopsy findings. "Television programs have given
some people unrealistic expectations about death investigation. DNA results
do not come back in an hour," notes Dr. Mitchell. Two of Mitchell's nurses
exclusively conduct follow-up, tying up loose ends and notifying waiting
families of final rulings.
It isn't hard to see why nurses are the ideal professionals for the role of death
investigator. Nurses combine superb assessment and teaching skills with
empathy, concern, and kindness and are accustomed to the hard work
required of the death investigator. Nurses can understand and interpret
complicated medical records and medical histories of the deceased.
Harris County's NDIs come from diverse nursing backgrounds, including
emergency nursing, intensive care, psychiatry, and neonatal intensive
care. Dr. Mitchell was an FNE for 9 years before being recruited by
Harris County to set up the forensic nursing program. Although she
earned a doctorate in forensic nursing from the University of Tennessee
Health Sciences Center, this level of education isn't required to become
an NDI. To build her staff, Dr. Mitchell looks for strong assessment skills
and a desire to work in a forensic field.

Forensic Psychiatric Nurse

Paul Clements, PhD, APRN, BC, interacts with children who have
experienced emotional trauma of the most unimaginable kind: witnessing the
murder of a parent or other family member. In the aftermath of homicide,
children are at significant risk to develop posttraumatic stress disorder.
[10]
Developmentally appropriate drawing tools and a simple, open-ended
request to draw what they know about the death of their family member is a
nonthreatening way to begin interactions with bereaved children. This
activity enhances the child's sensory memory (what the child saw, heard,
and felt) and establishes a helping relationship with reluctant or nonverbal
children.[11] The child's drawing and the accompanying narrative storytelling
provide a platform for deeper exploration of events, insight into the child's
experience of trauma and bereavement, and guidance for assessment and
intervention.[12]
"When one parent murders the other, the child suffers a double loss,"
explains Dr. Clements, an Assistant Professor at Old Dominion University
School of Nursing in Norfolk, Virginia. "Children are the invisible victims."
Because these children may also be important witnesses, Dr. Clements
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helps police officers learn how to talk to and question children who have
experienced a family homicide. Questions must be worded carefully to avoid
frightening the already traumatized child into thinking he or she is guilty or
responsible for the death. Dr. Clements also counsels the other family
members, who often do not appreciate the degree of trauma suffered by the
child, about their interactions with the bereaved child.
"What has become evident during interviews with these children is that the
things adults think are helpful and important are usually not what the
children think are important. Children often believe that they are the
equivalent of 'damaged goods,' that they are no longer normal like other
kids. Adults keeping silent or whispering about the murder to protect the
child only reinforces the stigma of guilt." Dr. Clements helps these children
not to forget the loved one or what happened, but to remember the
deceased and put what has happened into an adaptive perspective. He
helps the child find an anchor for safety to get through the acute phase of
trauma, and helps surviving adults in the child's life understand puzzling
delayed responses, such as regressive behavior.[13]
As a forensic psychiatric nurse, Dr. Clements works with both the offenders
and survivors of a wide array of violent offenses, including interpersonal
violence, sexual assault, child molestation, elder abuse, stalking, suicide,
homicide, arson, motor vehicle accidents, industrial and occupational
deaths, sudden infant death syndrome, and gang violence. Believing that
forensic nurses must also work to prevent violence, Dr. Clements has
recently become a certified gang specialist.
Gaps remain, however, in the continuity of care across different
forensic specialties. "Ideally, forensic nurses will refer patients
to other forensic nurses for continuing care," suggests forensic
nurse Paul Clements. For example, when a SANE nurse makes a
referral for ongoing psychiatric care for a victim of rape, the ideal
professional to provide this care is a forensic psychiatric nurse.

Forensic Nurse Educator

When prospective forensic nurses first enter Jamie Ferrell's classroom, they
are occasionally under the wrong impression about what forensic nurses do.
As a faculty member of theNational Forensic Nursing Institute (NFNI),
Ferrell's job is to enlighten them about forensic nursing, dispel the myths,
and provide a foundation for incorporating forensic principles into nursing
practice.
21

One of the misconceptions created by popular television programs about

forensics is that forensic nursing involves everything from gathering the
evidence to performing the autopsy to going out and solving the crime.
Ferrell turns their fascination with television forensics into a learning
opportunity, pointing out how carefully the evidence is handled in a homicide
investigation. Why, she asks her students, shouldn't a victim of sexual
assault or interpersonal violence be accorded the same degree of care and
attention? As a forensic nurse educator, Ferrell emphasizes the importance
of protecting the health and welfare of underserved populations.
Ferrell teaches a variety of forensic courses through the NFNI, an
organization that provides professional and community education in
forensics. Her students include not only nurses, but physicians, physician
assistants, law enforcement, teachers, counselors, attorneys, child
protective service case workers, criminalists, and even parents. She has
traveled far and wide (28 states and 12 countries) to teach classes in adult
and pediatric SANE, domestic violence, child maltreatment, elder abuse,
and basic evidence collection and management. Ferrell also teaches an 80hour forensic nursing course at Memorial Hermann Texas Medical Center in
Houston, Texas. This course, coupled with a clinical preceptorship, prepares
nurses who have an interest in forensic nursing to work on the hospital's
extensive Forensic Nurse Response Team.
"Nurses who think they might be interested in a more specialized forensics
role should seek out a local or national conference with forensic topics on
the program to get exposure to forensics and what it really means," advises
Ferrell. She also believes that it is time for forensic nursing science to be
incorporated into all basic nursing school curricula, because no matter
where you practice nursing, you overlap with the law and apply the
principles of forensics to your nursing care.
Meliss Vessier-Batchen, DNS, RN, CFN, an Associate Professor of Nursing
at Our Lady of the Lake College in New Orleans, Louisiana and a forensic
nurse investigator at St. Tammany Parish Coroner's Office, agrees. She
uses case examples to highlight forensic principles for her undergraduate
nursing students. For example, she tells them, imagine that you are taking
care of a paraplegic patient who dies as a result of a long-term infection in a
wound that was originally a gunshot wound received 10 years earlier in a
gang fight. Because the patient's original wound was caused by a malicious,
intentional act, the case is now a homicide. The medical examiner/coroner's
22

office should be notified; it is possible that new charges will be filed. If the
healthcare providers are not educated about forensics, the patient's history
could be overlooked and justice would not be served.

The Challenge Ahead

Although there are many more forensic nurses than there were 10 or 20
years ago, forensic nursing is still addressing the challenges of a growing
specialty. One of these is recognition of forensic nursing practice not only by
the public, but by the nursing profession itself. Although forensic nursing
achieved official recognition by the American Nurses Association in 1995,
widespread understanding of the role of the forensic nurse has not yet been
realized. Image building is all the more difficult because of the diversity of
roles and patients found under the umbrella of forensic nursing.
When Dr. Meliss Vessier-Batchen was collecting data for her doctoral
dissertation, "Life After Death: A Comparison of Coping and Symptoms of
Complicated Grief in Survivors of Homicide and Suicide Decedents," in the
aftermath of Hurricane Katrina, a hurricane wasn't her only obstacle. She
found that the combination of nursing, a profession associated with caring,
and forensic, a word associated with death, was difficult for many people,
including other nurses, to understand. If all of your subjects are dead, her
colleagues asked her, what will you do your research on?
Forensic nursing practice is not new, but its science is at an early stage.
Forensic nursing is rooted in clinical care and, like other nursing disciplines,
must conduct the necessary research to support evidence-based practice.
[14]
Research into the primary prevention of violence, the effects of violence,
and the outcomes of forensic nursing practice is also needed, both in the
United States and on a global scale.
Editor's note:
Read the first article of this 2-part series, Forensic Nursing: Part 1. Evidence
Collection for Nurses
Related Resources
American Association of Legal Nurse Consultants
http://www.aalnc.org/hire/roll.cfm

23

American Board of Forensic Nursing

http://www.abfn.us/index.html
American Board of Medico-Legal Death Investigators
http://www.slu.edu/organizations/abmdi/
American Forensic Nurses
http://www.amrn.com/
International Association of Forensic Nurses (This group publishes
the Journal of Forensic Nursing.)
http://www.iafn.org
National Forensic Nursing Institute
http://www.nfni.org/1.html
Sexual Assault Nurse Examiner, Sexual Assault Response Team
http://www.sane-sart.com/
US Department of Justice, Office of Justice Programs, National Institute of
Justice. Death Scene Investigation: A Guide for the Scene Investigator.
Washington DC, 1999.
http://www.ncjrs.gov/pdffiles/167568.pdf

References
1. Shives LR. Basic Concepts of Psychiatric-Mental Health Nursing. 7th edition.
Philadelphia, Pa: Lippincott Williams & Wilkins; 2007.
2. Lynch VA. Forensic nursing science and the global agenda. J Forensic Nurs.
2007;3:101-111. Available at: http://www.medscape.com/viewarticle/565600. Accessed
December 1, 2007.
3. Lynch VA. Forensic nursing. In: Burgess AW, ed. Advanced Practice in Psychiatric
Mental Health Nursing. Stamford, Conn: Appleton-Lange; 1998.
4. Lynch VA. Forensic nursing science. In: Hammer RM, Moynihan B, Pagliaro EM, eds.
Forensic Nursing. Sudbury, Mass: Jones and Bartlett; 2006.
5. Burgess, AW, Berger AD, Boersma RR. Forensic nursing: investigating the career
potential in this emerging graduate specialty. Am J Nurs. 2003;104:58-64.

24

6. McMahon P. Forensic nursing in multiple settings. On the Edge. 2007;13. Available at:
http://www.iafn.org/publication/ote/oteFall2007.cfm#1. Accessed December 20, 2007.
7. Pyrek K. Forensic Nursing. Boca Raton, Fl: CRC Press; 2006.

8. Sievers V, Murphy S, Miller JJ. Sexual assault evidence collection more accurate when
collected by sexual assault nurse examiners: Colorado's experience. J Emerg Nurs.
2003;29:511-514. Abstract

9. Campbell R, Patterson D, Lichty LF. The effectiveness of sexual assault nurse examiner
(SANE) programs: a review of psychological, medical, legal, and community outcomes.
Trauma Violence Abuse. 2005;6:313-329.Abstract
10. Clements PT, Burgess AW. Children's responses to family member homicide. Fam
Community Health. 2002;25:1-11.
Forensic Nursing: Investigating the Career Potential in this Emerging Graduate Specialty
Article Publisher: American Journal of Nursing - Date: Mar. 2004
Source: American Journal of Nursing, Mar. 2004, Vol. 104, No. 3
Citation: Burgess, A. W., Berger, A. D., & Boersma, R. R. (2004, March). Forensic nursing:
Investigating the career potential in this emerging graduate specialty. American Journal of
Nursing, 104 (3), 58-64.
James Byrd, 48, was angry. There were still pieces of pulp in the orange juice container after his
girlfriend washed it. In a rage, he hit her and stamped on her stomach. She was ill that night, and
for the next four days, but Mr. Byrd wouldn't let her leave the house to seek health care. Finally,
when he left the house with their 10-year-old daughter, the victim dragged herself outside, hailed
a cab, and went to the hospital. She couldn't walk into the ED. Taken directly to surgery, she was
found to have a lacerated pancreas.
Surgeons removed her spleen and sutured her pancreas. During her recovery in the hospital, a
prosecutor and a nurse recorded her statement and her appearance on videotape. She told of the
years of domestic violence (primarily psychological) she'd endured. Mr. Byrd was arrested and
jailed and she returned home.
When Mr. Byrd's trial began a year later, a surgeon and an ED nurse testified to their
documentation of the victim's injuries, surgery, and recovery. But when the victim took the stand
she refused to testify against her boyfriend. How could the prosecution convince a jury of the
defendant's guilt without the victim's testimony? Would the jury understand that it's common for
victims of domestic violence to refuse to testify against their abusers? A forensic nurse with a
well-established reputation in the field of domestic violence was brought in to explain the victim's
refusal.
Mr. Byrd was convicted of two counts of assault in the first degree and faced a sentence of 25
years in prison.
Forensic nursing, one of the newest specialty areas recognized by the ANA, is gaining momentum
nationally and internationally. Forensic nursing practice is, according to the International
Association of Forensic Nursing (IAFN), the "application of nursing science to public or legal
proceedings."1Forensic nurses investigate real and potential causes of morbidity and mortality in a
variety of settings. Responsibilities range from collecting evidence from perpetrators and survivors
of violent crime to testifying in court as a fact witness (someone who saw a situation firsthand) or
an expert witness (someone who offers an opinion of a particular situation). Forensic nurses
understand evidence collection (such as forensic photography) for subsequent legal and civil
proceedings and are the "bridge between the criminal justice system and the health care system.2
The American Board of Forensic Nursing is one of 13 executive advisory boards of the American
College of Forensic Examiners International (ACFEI). The ACFEI publishes The Forensic

25

Examiner, a peer-reviewed journal, and offers certification programs to nurses and other health
care professionals. For more information go to www.acfei.com.
THE HISTORY OF FORENSIC NURSING
Today, screening for violence is a minimum standard of care. Both the Centers for Disease Control
and Prevention (CDC) and the Joint Commission on Accreditation of Health Care Organizations
(JCAHO) recommend screening for family violence in hospitals and clinics. JCAHO's
recommendations have been in place since 1992, and in 1998 the CDC backed efforts to improve
the recognition and treatment of victims of domestic violence with the publication of Intimate
Partner Violence and Sexual Assault: A Guide to Training Materials and Programs for Health Care
Providers.Once considered a problem exclusively for the criminal justice system, violence is now
regarded as a public health issue. Yet it's taken years for violence to reach this level in the public's
awareness.
The efforts of the health care community to stem the tide of violence in America gained
momentum in 1985, with the Surgeon General's Workshop on Violence and Public Health. In his
opening remarks, U.S. surgeon general C. Everett Koop, MD, encouraged the 150 attendees to
develop recommendations that could become the "stimuli of change and progress everywhere." He
championed a multidisciplinary approach that could be embraced by professionals in medicine,
nursing, psychology, and social services. "Our focus will be squarely on how the health professions
might provide better care for victims of violence and also how they might contribute to the
prevention of violence," he said.3
At the same time, nursing was enjoying new strength as a provider of health care services to
victims. Nurses had volunteered at many of the rape crisis centers that opened in the 1970s and
by the mid-1980s were widely acknowledged for the expertise they had developed as a result. In
addition, scientific competence had become integral to the profession. This combination of factors
opened doors for nurses to collaborate with other providers, initiate courses and programs of
research on victimology and traumatology, influence legislation and health care policy, provide
expert testimony in criminal and civil court cases, and ultimately, create a new specialty.
Forensic nursing has its roots in the 18th century, when midwives testified in court on matters
such as virginity, pregnancy, and rape. 4 (By contrast, the discipline of forensic medicine began
early in the 16th century and focused on pathology and cause of death. 4) The current model of
forensic nursing evolved from the role of the police medical officer found in the United Kingdom
and other countries.5
The skills of the forensic nurse - observation, documentation, and preservation of evidence-are
critical in determining the legal outcome of violent crimes. 6
THE NEED FOR FORENSIC NURSING EDUCATION
With training, health care providers can identify both victims and perpetrators of crime. 7,8 In its
recent publication, Violence as a Public Health Problem, the American Association of Colleges of
Nursing states that "as members of the largest group of health care providers, nurses should be
aware of assessment methods and nursing interventions that will interrupt and prevent the cycle
of violence."9 Such efforts may focus on the ED, where most seriously injured people are
treated."10Results of a 1999 study underscore the value of instruction: after the ED nursing staff in
an urban, level l trauma center underwent a four-hour session an screening for intimate-partner
violence, 18% of women ages 18 and older visiting the ED were identified as victims of violence
and referred to social services.11 Before the training, such identification and referral occurred in
just 1% of the women presenting to the ED.
In October 2002 IAFN Scientific Assembly, a group of forensic nursing faculty agreed that although
continuing education in forensics (such as evidence collection and violence prevention) can
provide an overview of the field, it's inadequate for practice. Thus, many nurses are pursuing
education through college and university programs. (See Forensic Nursing Programs, page 63, for
a list of university programs.) Others are seeking education in forensics outside of nursing.
FORENSIC NURSING PROGRAMS

26

There are four primary routes for obtaining training in forensic nursing.
Continuing education courses supplement nursing degree programs and are used for
professional education and to fulfill renewal criteria for state licensure.
Certification programs have specific content, entrance requirements, and often a written
examination. Clinical internships may be required.
A minor or concentration in forensics is available in some university undergraduate and
graduate nursing programs.
Formal graduate study builds on the foundation of the baccalaureate.
In 1997 the ANA published The Scope and Standards of Forensic Nursing Practice, which calls for
the synthesis of education and experience for forensic nursing proficiency. The ANA recommends
that in addition to attending core graduate nursing courses, graduate students carry out a clinical
internship and complete the forensic nursing curriculum required for the degree.
Graduate clinical internships may be completed in many settings, including a state forensics crime
laboratory, a medical examiner's office, a victim advocate's office, a shelter for victims of domestic
violence, a forensic psychiatry unit, or an ED.
Forensic nursing curriculums focus on victimology, perpetrator theory, forensic mental health,
interpersonal violence, criminology, and criminal justice. Other areas of study include the
following:
The fundamentals of forensic nursing include evidence collection; documentation; interviewing
skills; criminal, procedural, and constitutional law; scope of practice; interdisciplinary
collaboration; identification of nursing roles; and testifying in court as an expert witness.
Forensic law. Forensic nurses must understand the legal issues surrounding expert testimony
in legal proceedings; issues such as culpability, burden of proof, rationale for punishment, and
mitigating circumstances; and defenses such as justification, insanity, entrapment, and duress.
Forensic science. Topics include the collection and preservation of evidence, the interpretation
of DNA-laboratory reports, forensic chemistry, toxicology, cause of death, blood spatter
interpretation, manner and mechanisms of injury, wound identification, and cause.
SPECIALTY ROLES IN FORENSIC NURSING
As their responsibilities evolve, forensic nurses are assuming increasingly diverse roles, in risk
management, employee litigation, bioterrorism, and domestic and international investigations of
human rights abuses. Newly proposed is the child abuse nurse examiner.12 The most common
roles are sexual assault nurse examiner (SANE), advanced practice forensic nurse or forensic
clinical nurse specialist, and nurse death investigator and nurse coroner.
The SANE is the most common forensic nursing specialty. SANEs care for victims of sexual assault,
collect and document forensic evidence needed to pursue a criminal case, and testify at trial.
Programs that teach nurses to work with sexual assault victims have existed in the United States
since 1976. They typically consist of more than 40 hours of classroom instruction followed by a
number of hours of clinical practice.13 Initial requirements, training programs, continuing
education, and competency requirements vary by state (see www.sane-sart.com for a list of
existing SAT, programs and resources for the development of new educational programs).
Newer programs, such as those for the sexual assault forensic examiner (SAFE) or the forensic
nurse examiner (FNE), have begun to replace SANE programs. These programs will expand the
scope of forensic nursing to include not only sexual assault incidents but the gathering of forensic
evidence in cases of domestic abuse or automobile accidents.

27

The IAFN (see "Who's Who in Forensic Nursing," page 60) recently published SANE education
guidelines and is currently working with the U.S. Department of Justice Office on Violence against
Women (OVW) to develop a national sexual assault forensic examination protocol. The OVW will
also develop training standards to accompany the protocol. The IAFN offers a certification program
for the sexual assault nurse examiner-adult and adolescent (SANE-A). The first SANE-A
certification examination was given in April 2002 (certification is valid for three years). 14 As of
September 2003, there were 352 IAFN-certified SANE-A nurses. 15 To be eligible for the
examination, applicants must hold a valid U.S. RN license, have a minimum of two years of
practice as an RN, have been "determined competent in current SANE practice" by an appropriate
clinical authority, and have successfully completed an adult-adolescent SANE education program
that includes either a minimum of 40 continuing education contact hours of classroom instruction
or three semester hours (or the equivalent) of academic credit in an accredited school of nursing.
President Bush's proposed initiative, Advancing Justice through DNA Technology, includes $5
million allocated in 2004 to "support the development of training and educational materials for
doctors and nurses involved in treating victims of sexual assault." HR 3214 was passed by the
House of Representatives in October 2003 and read to the Senate in December.16 The initiative
calls for more than $1 billion in five years, and if it's approved, some of the funds may be
appropriated for SANE and SAFE programs.
Ciancone and colleagues published a survey of SANE programs in the United States in 2000. 17 Of
the programs that responded, 55% had been in existence for less than five years; 16% for more
than 10 years. The median number of patients seen annually was 95. Roughly 75% of programs
were affiliated with a hospital, police department, or rape crisis center; more than half of the
examinations were conducted in a clinic, office, or hospital setting. Ninety percent offered
prophylaxis and treatment for sexually-transmitted diseases (STDs), but STD cultures, HN testing,
and screening for illegal drugs and alcohol were selectively performed. The authors suggested that
a standardized protocol could reduce inconsistencies among programs and that further research
be conducted.
Anecdotal evidence suggests that SANEs have made a profound difference in the quality of care
provided to sexual assault victims and in the outcomes of investigations and
prosecutions.13Further, SANE training allows evidence to be collected more - quickly and in a
manner that is compassionate and doesn't traumatize a victim further.
Advanced practice forensic nurse and forensic clinical nurse specialist. In addition to
working with victims of crime and their families, advanced practice forensic nurses and forensic
clinical nurse specialists may work with perpetrators, people involved in paternity disputes, and
cases involving workplace related injuries, medical malpractice, automobile accidents, food or drug
tampering, or medical equipment defects.4 They may be researchers or clinicians; in hospitals they
may serve as consultants and educators. They can assess a patient's risk of being victimized
(through intimate-partner abuse, for example) and help reduce that risk through patient
education.
Nurse death investigators and nurse coroners are two roles discussed in the ANA's Scope
and Standards of Forensic Nursing Practice; each role varies by state. Currently, 22 states have
medical examiner systems, 11 states use the coroner system, and 18 states use a mixed medical
examiner and coroner system.18,19 (For detailed information, go
towww.cdc.gov/epo/dphsi/mecisp/summaries.htm.) One key difference between the two is that
coroners are elected to the position, while the governor appoints medical examiners (who must be
physicians). Nurse death examiners work for the medical examiner and investigate the
circumstances of a death before the body can be released. Nurse coroners can perform death
investigations, as well as issue death certificates, a responsibility that differentiates them from
nurse death investigators. Catherine O'Brien, a nurse death investigator, considers death "another
point on the continuum of care.20 She emphasizes that because the majority of cases referred to a
medical examiner's office are natural deaths, nurse death investigators should be trained to
handle natural death cases, which are not the focus of law enforcement personnel.
There are many death investigator programs available. One, the American Board of Medicolegal
Death Investigators, located in the Division of Forensic Pathology- at St. Louis University School of
Medicine, offers two levels of certification: the registry (or diplomate) level and the fellow (or
advanced board certification) level. One approach to becoming a registry candidate is to have 30
hours of formal death investigation training and complete an examination and a performance
evaluation. Candidates looking to become fellows must be certified at the registry level for at least

28

six months, have at least 4,000 hours of death investigator experience, and currently be employed
as a death investigator.
FORENSIC NURSING RESEARCH
The ANA's Scope and Standards of Forensic Nursing Practice encourages research to validate and
improve forensic nursing practice.21 Research in recent decades has increased awareness of sexual
trauma considerably; it has also identified the effects of such trauma on family members and the
community.22 Yet sexual violence still affects hundreds of thousands of women and children each
year. Nurses could be more influential in reversing this trend by identifying victims of sexual
violence in their care, improving the treatment of trauma, and designing research protocols aimed
at prevention.
An important research question is what difference the use of SANEs makes in the arrest and
prosecution of rape and sexual assault cases. Another possible area of inquiry is the identification
of signs consistent with consensual or nonconsensual sex, a critical issue in acquaintance-rape
trials. Forensic nurses in the United Kingdom and Scandinavia have already conducted important
research on the behavior specific to dangerous patients and on nurses' attitudes toward patients
with personality disorders.23-26
REFERENCES
1. International Association of Forensic Nurses. About IAFN. [Web site].
2002.http://www.iafn.org/about/default.html.
2. Benak, Rose. Focus on Diane Stuart. On the edge 2003;9(4):21.
3. U.S. Public Health Service, Services. Surgeon General's workshop on violence and public
health. Report. [Web site]. 1986. http://profiles.nlm.nih.gov/NN/B/C/F/X/_/nnbcfx.pdf.
4. Lynch VA. Forensic nursing. In: Burgess AW, editor. Advanced practice in psychiatric mental
health nursing. Stanford, CT: Appleton-Lange; 1998.
5. Lynch VA. Clinical forensic nursing: a new perspective in the management of crime victims from
trauma to trial. Crit Care Nurs Clin North Am 1995;7(3):489-507.
6. Malestic SL. Fight violence with forensic evidence. RN 1995;58(1):30-2.
7. Rollins JA. Nurses as gangbusters: a response to gang violence in America. Pediatr
Nurs1993;19(6):559-67.
8. Sullivan LW: Forum on youth violence in minority communities. The prevention of violence - a
top HHS priority. Public Health Rep 1991;106(3):268-9.
9. American Association of Colleges of Nursing. Violence as a public health problem. (Web site].
2002. http://www.aacn.nche.edu/Publications/positions/violence.htm.
10. Shepherd J. Violence as a public health problem. Combined approach is needed. BMJ
2003;326(7380):104.
11. Larkin GL, et al. Universal screening for intimate partner violence in the emergency
department: importance of patient and provider factors. Ann Emerg Med 1999;33(6):669-75.
12. Sinnee H. Slipping through the cracks. On The edge 2003;9(4):10-3.
13, Litrel K, U.S. Department of justice. Sexual Assault Nurse Examiner (SANE) programs.
Improving the Community Response to Sexual Assault Victims. [Web site].
2001,http://www.ojp.usdoj.gov/ovc/publications/bulletins/sane_4_2001/welcome.html.

29

14. International Association of Forensic Nurses. SANE-A certification exam, On the

edge2003;9(1):13-4.
15. Council report of the IAFN. On the edge 2003;9(4):24.
16. U.S. Department of Justice. Advancing justice through DNA technology. [Web site].
2003.http://www.usdoj.gov/ag/dnapolicybook_cov.htm.
17. Ciancone AC, et al. Sexual Assault Nurse Examiner programs in the United States. Ann Emerg
Med 2000;35(4):353-7.
18. Centers for Disease Control and Prevention. Death Investigation Summaries. [Web site].
2003.http://www.cdc.gov/epo/dphsi/mecisp/summaries.htm.
19, Pyrek K. Nurse Coroners Slowly Gain Ground. [Web
site].http://www.forensicnursemag.com/articles/311feat2.html.
20. O'Brien C. Death: another point on the continuum of care. [Web site].
2003.http://www.forensicnursemag.com/articles/311perspect.html.
21. American Nurses Association. Scope and standards of forensic nursing practice. Washington,
DC: American Nurses Publishing; 1997.
22, Burgess AW, Frederich A. Sexual violence and trauma. Policy implications for nursing. Nursing
and Health Policy Review, 2002;1(1):17-36.
23. Woods P. How nurses make assessments of patient dangerousness. Mental Health
Nursing1996;16:20-2.
24. Woods P. Twenty years of admission to special hospitals. Psychiatric Care 1997;4(1):22-5.
25. Almvik R. Woods P. Predicting inpatient violence using the Broset Violence Checklist (BVC). lnt
J Psychiatr Nurs Res 1999;4(3):498-505.
26. Bowers L, et al. Factors underlying and maintaining nurses' attitudes to patients with severe
personality disorder. [Web site].
2000.http://www.city.ac.uk/barts/research/reports/pdf/bowers_1/sdp.pdf.

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31

Presentation outline:- introduction

- Overview of forensic nursing.
- Definition of forensic nursing.
- Historical view of forensic nursing
- Forensic psychiatry and the Palestinians
- Principles of forensic nursing.
- Presentation of mental health need in forensic client.
- Specific forensic nursing skills.
- Client assessment.
- Care planning and intervention

Introduction:
32

When many people hear the term Forensic Nursing, they are not exactly
sure of what that means. With the advent of shows like "CSI", "The
Forensic Files" or "Bones", many envision the forensic nurse as a type of
medical detective out at a murder scene.
Put simply, a Forensic nurse is a nurse with specialized training in forensic
evidence collection, criminal procedures, legal testimony expertise, and
more. The Forensic nurse becomes that liaison between the medical
profession and that of the criminal justice system. When you combine the
medical training of a nurse, with the investigative prowess of police
detectives and the legal training of a lawyer, you have created a formidable
enemy for criminals.
Most Forensic Nurses work out of a hospital, at the first point of contact.
The Emergency Room. Most people who come to the emergency room
don't know that they may be in need of a forensic nurse when the present at
the hospital. Trying to accurately assess a patient can be difficult enough,
but toss in the chaos of a typical emergency room and things really go
downhill in a hurry. Take for example the case of the distraught mother
who brings in her son who is complaining that his arm hurts. The mother
says he ran into a door trying to catch the dog. Better check vitals and get
an x-ray of the arm to see if its broken right? Did you make the child
change into a gown? did you get a complete head to toe assessment?
Because without it, you would have missed the evidence of previous
contusions on his legs from two weeks ago when he was beat with a
wrench for not cleaning his room right.
Or what about the woman who comes in stating she was in a car accident.
Her boyfriend who was driving says she hit her head and cut her face as the
glass shattered. Did you notice that most of her injuries were on the left
side of her face? Logically if she was the passenger most of the injuries
should be on the right side, since that would be the most likely point of
impact.
Forensic nursing can also expand outside the world of criminal
investigation. After the devastation of hurricane Katrina in the gulf states,
identification of some of the remains found could only be determined
through the use of forensic evidence collection. This type of work is
usually referred to as Medicolegal Death Investigation.
If I become a forensic nurse does that mean that I have to work with dead
bodies? Of course not, but that is one of your options if you should choose
to learn more about that career path. There are many career branches that
open up to forensic nurses including; expert medical witness, Sexual
Assault nursing, Nurse death investigator, or Medicolegal death
investigation, community education. The list goes on and on

33

Medicolegal death investigation is a growing field for nurses, but more

often than not a forensic nurse will spend a majority of their time treating
victims of a sexual assault or performing examinations for a child abuse
case. As part of the training to becoming a Forensic Nurse education on
legal testimony and the proper collection of evidence and how to preserve
that valid chain of evidence is critical.
Definition of forensic nursing:
Forensic nursing is the term used when nursing is applied to those people
who have come into contact with the criminal justice system due to their
offending behaviors.
Forensic nursing relates to the care, treatment and management of those
persons who come into contact with the criminal justice system. This
includes: high security, medium security, low security hospitals and
community setting. It can also include police station, courts and prisons

Historical overview:
The definition of forensic nursing is continually evolving. In 1997 it was
defined as "the application of forensic science combined with the biopsychological education of the registered nurse, in the scientific
investigation, evidence collection and preservation, analysis, prevention
and treatment of trauma and/or death related medical-legal issues."
(IAFN/ANA, 1997)
The word "forensic" comes from the Latin word forensis meaning public
debate. The word forensic is used now to describe the debates that occur in
courts of law and is even more broadly defined as any matter that is
"pertaining to the law." (Evans, Wells, 1999)
In 1998 that definition was expanded as follows. "Forensic Nursing is the
application of nursing science to public or legal proceedings; the
application of the forensic aspects of health care combined with the biopsychosocial education of the registered nurse in the scientific investigation
and treatment of trauma and/or death of victims and perpetrators of abuse,
violence, criminal activity and traumatic accidents. " (IAFN 1998)"
Forensic Nursing is the health care response to (criminal and interpersonal)
violence. Identification of crime victims, prevention of further injury or
death due to cyclical violence, and early detection of potentially abusive
situations are critical steps to stem the effects of human violence. Forensic
Nursing provides a continuity of care from the emergency department
and/or crime scene to courts of law and a wider role in the investigation
of crime and the legal process that contributes to a safer, healthier society."
(IAFN, 1998)

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Forensic psychiatry and the Palestinians:

According to El-Sarraj, after the six Day war and during the Israel
occupation, level of antisocial behavior and aggression, including
homicide, increased within Palestinian population. In addition drug abuse,
especially cocaine, spread among younger Palestinians. Similar increases
in criminality and drug abuse have occurred more recently within Israel
Arab communities, though aspect of social change are not identical for
Palestinians in the territories and Arab living within Israel. The concept of
family honor remains prominent for Muslims, with episodes of young
women being Murdered by their fathers or brothers for having brought
"shame" on the family continuing to occur.
The psychiatric hospital in Bethlehem and Gaza are generally unable to
take offender patients who may require a significant degree of security on
account of their being dangerous to society. Indeed, the provision of high
and medium secure facilities for dangerous mentally disordered offender is
also a current issue in Israel. In practice Israel prisons have provided
psychiatric care for most dangerous offender, whether or not mentally
disordered and whether Palestinian or Jewish. The rate of incarceration in
Israel prison was recorded as being higher than in any country in Western
Europe except Northern Ireland, though than in the united states.
What are the Specialty Roles in Forensic Nursing?
Educating and informing potential employers regarding the profession of
forensic nursing and the valuable skills provided by qualified forensic
nurses. Meeting and establishing professional relationships with other
forensic professionals, including crime scene technicians, medical
examiners and attorneys is called "networking". Through networking you
will establish a professional identity within the forensic community which
will ultimately help. Always join as many professional forensic
organizations as you can. The International Association of Forensic Nurses
(IAFN) will keep you informed of professional developments in the field of
forensic sciences. As their responsibilities evolve, forensic nurses are
assuming increasingly diverse roles, in risk management, employee
litigation, forensic nurse investigator, forensic clinical nurse specialist,
forensic nurse educator, bioterrorism, domestic and international
investigations of human rights abuse, psychiatric forensic nursing, forensic
geriatric nursing, correctional nursing, emergency room forensic nursing,
pediatric forensic nursing, sexual assault and domestic violence. Newly
proposed is the child abuse nurse examiner. The most common roles are
sexual assault nurse examiner (SANE), advanced practice forensic nurse or

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forensic clinical nurse specialist, nurse death investigator and nurse

coroner.

Sub Specialties of Forensic Nursing

There are many different roles and specialties that a forensic nurse can try
to specialize in. the following list is meant to give some helpful ideas of
careers for forensic nursing, and should not be viewed as a complete list of
nursing career choices.
- Medical Examiner's office
- Medical Legal Consultant
- Emergency Room Nursing
- Medicolegal death investigator
- Evidence collection trainer
- Expert medical witness
- Law enforcement teams

Principles of forensic nursing

In working with forensic client, five guiding principles are required:
partnership, engagement, flexibility, pragmatism and team working.
Partnership
The need for collaboration and negotiation are paramount
The nurse should be working towards restoring
Engagement
The need for honesty, genuineness and acknowledging the limitation of
forensic mental health are crucial.
Flexibility
Forensic nursing requires a great deal of the nurse. Decisions about care
and risk need to be constantly evaluated and re-evaluated, sometimes on
second by second basis.
Pragmatism
The focused of nursing is based on the principles of Pragmatism as
opposed to the application of theories or models.
Team working
This includes working with other professionals and encouraging the whole
team to work in partnership with the client. Team working can often
involve including the
family in assessing and meeting the clients needs.

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What do Forensic Nurses actually do?

"Forensic Nurses work with patients who are in some way involved in the
criminal justice system. That is, patients who have allegedly committed or
who have been convicted of a criminal offence, or alleged victims of crime.
"The forensic nurse provides direct services to individual clients,
consultation services to nursing, medical and law-related agencies, as well
as providing expert court testimony in areas dealing with trauma and/or
questioned death investigative processes, adequacy of services delivery and
specialized diagnoses of specific conditions as related to nursing." (IAFN
1998).
The services provided by forensic nurses can include examination of
victims of abuse, sexual assault, violence, trauma or death, with
documentation of injuries and findings, both in the written record and
photographically. These services can include recognition, collection and
preservation of physical evidence, either from the victim, the victims
clothing or from the scene of the crime, accident or injury. These services
can include examination of suspects for injuries, as well as collection of
trace evidence and/or exemplars to be used for comparison to those found
on the victim or at the scene.
These services can include the collection of legal blood and urine
specimens for alcohol and drug testing. These services can include
providing physical and emotional comfort to victims and their family
members, as well as help with decisions about organ and tissue donation.
These services can include examining medical records for any clues as to
cause and manner of death, or to possible liability in civil or criminal
proceedings.
Services provided by forensic nurses can include assessments of infants,
children, teenagers, adults and the elderly; of the mentally well and the
mentally ill; of the victim or the offender; of the innocent as well as the
convicted and the incarcerated; of the living as well as the dead.

Presentations of mental health need in forensic clients:

Forensic clients are defined by the nature of their offending or their
propensity for potential offending and not by the nature of their mental
health needs. There is violence. Individuals with psychotic disorders are
more likely (than the general population) to behave violently towards other
(bernnan et al 2000) and to have criminal convictions for violence (Wallace
et al 1998).
Consequently, a whole spectrum of mental health needs may be present.
Invariably, there are tow factors that the nurse is required to consider:

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- The mental health needs of the client

- The actual or potential offending behavior.
This leads to focus on forensic nursing as having one of three potentialities
(Rogers & Curran 2004)
Assessment, care, intervention and management for actual or potential
offending only (e.g. sexual offending)
Assessment, care, intervention and management for mental health needs
only (e.g. delusional beliefs)
Assessment, care, intervention and management for both (e.g. violence to
other which is driven by delusional beliefs)
Ordinary, forensic nursing is focused on the third of these three
potentialities, where it is considered that either the offending behavior
harms the persons mental health or the person mental health leads to actual
or potential offending.

Specific forensic nursing skills required:

Forensic nurse requires a wide range of knowledge and skills. A client may
be depressed, suicidal and self-injurious after killing their children while in
psychotic state. Another client may have post-traumatic stress disorder
(PTSD) after crashing a stolen car they were driving in which their best
friend died. Yet another client may be suffering from paranoia and
command hallucinations causing behaviors that are difficult to manage in
an acute mental health unit.
*1* Formulating risk
Mental health needs will be the main reason for contact with forensic
nurses, there will also be the potential for, or the occurrence of actual
offending behavior. The ability to skillfully formulate risk and the
relationship between risk and mental health need develops over time
through practice, discussion with client, seeking feedback about working
formulation, and discussions with clinical team member and sometimes
with family member. Experience in formal methods and procedures of risk
assessment are necessary.
*2* Awareness and management of self
Forensic nursing should also have an ability to remain objective, logical
and evidence based. Occasionally a client may challenge our own beliefs
and values through the nature of their offence.
Asking question about the behavior is more useful :
- What were the clients experience at that time?
- What function did the behavior serve?
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- What were the clients circumstances at the time?

*3* Communication
Effective communication is also essential as forensic services rely on the
quality of information
*4* Collaboration
By far the most important skill collaboration. Collaboration is a term that is
often used in the wider mental health literature.
Collaboration is paramount within forensic settings and requires the
therapist to: (work with, as opposed to work against people)

What are Some Additional Settings for Forensic Practice?

Tissue and Organ Donation: In large trauma facilities, the skills of an
experienced, knowledgeable forensic nurse are a significant contribution to
the crisis intervention team working with families of potential donors. The
nurse needs to know the specifics regarding the "legal framework of organ
donation, familiarity with brain death criteria, and confident skills in
required consent request... The nurse must meet the legal requirements and
at the same time provide emotional support to the grieving family." (Lynch,
1995)
Pediatrics: Forensic nurses may specialize in the recognition, evaluation,
treatment and support of young victims of abuse through various facilities
and organizations. Child abuse and neglect cases can be handled by
forensic nurses depending on the protocols for that facility. Each facility
will have protocols which specify who may examine and counsel pediatric
victims. In some cases, SAFE nurses may not have authority to work with
these patients.
Correctional: Correctional nurses have a great deal of autonomy, provide
acute and chronic assessments, dispense medications, manage acute illness
and injuries, perform health screenings, and educate inmates on various
health related topics. Correctional facilities also reflect the society at large,
therefore the incarcerated population is aging and has a wide range of
health issues that need to be addressed while serving their sentence. Some
facilities are privately owned and hence hire their own healthcare staff or
contract with healthcare companies to supply staffing needs. There are
institutions of all sizes and for many different populations and age groups.
Psychiatric: There are but a few states in the nation that have the
Psychiatric Forensic Nursing Classification. Employment is usually
through the state civil service system, associated with the Department of
Public Welfare. Nurses working in this role are responsible for psychiatric
evaluation and treatment of criminal offenders by order of the court
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system. The offenders are typically admitted to a state facility for a brief
period of evaluation and then returned to the county jails for sentencing.
This specialty is closely tied to correctional nursing, violence issues with
children at all age levels. School nurses are accessible and trusted
healthcare professionals who can work with students on skills such as
conflict resolution, stress management, suicide/injury prevention, and
relationship management.
School Settings: In the educational environment, school nurses are in a
position to observe, assess, educate and intervene when necessary.

Assessment:
Assessment should cover psychiatric, psychological and social functioning,
risk to the individual and others, including previous violence and criminal
record, any needs arising from co-morbidity, and personal circumstances
including family or other carers, housing financial and occupational status.
Assessment goals
A comprehensive assessment will result in:
- A detailed and precise description of the problems the client
is experiencing.
- A clear description of the clients current symptoms
- A comprehensive risk assessment
- A description of the clients social, occupational and domestic
circumstances
- The support available to the client
- Family/carer perspectives
- An over management care plan
- A treatment care plan
- Methods for treatment to be evaluated

Timing of assessment:
Frequent assessment is potentially the backbone of the forensic nursing.
Frequent assessment reduce the likelihood that a clients mental health
needs or risk have increase without the nurse being aware. Usually it is
uncommon for the clinical team member to want to assess the client
through interview and psychometric measurement within the first week or
tow of contact.
Pre-admission assessment is cornerstone if many forensic services when
admission is likely.

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Sources of assessment information:

Assessment information come from a variety of people (client,
carer/family, referrer, criminal justice system) and in several ways (letters,
verbal reports, case note, court reports).
The primary source of information in the assessment setting is patient
himself or herself.
Secondary source are the assessor, family and carers, case record, court
reports, questionnaires and rating scales.

Assessing risk:
Assessing risk is not unilateral procedure, but should involve all the
professions and involve a range of assessment that are captured on record.
Risk assessment can be categorized as risk to self and risk to others.
Known factors associated with a risk of self-injurious behavior include:
- Past self harm attempts ( nature, motivation, dangerousness)
- Presence and severity of current depression
- Presence of current suicidal ideation (method, ability to
complete method, motivation)
- Past and current drug or alcohol use
- Past and current psychotic symptoms and their nature.
Risk to others includes assessment of the following:
- Known history of violence
- Severity of previous violence
- Who the victim of violence were
- Thoughts of violence
- Previous and current psychotic symptoms and their nature
(e.g. paranoia, command hallucinations)
- Past and current drug or alcohol use.

Observation:
Observation is a key intervention. Observation has been defined as
(standing nursing and midwifery advisor committee 1999,p2)
Regarding the patient attentively while minimizing the extent to which they
feel under surveillance.
Has classified observation into four levels:
- General observation
- Intermittent observation
- Within eyesight
- Within arms length

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Observation forms three functions:

- First, its a process of ongoing assessment of the client.
- Second, is used as a management procedure. (when a patient
is at risk of suicide)
- Third, observation is used as a potential means of engaging
with and developing a relationship with clients.

Inter-observer agreement:
The first is inter-observer agreement. This relates to whether all those
involved in observation identify all relevant instances of the behavior or
symptom and record these in the same way.
The second factor relates to whether the same observer will reliably
produce similar accounts of the same behavior conducted at different times
or in different settings.

Reactivity
A final, and very important, factor to consider is the effect of the observer
on patient and their behavior. In some cases the behavior or symptoms that
are being assessed may vary according to the presence of the observer. This
is known as reactivity.
For example, some patients may appear more agitated, anxious and
aggressive if they are aware that their behavior is being regularly
monitored.
Care plans that are designed to manage are in effect plans where the nurse
has determined situations where the mental health staff take control from
the client.
A comprehensive care plan to manage problem areas should include:
- The specific problem behavior that the plan is designed to
manage
- Triggers for the problem behavior
- Strategies to address such triggers in an attempt to avert their
occurrence
- Nursing strategies to be employed before the management
plan is implemented
- The specifics of the management plan and roles of each nurse
- Strategies to be used with the client in order to assist them to
regain control of the problem behavior as soon as is practical
- The care that should be provided after the event including
discussions with the client in order that all concerned can

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learn from the event and evaluate the usefulness of the care
management plan
- Reporting and recording processes

Care plans designed to intervene

A comprehensive care plan to intervene with mental health need should
include:
- A clear statement of the problem including relevant results
from measurement procedures
- The treatment goals (preferably specified in the clients word
and not the nurses)
- The interventions that are to be used
- Who is responsible for conducting the interventions
- Methods for monitoring progress and the frequency of such
monitoring
- The familys or carers involvement in such intervention

Examples of specific clinical areas:

A large degree of variation exists between peoples mental health and
offending behavior. People commit offences for a variety of reasons,
including financial gain, when influenced by peer or group pressure, when
under the influence of drugs and or alcohol or as a result of behavioral
responses to hearing voices or delusional beliefs.

Problem solving strategies

A persons offending behavior may relate to poor problem solving skills
related to certain triggers.
Problem solving including:
- Identifying when problems arise
- Generating alternative behaviors/strategies
- Identifying steps to reach an alternative goal
- Practicing implementing new skills through role-play

Interventions for delusional beliefs

Provide clients with a normalizing as opposed to alienating rationale for
their experiences.
The focus of intervention is to develop a safe and therapeutic relationship
whereby the client can view their problems as worthy of examination and
exploration.

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Interventions for command hallucinations:

There is a known high prevalence of people with command hallucinations
in forensic environments, found 38% of patients had command
hallucinations.
An examination of the research literature shows that:
- There is evidence for relationship between violent content
command hallucinations and violence.
- There is relationship between self-harm command
hallucinations and self-harm behavior in inpatient settings.
Highly supportive and structured cognitive behavioral strategies are
employed to assist the client to examine their perceptions about command
hallucinations
- Educating people about mental health symptoms can help
them consider alternative explanations.
- Coping strategy enhancement can be used

Reference:
-Mental health nursing 2009.
-Gaza community mental health program 2007.

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