FORENSICSInNursing

“Current Trends in Forensic Science”

Dr Kithsiri Edirisinghe MBBS MSC MD ( Medical Administration )

Cherry, B. & Jacobs, S. (2008). Contemporary nursing: Issues, trends, and management. (4th ed.) St. Louis: Mosby.

Martin, N. (2009). Forensic nursing: What, who, where. The Kansas Nurse, 84(3), 3-5.

Pyrek, K. (2009). Forensic nursing pioneers ponder the future. Retrieved from http://www.forensicnursemag.com/articles/3b1cover.html

(2009). Forensic nurse: Job outlook for forensic nursing. Retrieved from http://education-portal.com/articles/Forensic_Nurse:_Job_Outlook_for_Forensic_Nursing.html

(2009). Forensic nursing. Retrieved from http://www.mynursingdegree.com/forensic-nursing-certificate-online/

(2009). The forensic nurse. Retrieved from http://www.theforensicnurse.com/

References

• Nursing science applied to the law

• Investigation/treatment of:

• Violence

• Abuse

• Criminal activity

• Traumatic accidents

What is Forensic Nursing?

A nurse (RN) with specialized training in:◦ Forensic evidence collection◦ Criminal procedures◦ Legal testimony expertise

Specialty Roles:◦ Clinical forensic nurse (CFN)◦ Sexual assault nurse examiner (SANE)◦ Legal nurse consultant◦ Forensic psychiatric nurse◦ Forensic correctional nurse◦ Forensic gerontology nurse◦ Nurse attorney◦ Death investigator/Forensic nurse investigator ◦ Forensic nurse educator

The Forensic Nurse

• 1992-1st national convention of sexual assault nurses

• International Association of Forensic Nurses (IAFN)

• 1996-American Association of Nurses

History

• 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

Current Status of Forensic Nursing

• Evaluation of victims of sexual assault

• Collect evidence (sexual assault victims and crime scenes)

• Interview the victim

• Investigate causes of morbidity and mortality

• Testify in court

Job Description

RN

Entry-level position is sexual assault nurse examiner (certification)

Specialized training

40 hrs didactics

40 hrs clinical work

Should be trained in handling and collecting evidence such as hairs, fibers, and swabs of fluid for DNA testing

Tools to be familiar with:◦ Digital camera◦ Omnichrome◦ Coloscope

Job Qualifications

• Varies depending on the part of the country and experience

• Starts at $26/hr and can reach as much as $100/hr

• On-call rate of $1-4/hr

• SANE-1 ½ times base pay

• Per case basis: $150-$400

Salary

Advantages Disadvantages

• Important resource

• Challenging and exciting

• Different specialty areas

• Make a difference

• Demanding hrs • Challenging • Emotional cases

• Forensic nursing will continue to advance and evolve

• New roles and opportunities (increase in the next ten years)

• Increasing crime rates

Future Trends

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/FNE/SART

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/FNE/SART

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

• Rape Crisis

• Medical Response

• SANE/RN

• Physician

• ANP

• PA

• Crime Lab

• Counseling Services

• Forensic Scientist

• CPS/APS

• 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• Provide victim centered

services

• Provide compassionate care

• Provide community awareness

• Where to come

• How we will treat you

• Encourage reporting of Sexual Assaults

• Encourage successful apprehension and prosecution of guilty offenders

• Aid in the identifying of false reporting

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 unless an outcry is made.

• History from Patient (to diagnosis & treat)

• Head-to-toe Assessment

• Detailed Genital Exam

• Collection of forensic evidence

• Treatment for injuries, STD’s & pregnancy

DFSA• 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:• Drugs uses• Reporting• Collection of evidence• Lab methodologies• Dosages

JPS Health Network StatisticsNo. of Exams

050

100150200250300350400450500

1996

1997

1998

1999

2000

2001

2002

2003

2004

No. of Exams

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 Violenceis 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

MEDICAL EXAMINER AND CORONER JURISDICTIONS IN THE UNITED STATES - 2002

DC

State ME, mixed county ME and CoronersState ME, mixed county ME and Coroners

State ME, coroners in every county or districtState ME, coroners in every county or district

Mixed ME and Coroners Mixed ME and Coroners

Coroners in every county or districtCoroners in every county or district

State ME, no coronersState ME, no coroners

District ME, no coronersDistrict ME, no coroners

County ME, no coronersCounty ME, no coroners

Source: Centers for Disease Control. (2004).

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)

• Pediatric Forensic Nurse

• Forensic Psychiatric Nurse

• Nurse Death Investigator/Coroner

• Correctional Nurse

• Legal Nurse Consultant

• Nurse Attorney

Lynch, (1993)

The Forensic Nurse Death Investigator

What is a Forensic Nurse Death Investigator?• A Registered Nurse who:

• applies the nursing process to death investigation across the life span

• collaborates with interdisciplinary agencies

• identifies trends

• conducts and/or participates in research

• promotes health and safety through community education.

IAFN, FNDI Standards of Practice, 2004, (draft)

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 Medical 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 !