Vol. 6 Issue 6
Forensic nurses get answers, comfort patients and serve as a bridge between the healthcare and criminal justice systems
While the word "forensic" may conjure up images of television shows like CSI and Bones, the term actually means "pertaining to the law." Quite simply, forensic experts apply scientific principles to resolve legal issues.
"Forensic nursing is a very up-and-coming field, and all of the players in the field of criminal justice have acknowledged the contribution that nurses can make," explained Karen Carroll, RN, SANE-A, associate director of the Bronx SART [sexual assault response team] at North Central Bronx Hospital and former SART program coordinator for Westchester County. "Forensic nurses are the bridge between healthcare and criminal justice.
"Forensic nursing is a fairly new specialty as far as being given a name, but we've actually been doing this type of nursing for years without knowing it," Carroll continued. "We've been diligent in our patient assessments and we've been careful in how we objectively document our observations."
A Varied Specialty
Donna Gaffney, DNSc, RN, FAAN, SANE-A, associate professor of nursing and coordinator of forensic nursing specialty courses at Seton Hall University in South Orange, NJ, described the depth of the field.
"I think the most important thing to remember is forensic nursing is not just about crime or sexual violence or child abuse," she noted. "For example, one of the areas we're working on in our program is disaster response and addressing the needs of victims of mass casualty events. There can be injuries, illnesses and accidents which all require thorough and accurate documentation and reporting."
While forensic nurses are involved in physical assessment, treatment and evidence collection, they also have a larger role. Gaffney and some of her graduate students were very involved in the aftermath of 9/11 as well as the hurricane relief efforts on the Gulf Coast.
"Witnessing the trauma of others requires knowledge of the neurobiology of traumatic response and psychological first aid," she said. "This is emotionally demanding work."
Issues related to terrorism and bioterrorism also fall within the realm of forensic nursing. "Consider the patient who is admitted to the emergency department or clinic with an unusual rash," Gaffney said. "Forensic nurses must understand symptomatology, etiology and treatment, from both infectious disease and bioterrorism perspectives."
Prevention is a key component of forensic nursing as well, and the International Association of Forensic Nurses (IAFN) has received a grant from CDC to focus on primary prevention of interpersonal violence.
"Nursing is, at its heart, all about teaching, and every communication we have with another person is an opportunity to educate them," Carroll said.
Caring for Victims
Perhaps the best-known forensic nursing role is that of a sexual assault nurse examiner, or SANE. Annie Lewis-O'Connor, PhD, MPH, APRN, nurse practitioner and assistant professor of emergency services at Boston Medical Center, cares for both pediatric and adult victims.
"Essentially, the aspect of forensic nursing that I work in incorporates evidence-based nursing practice into the care of individuals who are victims of interpersonal violence," she said.
Barbara Moynihan, PhD, RN, APRN,BC, coordinator of the MSN forensic nursing track at Quinnipiac University in Hamden, CT, and co-author of Forensic Nursing: A Handbook for Practice, is a former ED head nurse. "That's where I really began to look at the needs of people who had been victims of some form of interpersonal violence, as agencies and community services began to form in the early 1980s," she said.
"In the early years of the evolution of forensic nursing there were turf issues between disciplines that weren't always in the best interest of the victim," Moynihan said. "Today, we've really broadened the scope of forensic nursing to foster multidisciplinary collaboration and expand services to both victims and perpetrators."
Carroll expressed appreciation for the SART program grants established in New York City by Mayor Michael R. Bloomberg.
"It's an exciting time for forensic nursing in the five boroughs," she said. "As a rape survivor, I've jumped on this opportunity to make history, bringing vitally needed services to victims of interpersonal violence in the city."
Eileen Allen, MSN, RN, FN-CSA, SANE-A, SANE/SART program coordinator for Monmouth County, NJ, heads a group of 12 nurses who take a history of the incident, a medical history on the patient and complete a thorough physical exam.
"We're trained in evidentiary rules of the legal system, as well as forensic photography and psychosocial aspects of victimization," she emphasized. "We also have significant training in accurate and appropriate documentation of both the history of the incident and our exam findings."
Special Skill Sets
Lewis-O'Connor talked about the special skill set used to collect evidence in sexual assault cases.
"These very precise skills are quite involved, and you need to do a number of cases before you become proficient," she said. "Many years ago, we were collecting evidence not knowing best techniques, and very often law enforcement couldn't use the evidence we provided."
Lewis-O'Connor also emphasized forensic nurses take patient histories very differently than they were taught in nursing school.
"When a typical patient comes into the ED with a fever, for example, we ask a lot of probing questions so we can get an idea of the source of that fever," she said. "With sexual assault victims, we don't probe as much because we don't want to be asking leading questions about the crime.
"As forensic nurses, we have learned that approach is all wrong it is leading the victim. It's not up to us to ask, 'So how many drinks did you have that evening?' We leave that component of the history-taking up to the police and attorneys involved in the case."
Carroll said she's found her SANE experience has led her to become more observant of the whole picture when she interviews patients.
"Forensic nursing teaches us to look at the big picture and take a close look at what happened to the patient before she came into the acute care setting," she noted. "We need to listen and be more open to what patients don't even know they're telling us."
Nancy Cabelus, MSN, RN, a state trooper with the Connecticut State Police and a doctoral student in the PhD nursing program at the University of Tennessee in Nashville, talked about the good fit between nursing and law enforcement.
"As I got into the forensic aspects of my law enforcement role, my nursing skills really supported me throughout my career," she noted. "The interpersonal skills, ability to talk with people and gather information, the critical eye I developed as a nurse, and my ability to assess a situation and document my findings were all crucial as a state trooper."
"Nurses are really detectives at heart," Cabelus continued. "Think of how we gather data and figure out what's causing abnormalities in a patient! You have to put on your detective hat when you're evaluating what's going on."
Cabelus has successfully combined careers in both law enforcement and nursing. "I was a state trooper, beginning with highway patrol and eventually working my way into criminal investigations, doing some high-profile homicide cases."
She will soon be retiring from her law enforcement job and will work as an expert forensic nurse consultant to a specialized unit within the Department of Justice in Bogota, Columbia, over the next 2 years.
Making a Difference
Whatever their role or setting, forensic nurses are making a significant difference in the lives they touch. Lewis-O'Connor, who has just completed a study with Ann Burgess, DNSc, RN, professor at Boston College, and Elaine Nugent of the American Prosecutors Research Institute, explained, "We found significant and statistically different findings that indicate more evidence is collected when a SANE is involved, more DNA is discovered, and there is a direct association between the SANE response and the likelihood that charges will be filed by the prosecutor.
"When the defendant's attorney sees the evidence, he'll often tell the client, 'You'll probably end up going to jail, so I'd recommend a plea bargain.'"
Noting there was significant debate among professionals caring for sexual assault victims when she entered the field 15 years ago, Lewis-O'Connor remarked, "Today, however, we have collaborative and collegial relationships with the courts, the police, rape crisis/social workers, nursing, the district attorneys' offices and the medical community.
"That collaboration is a win-win, and everyone benefits especially the victims."
Moynihan concurred, "What we as educators need to present at both the undergraduate and graduate level in nursing are the knowledge, skills and ability to look at every clinical situation through a forensic lens," she said.
"The forensic nurse can establish a safety net that will enable clients to reach out for help. This growing area of specialization, particularly in these troubled times, is gaining momentum and meeting the challenges of nursing in today's world."
Sandy Keefe is a regular contributor to ADVANCE.