Although forensic nursing was recognized as a specialty by the American Nurses Association as recently as 1995, nurses have long worked with forensic patients, particularly victims and perpetrators of violence.1 And while it is common to link the field of forensic nursing with death investigations or emergency department and correctional health settings, a significant amount of forensic nursing takes place within primary care settings.
Primary care nurse practitioners are in an ideal position to identify victims and perpetrators of violence and to prevent future episodes of violence. To accomplish this, nurse practitioners need to screen all patients for potential victimization or offending behavior - and document their findings appropriately.
Forensic Nursing and NPs
Forensics involves legal issues, and literally means "used in or suitable to courts of law or public debate."2 Forensics traditionally was associated with death and homicide. Today, trends in hospital and community health care have broadened this specialty to include identification of previously unidentified trauma and the collection of evidence from living patients.3
Forensic nursing encompasses three areas:4
application of the nursing-related sciences to public or legal proceedings
application of the forensic aspects of health care in the scientific investigation
treatment of trauma or death of victims and perpetrators of abuse, violence, criminal activity, traumatic accidents and environmental hazards.
Nurses share responsibility with the legal system to augment the resources available to patients with liability-related injuries, crime victims and perpetrators or suspects in police custody. This mutual responsibility represents a new perspective in the holistic approach to legal issues surrounding patient care in clinical and community-based institutions. Support is strong for this concept - mainly from people who recognize the amount of knowledge required to go beyond the traditional interventions for crime victims and fill a greater role through forensic expertise in health care.3
All NPs treat a variety of patients, including sexual assault victims and perpetrators; victims and perpetrators of partner violence, child abuse, elder abuse and workplace violence; juvenile delinquents; victims of traumatic accidents; patients with criminal backgrounds; and mentally disturbed offenders. Yet NPs may not always be aware that their patients have histories of victimization or criminal activity. Therefore, it is critical to screen for forensic data.
Forensic Screening for Victims
Violence presents in various forms: verbal abuse, emotional abuse, threats, animal cruelty, property destruction, physical harm, sexual assault, rape, financial abuse, the withholding of care, and homicide. Anyone can be victimized, and children as young as 2 can show warning signs of violent behavior.5 Victims can become offenders. For example, 48% of incarcerated women report being physically or sexually abused prior to being jailed, and 27% report having been raped.6
Screen all patients for signs of victimization and violent offending - and be sure to screen across patient populations. Thus, pediatric NPs should screen parents for partner violence; adult NPs should screen patients for child and elder abuse, and so on. All NPs should screen for animal cruelty, which has been associated with numerous forms of violence, as well as the presence of weapons in the household.7
Intimate Partner Violence
Intimate partner violence (IPV) affects women and men in both heterosexual and same-sex relationships, and it can occur in teens through older adults. Approximately 870,000 women are abused by their partners each year, but in a study of 149 abused women presenting to the justice system for protection orders or to file assault charges, only 24% (n = 36) of the 126 (86%) who had sought health care in the previous year had been assessed for IPV.8 Abuse of men has received little attention, but does exist. The rate of domestic violence in the gay community is similar to that in the heterosexual community.9,10 Between 8% and 53% of adolescents report a history of being physically assaulted by an intimate partner, and unlike abuse in adult relationships, studies find similar rates of victimization among boys and girls.11
The American Medical Association and other organizations recommend screening for IPV, and several clinically useful, reliable and valid screening tools are readily available. These include the Partner Violence Screen, the HITS (Hurt, Insulted, Threatened, Screamed), and the WAST (Women Abuse Screening Tool). Positive results from these tools should be followed by the Danger Assessment and the HARASS (Harassment in abusive relationships: A self-report scale) questionnaires to assess for domestic homicide risk. Risk factors for this include the victim leaving for another partner, the perpetrator's use of a gun, stalking, forced sex, and abuse during pregnancy.12,13