Forensic Nurses: Victims' Best Advocate, Criminals' Worst Nightmare
Monday April 21, 2003
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Often in such cases, the victim is reluctant to tell anyone - she sticks her head in the sand and hopes that the horrible incident will just go away. Meanwhile, she's emotionally ravaged and at risk for sexually transmitted disease, and her assailant is free to drop his date rape drug in another victim's drink. In criminal situations like this, a forensic nurse is the victim's best advocate and the criminal's worse nightmare.
A Multifaceted Specialty
Recognized as a nursing specialty in 1995 by the American Nurses Association, forensic nursing draws on nursing science and applies it to legal proceedings, bringing continuity of care and well-documented evidence from the ED or crime scene to the courtroom. According to clinical forensic nurse specialist/educator Katherine Scholl, RN, SANE-A, CMI-3, DABFN, FACFE, who works for Wuesthoff Health Systems in Brevard County, forensic nursing is a broad term that can include holding positions in a coroner's office, specialized hospital unit, or law enforcement agency. Forensic RNs deal with issues like sexual battery, domestic violence, homicide, and homeland security issues. "If it involves the law in any way, it comes under the umbrella of forensic nursing," she says.
As a forensic nurse (FN), Scholl is the on-call sexual assault nurse examiner for adults (SANE-A) at Wuesthoff's Rockledge and Melbourne facilities. She also does in-house education for bioterrorism and is involved with disaster planning. "After September 11," says Scholl, "anything related to terrorism now falls under Federal Bureau of Investigation jurisdiction. This means forensic specialists are needed to clearly establish where and whom evidence comes from in a disaster."
If a gunshot victim is taken to the ED, for example, staff may clean a wound, washing away important forensic evidence like gunpowder residue - or they may suture without first photographing and measuring the wound. It takes a dedicated forensic expert to focus on gathering crucial evidence for legal proceedings while life-saving measures are being undertaken.
FNs are frequently subpoenaed to offer expert testimony in the courtroom. Scholl loves the opportunity to state the facts and report what she's seen: "I get a real kick out of going to court."
Time and Expertise
Traumatized victims of crime need someone like an FN who has the time and training to comfort them as well as help them understand the importance of meticulous collection of evidence.
It's not unusual to see victims of sexual battery in the ED at Shands at AGH in Gainesville, the hometown of the 48,000-student University of Florida. Because the school is so big, the ED is covered around the clock by nine forensic nurse examiners (FNEs) certified in handling sexual assault cases.
FNEs at Shands have extensive classroom training and have met all requirements for the hospital's certification program, including riding along with police, training in evidence collection with the Florida Department of Law Enforcement, and performing a set number of supervised pelvic exams. Conducting community outreach programs is a component of the program, as well.
When a rape victim arrives for help, ED staff members pick up the slack, freeing the FNE to address acute medical needs, such as pain or bleeding. The victim is then whisked away to a quiet room where a comprehensive exam can be performed. The FNE carefully collects evidence and maintains chain of custody - a specific process for properly documenting and handling evidence - which can be crucial in developing a strong legal case.
It's often a challenge to meet the 72-hour industry standard for evidence collection when a victim is reluctant to be examined or press charges. This is where the FNE's expertise comes into play. "We need to make sure the victims understand that charges can be dropped later if they want," says Shands ED nurse Rebecca Norton, RN, FNE. "But if we miss that opportunity to collect evidence within that 72-hour window and they decide to press charges later, they may be out of luck."
Education Varies
According to the International Association of Forensic Nurses (IAFN), sexual assault nurse examiners (SANEs) are forensic nurses trained to treat victims of emotional trauma and physical injury and collect forensic evidence for a trial. The certification is a primary entry point into forensic nursing from which RNs can expand their practice. SANE certification indicates a nurse has not only met educational and employment requirements, but has also passed IAFN's standardized test.
Forensic nursing entry points can also range from continuing-education credits that help define a job description to certificates or nursing degrees with an emphasis on forensics, the latter helping open doors into clinical/research nursing education. Many nursing schools these days are including forensics in accredited curricula at both undergraduate and master's levels.
Pam Kelly, RN, CNM, forensics director of the nurse examiner's program (NEP) at the Crisis Center of Tampa Bay, has on staff eight advanced practice nurses trained to handle sexual assault cases. The NEP, the first of its kind in Florida, promotes the physical and psychological health of sexual assault survivors through crisis counseling and medical and referral services; it also helps the judicial process through evidence collection and provision of expert testimony.
"One of our nurses is SANE certified through the IAFN," says Kelly, who hopes to establish the crisis center as a facility for clinical training for certification. "Even though we've been doing this work for 22 years and we call ourselves forensic nurses, our goal is to get all our NPs SANE certified."
In January, Boca Raton-based Kaplan College launched a yearlong forensic nursing certificate program, the first Health Care Pathways online program of its kind. Nurses worldwide with a certain knowledge base can gain additional skills in legal, scientific, and psychosocial aspects of forensic nursing, all at the click of a mouse. "Part of the advanced education certificate curricula involves assessing the community for gaps in social services and gaining skills in incident stress, crisis counseling, and group intervention," says program developer and senior faculty member Julie Brown, MD, RN, MBA, ASN.
Science, Technology, and Funding
One of the biggest frustrations in forensic nursing is the legal system's inability to keep every perpetrator locked up. "Most rapists rape again in three years," says Kelly. "Also, it's very upsetting that in the last year, we're seeing a 32% increase in violence [against] the 12- to 17-year-old and elderly categories."
Kelly says tools like the colposcopy machine, used for imaging genital trauma, have helped her FNEs gather 25% more evidence than they might with the unassisted eye.
The combined DNA index system - more familiarly known as CODIS - for tracking DNA from state to state has also put some muscle behind identification of perpetrators.
On the legislative front, a White House-backed DNA evidence-related measure
calls for $5 million dollars in fiscal 2004 to support development of training and educational materials for physicians and nurses involved in treating victims of sexual assault, including programs like SANE.
"Forensic nursing is a prime field for nurses," says Cindy Keller, RN, BSN, director of critical care and emergency services at Shands at AGH. "We're detail-driven folks, and we know how to document. In fact, with our FNEs' interventions, the community's conviction rate has increased. The attorneys in town believe rapists know we have experts here. I think forensic nurses are
a real deterrent."
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