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Margaret M. Sloane, RN, BSN
A college freshman barely 18 years old is away from home for the first time. She goes to a party with a group of friends and is offered alcohol. She refuses and accepts a soft drink. At one point, she puts down her glass, dances for a few minutes, and returns to reclaim her drink. The next thing she remembers is waking up naked in a strange bedroom. She aches all over and suspects that something terrible has happened while she was unconscious.
Often in such cases, the victim is reluctant to tell anyone. 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 Katherine Scholl, RN, SANE-A, CMI-3, DABFN, FACFE, a clinical forensic nurse specialist-educator, 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 home-
land security issues. "If it involves the law in any
way," she says, "it comes under the umbrella of forensic nursing."
As a forensic nurse (FN), Scholl is the on-call sexual assault nurse examiner for adults (SANE-A) at Wuesthoff Health Systems' facilities in Rockledge and Melbourne, FL. She also conducts in-house training for bioterrorism and is involved with disaster planning. "After September 11, anything related to terrorism now falls under FBI jurisdiction," she says. "This means forensic specialists are needed to clearly establish where and whom evidence comes from in a disaster."
For example, if a gunshot victim is taken to the ED, staff members 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 undertaken.
A forensic nurse specialist and educator in private practice in Erie, PA, Lynda D. Benak, RN, MSN, vividly recalls an ED experience that shows the value of forensics in a clinical setting. A gunshot victim had arrived in the ED where Benak worked. When efforts to save him were unsuccessful, the patient was pronounced dead, but a police photographer noted that no bullet was ever retrieved. Yet, when clothing that had been cut away during treatment was placed back on the body, Benak could see a bullet's entry hole in the lower-right pocket of the jacket. The angle of entry and passage through the body indicated that the piece of metal had exited out the left shoulder. When Benak looked between the shirt and the jacket at the shoulder, she found the bullet: Having passed through the body, it had lacked the force to make it through the layers of clothing. "Had I not known to look," says Benak, "the evidence might have been lost."
Time and Expertise
Traumatized victims of crime need someone like an FN with 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. When a rape victim arrives for help in the busy ED, staff members pick up the slack, freeing the FNE to address acute medical needs like 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 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."
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 the 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.
Science, Technology, and Funding
Forensic nursing relies on detailed detective work, says Barbara Madden, RN, EdD, SANE, of the Massachusetts Department of Public Health. An FN herself, Madden recalls the time a comatose patient arrived for treatment in the ED where she worked. The patient had the usual hospital toxicology screen, looking for substance abuse like cocaine, barbiturates, or alcohol. Gamma hydroxyl butyrate (GHB), known as the date rape drug, was not a routine screen for this hospital. After noting that the patient had genital bruises and swelling, Madden suggested a screen for GHB, and it came up positive. "It took a forensic nurse," she says, "to connect the whole picture."
Another frustration in forensic nursing is the legal
system's inability to keep every perpetrator locked up. "Most rapists rape again in three years," says Pam Kelly, RN, CNM, forensics director of the nurse examiner's program (NEP) at the Crisis Center of Tampa Bay, the first program of its kind in Florida. "Also, it's very upsetting that in the last year, we're seeing a 32% increase in violence [against] 12- to 17-year-old and elderly patients."
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 fiscal 2004 funding to support development of training and educational materials for physicians and nurses to collect sexual battery evidence. Money is also included for programs like SANE certification.
Benak uses the catch phrase "Knowledge demands response to knowledge" in her presentations to explain how forensic nursing is enjoying increased recognition as a critical component in healthcare delivery. "Attorneys are beginning to see forensic nurses as valuable tools in the courtrooms," she says. "With forensic education added to our nursing skill set, we are good jury educators and can be very useful in that element."
Margaret Sloane, RN, BSN, is a frequent contributor to Nursing Spectrum.