Global Expansion of the Forensic Nursing Specialty
Patricia A. Crane, Ph.D., MSN, RN, WHNP-BC, DF-IAFN, Associate Professor, School of Nursing, University of Texas Medical Branch
Forensic nurses address sexual assault, child abuse, domestic violence and elder abuse trauma victims, and their long term mental and physical health effects. The impact of trauma has been repeatedly documented in the health literature. Violence is considered a public health issue, a legal matter, and a very private health issue. The health care needs of victims of violence necessitate that nurses and all health care workers act as teams with criminal justice officials and the police. The team efforts caring for traumatized patients who cannot act on their own behalf will result in the most effective advocacy, education, prevention, and intervention outcomes.
Since the early 1970’s and the unique care provided by forensic nurses has been recognized globally, although historically nurses have documented their involvement in medical-legal-ethical work. This manuscript will define forensic nursing and explain forensic nursing roles. Forensic nursing development and organization will briefly be reviewed as well as the ethical responsibilities and implications for clinical, education, and research outcomes.
What is a Forensic Nurse?
A forensic nurse provides specialized care for patients who are victims and/or perpetrators of trauma. Forensic nurses identify with their nursing identity first, and yet the specialized role goes far beyond routine nursing care. Forensic nurses also have knowledge of the legal system and skills in injury identification, evaluation and documentation. A patient’s immediate medical needs are addressed initially, then evidence is collected, medical testimony in court may be required and consultation with legal authorities and other professionals (International Association of Forensic Nurses [IAFN], 2013).
Forensic nurses are skilled health care professionals who work in collaboration with other health experts, criminal justice and legal professionals. Simply caring for the patients who are victims of crime is not enough. The forensic nurses see the professional role as an intersection among various team specialists, a concept that developed in the early 1970’s. They must have a special understanding of the law. Forensic nurses may work with Child Protection and Advocacy agencies that protect children and other vulnerable populations. All members of a forensic team need the input and advice from health, law enforcement, psychologists and psychiatrists who are trained to deal with trauma and its effects on patients’ health.
Relationships between health care and law enforcement professionals have developed out of necessity to guide professional responsibilities and assure legal compliance. Forensic nurses recognize the valuable link between a victim, the health care facility, and all experts working together to identify criminals and stop crimes.
Forensic Nursing Roles Development
In1994 a group of nurses gathered in the State of Minnesota, USA, at the initial forensic nursing national gathering to discuss their role of providing forensic medical care for victims of violence. Most of the nurses at the historic gathering were sexual assault nurses and today that remains the most commonly identified forensic nursing role in all countries of the world. They shared roles and responsibilities that expanded far beyond the sexual assault nursing role. It was at this initial gathering the IAFN was conceived and continues today with hundreds of nursing experts and scientists gathering from around the world. Each year more nurses from outside North America attend the Annual IAFN Scientific Assemblies. In addition more nurses from outside North America are obtaining their forensic education and developing programs to teach in their country of origin to meet the forensic nursing education needs and the health needs of trauma victims.
The sexual assault nurse examiner who works in a hospital program is the initial role for many nurses in the specialty who find that with additional training and experience they are prepared for other roles. Sexual assault experts and educators train nurses to conduct forensic medical examinations in all continents, and nurses also attend trainings and IAFN conferences in the USA.
Nurses from other countries (Asia, Central and South America, Europe) claim they may not be allowed to perform fully or as autonomously as a forensic nurse in North America, particularly if genital exams were needed for victims of sexual abuse. It would not be in the nursing purview according to the laws that govern nursing in other countries. A midwife or the physician would perform the pelvic examination. The practice of a sexual assault nurse differs in all countries but the special training is critical for the best outcomes. With the assistance of nurse midwives, and in collaboration with physicians, nurses may do much of the interview and assessment, and assist the physician or midwife with the pelvic exam and with evidence collection.
Nurse Coroners or medical examiner systems have forensic nurses working as death investigators who may initiate or conduct the examination of a deceased person and the death scene to interpret findings, assess cause of death, and document data. Often the nursing science background goes beyond the knowledge of death investigators. The Coroner’s offices often house grief counseling services, organ donation and transfer services which employ forensically trained nurses in an expanded role. Specially trained teams include forensic nurse coroners and others with vast and varied forensic expertise that travel to other countries to investigate post war mass gravesites, victims of trauma, abuse, torture, and disaster (Martin, 2013).
Forensic nurses in patient care facilities such as long term care have a variety of responsibilities working with disabled and elderly persons, and investigating allegations of abuse of vulnerable populations. Monitoring drug administration and environmental safety issues, environmental safety, work related injuries and risks are potential forensic nurse responsibilities. Forensic nurses also investigate malpractice cases as legal consultants, and work with forensic nursing teams that investigate and collect evidence for domestic violence and abuse cases, auto accident cases, and others that present in the emergency department.
Forensic nurses work in secure environments with persons in custody awaiting trial and also with those who are incarcerated in prison convicted of crimes. They assure ethical and humane treatment, safety for all workers, in addition to meeting the mental health care needs and providing therapy for patients and families of victims and perpetrators of crime.
Ethical Responsibilities
The International Code of Ethic for Nurses is considered to be the nonnegotiable standard on which nurses around the globe base their professional practice (International Council of Nurses [ICN], 2012). The obligatory actions to their patients are to promote health, to prevent illness, to restore health, and to alleviate suffering. The nursing responsibility for collaboration with health care professionals and advocacy are emphasized. Application of this code as a guide to action ensures fairness, a non-biased approach, and impartiality that are crucial in forensic nursing. The code imparts an obligation to respect confidentiality and inform patients of its limits (Constantino, Zalon, & Young, 2013). In order to promote public health globally the forensic nurse must understand the societal factors related to violence in the community where forensic nursing is practiced. An expanded discussion of ethical legal issues for forensic nursing is provided by Constantino, Zalon, & Young (2013).
Implications for Forensic Nursing Outcomes
The importance of the need for forensic nurses on a global level was recently emphasized by 113 Ministers at the United Nations signing a declaration that prohibits amnesties for sexual violence in peace agreements and allows apprehension of suspect s anywhere in the world. They pledge a new International Protocol to help ensure evidence collection that will stand up in court (Associated Press, Sept. 2013). Evidence will be used in court to bring guilty persons to justice. Evidence from the research perspective is critical to translate into practice for the growth and development of forensic nursing science globally. Nursing outcomes may be applied to practice or to research. Outcomes regarding evidence could include cases with and without evidence or involvement of a forensic nurse, or cases that proceeded to court, and the impact of evidence in court on cases.
Eradication of interpersonal crimes with prevention efforts is one top priority with forensic nursing practice. Outcomes to measure may include assessment of the type and frequency of injury from abuse in order to develop the most appropriate prevention and intervention strategies in a specific region or community population. Focused intervention programs will help to eliminate health disparities related to long term negative health effects following interpersonal violence. For example response to an elder neglect report could include counseling and family home visits from nurses, connecting families with resources in the community such as elder day care programs.
In education programs and clinical trainings, evaluation and measurement should always be included. Using standards of education in forensic training programs and the measurement of learners’ knowledge can be measured before and after trainings.
Forensic nursing will be most effective in its global expansion and have a positive impact on health outcomes when the development of training and education programs include forensic nursing experts. Accessing education and competency skills trainings to share in various countries is the initial step. Programs taught and made to fit local law, customs, and culture will be the most useful. Sensitivity training and self-care must precede forensic education and be incorporated as part of the ongoing support of the forensic team. Forensic nursing work is more stressful for some than for others and having the psychologist or counselor on the team is crucial for the health of the forensic team.
In the global health arena, all forensic nursing knowledge is only of value if it is useful in the society in which it is being applied. Therefore the forensic nurse educators must also apply and share knowledge in classroom with cultural sensitivity that is appropriate for their society with ethical principles in mind. Forensic nursing must be taught without bias, blame while incorporating the societal factors related to victimization, violence, safety in the community where forensic nursing is practiced. Specifically, cases and issues should be considered that impact the society or community of the nursing audience in order to discuss and develop appropriate solutions for prevention and intervention strategies. One example is human trafficking. The forensic nurse can play a key role in educating health workers and police about how to identify victims and help with their health issues.
Forensic nursing education courses are available online and through multiple universities, colleges, continuation education programs, and through the IAFN website
www.iafn.org. Brief trainings, online continuing education offerings and seminars can fill in the educational gaps globally needed for the forensic nursing team.
The CDC and the major institutions publish educational materials and requirements for proper care of forensic patients in their guidelines. A select number of courses with specific content may result in a certificate that verifies content learned or that a test of standard knowledge was completed for the forensic nurse. In addition degrees for the forensic nursing specialty may be earned at the master’s or doctoral level. (See sidebar.)
Summary
The interest in forensic nursing is spreading rapidly around the globe. There is no doubt that the impact nurses can have with health care and legal outcomes is tremendous and worthy of including in research. Advancing education must be based on standards and with measurable educational outcomes. As education and educators grow in number issues will emerge to define the forensic nursing needs in each region and community and allow for cultural and ethnic specific interventions.
References
1. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved
Women, Committee Opinion, Ault Manifestations of Childhood Sexual Abuse. Aug, 2011 # 498
2. Associated Press. 113 countries sign declaration pledging new action to end sexual violence in conflict.
3. Constantino, Zalon & Young (2013). The Ethical, Legal, and Sociocultural Issues in Forensic Nursing.
Forensic Nursing: Evidence Base Principles and Practice (Ed.: Constantino, Crane, & Young).
Philadelphia: F.A. Davis.
4. International Association of Forensic Nurses (IAFN). accessed September 29, 2013
www.iafn.org5. International Council of Nurses (ICN). (2012). The ICN code of ethic s for nurses. Geneva: ICN.
6. Martin, C. (2013). Forensic Explorations of Global Human Rights Violations and Genocide. Forensic
Nursing: Evidence Base Principles and Practice (Ed.: Constantino, Crane, & Young). Philadelphia:
F.A. Davis.
Sidebar
List of Forensic Programs in Colleges and Universities
Boston College, Chestnut Hill, Massachusetts, USA
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Masters in Forensic Nursing
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Cleveland State University, Cleveland, Ohio, USA
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Master of Science in Nursing-Forensic Track
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Duquesne University, Pittsburgh, Pennsylvania, USA
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Master of Science in Nursing
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Fairleigh Dickinson University, Teaneck, New Jersey, USA
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Master of Science in Nursing-Forensic Specialty
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Fitchburg State University, Fitchburg, Massachusetts, USA
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Master of Science in Forensic Nursing
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Johns Hopkins University, Baltimore, Maryland, USA
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Clinical Nurse Specialist Forensic Nursing Focus
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Monmouth University West Long Branch, New Jersey, USA
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Master of Science Forensic Nursing
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Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
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Master of Science in Forensic Science
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University of Central Oklahoma, Edmond, Oklahoma, USA
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Master of Science in Forensic Nursing
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University of Notre Dame Australia, Western Australia, Australia
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Graduate Diploma in Forensic Nursing
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Victorian Institute of Forensic Medicine, Southbank, Australia
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Graduate Certificate in Nursing (Forensic)
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University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Forensic Science Minor
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University of Tennessee, Memphis, Tennessee, USA
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Doctorate in Nursing Practice, Dual Family Nurse Practitioner and Advanced Forensic Nursing
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Xavier University, Cincinnati, Ohio USA
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Masters in Forensic Nursing
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