1. FORENSICS In Nursing “Current Trends in Forensic Science”
Dr Kithsiri Edirisinghe
MBBS MSC MD ( Medical Administration )

2. References
Cherry, B. & Jacobs, S. (2008). Contemporary nursing: Issues, trends, and management. (4th ed.) St. Louis: Mosby. Martin, N. (2009). Forensic nursing: What, who, where. The Kansas Nurse, 84(3), 3-5. Pyrek, K. (2009). Forensic nursing pioneers ponder the future. Retrieved from (2009). Forensic nurse: Job outlook for forensic nursing. Retrieved from portal.com/articles/Forensic_Nurse:_Job_Outlook_for_Forensic_Nursing.html (2009). Forensic nursing. Retrieved from (2009). The forensic nurse. Retrieved from

3. What is Forensic Nursing?
Nursing science applied to the law
Investigation/treatment of:
Violence
Abuse
Criminal activity
Traumatic accidents
Forensic nursing applies science to the law. It includes the investigation and treatment of: (read slide).

4. The Forensic Nurse A nurse (RN) with specialized training in:
Forensic evidence collection
Criminal procedures
Legal testimony expertise
Specialty Roles:
Clinical forensic nurse (CFN)
Sexual assault nurse examiner (SANE)
Legal nurse consultant
Forensic psychiatric nurse
Forensic correctional nurse
Forensic gerontology nurse
Nurse attorney
Death investigator/Forensic nurse investigator
Forensic nurse educator
A forensic nurse is a registered nurse with specialized training in (read slide). There are many different career specialties to choose from. I will talk about a couple of them. The sexual assault nurse examiner (or SANE) responds to reported cases of sexual assault. The SANE will obtain history, conduct an interview and physical exam, and will also perform a pelvic exam for collection of evidence. The SANE also educated the victim on sexually transmitted diseases and pregnancy risks. The victim will be provided with referrals for follow-up care. The majority of forensic nursing takes place with sexual assault victims. A death investigator or forensic nurse investigator is the first person at the crime scene with a forensic background. This person really has to know forensics to make an accurate call on time of death. Forensic nurse investigators work with detectives, collect evidence, examine the body, collect tissue and blood samples, and photograph the body and crime scene. Some people may think that forensic nurses have to work with dead bodies, but they don’t. It is just one of the options available for forensic nurses.

5. History 1992-1st national convention of sexual assault nurses
International Association of Forensic Nurses (IAFN)
1996-American Association of Nurses
The first national convention of sexual assault nurses took place in 1992 in Minnesota. Seventy nurses attended this convention. Shortly after the convention the International Association of Forensic Nurses was developed. It wasn’t until 1996 that the American Association of Nurses recognized forensic nurses.

6. Current Status of Forensic Nursing
New specialty area of interest
Education continuing to evolve
Colleges and universities
Healthcare facilities, correctional facilities, county prosecutors, coroner’s offices, medical examiner’s offices, insurance companies, psychiatric facilities
Disaster and emergency management
Forensic nursing is one of the fastest growing specialty areas. This is most likely because violence is increasing and resulting in more traumatic cases. Colleges and universities recently added programs. Forensic nurses practice in a variety of different areas including (read slide). They have expanded their role to include disaster and emergency management. Disaster preparedness includes forensic issues such as sexual assault, mass fatality, disposal of human remains, and critical incident stress.

7. Job Description Evaluation of victims of sexual assault
Collect evidence (sexual assault victims and crime scenes)
Interview the victim
Investigate causes of morbidity and mortality
Testify in court
Forensic nurses most often evaluate victims of sexual assault. They collect evidence, interview the victim, investigate causes of morbidity and mortality, and they also testify in court.

8. Job Qualifications RN
Entry-level position is sexual assault nurse examiner (certification)
Specialized training
40 hrs didactics
40 hrs clinical work
Should be trained in handling and collecting evidence such as hairs, fibers, and swabs of fluid for DNA testing
Tools to be familiar with:
Digital camera
Omnichrome
Coloscope
A forensic nurse must be an RN. A degree program is not necessary for entry into forensic nursing. The entry level position is that of sexual assault nurse examiner which only requires a certificate. Forensic nursing involves specialized training including handling and collecting evidence such as hairs, fibers, and swabs of fluid for DNA testing.

9. Salary Varies depending on the part of the country and experience
Starts at $26/hr and can reach as much as $100/hr
On-call rate of $1-4/hr
SANE-1 ½ times base pay
Per case basis: $150-$400
The salary of forensic nurses depends on the area of the country and years of experience. The average starting pay is $26/hr and can increase to as much as $100/hr. Some hospitals pay forensic nurses $1-4/hr just to be on-call. If a SANE is called in to work on a case, that person is typically paid 1 ½ times the amount of their base pay. Some hospitals pay on a case-case basis rather than hourly. In this case the nurse can earn as much as $400 per case.

10. Challenging and exciting Different specialty areas Make a difference
Advantages
Disadvantages
Important resource
Challenging and exciting
Different specialty areas
Make a difference
Demanding hrs
Challenging
Emotional cases
Forensic nurses are an important resource to health care and justice systems. The job is challenging which could be an advantage or disadvantage. A couple of disadvantages are demanding hours and emotional cases. One advantage that might outweigh the disadvantages is that forensic nurses make a difference in the lives of victims of sexual assault.

11. Future Trends Forensic nursing will continue to advance and evolve
New roles and opportunities (increase in the next ten years)
Increasing crime rates
As crime rates continue to increase, forensic nursing will continue to advance. Their will be new roles and opportunities for nurses in forensics. Opportunities are expected to increase quickly in the next ten years. Police forces want to strengthen their cases against criminals and forensic nurses are able to collect evidence and testify in court.

12. Forensics: Pertaining to the Law
Forensic Nursing: Application of Nursing to the Law

13. Forensics is not
about Dead People
IT's about the
LAW

14. Living Victims
Deserve
A Forensic
Specialist

16. What is Forensic Nursing?
The application of forensic science, combined with clinical nursing practice as they are applied to public or legal proceedings in the law enforcement arena.
It is the application of forensic aspects of health care combined with biopsychosocial education of the registered nurse in the scientific investigation and treatment of trauma, death, violent or criminal activity, and traumatic accidents within the clinical or community institution (Lynch, 1991).

17. Forensic Nurses Trauma/ER SANE/FNE/SART
Nurse Coroners/Forensic Nurse Death Investigators
Nurse Attorneys/Legal Nurse Consultants
Psychiatric & Mental Health
Correctional Health
Domestic Violence

18. 1. ER/Trauma

19. ER/Trauma Why are they needed Identification Care for the Survivor
Care for the Perpetrator
Identification & Collection of evidence
Clothes
Injury and patterns of injury

20. ER/Trauma Documentation What we do v. the crime committed
Chain of custody
Measurements in centimeters
Location
Description
Photography

21. 2. SANE/FNE/SART

22. SANE
A registered nurse who has been specially trained to provide comprehensive care to sexual assault patients, who demonstrates competency in conducting a forensic exam and the ability to be an expert witness.

23. Benefits of a SANE TEAM Willingness Specialty training
Comprehensive care
Fact based documentation (drop all opinions)
Forensic issue
evidence collection
chain of custody
courtroom testimony

24. SART-Sexual Assault Response Team
Law Enforcement
Rape Crisis
Medical Response
SANE/RN
Physician
ANP PA
Crime Lab
Counseling Services
Forensic Scientist
CPS/APS
Prosecution

25. Together Everyone Accomplishes More
Don’t tell other members of the TEAM how to do their jobs.
Together we can make offenders want to relocate.

26. SART Provide victim centered services Provide compassionate care
Provide community awareness
Where to come
How we will treat you
Encourage reporting of Sexual Assaults
Encourage successful apprehension and prosecution of guilty offenders
Aid in the identifying of false reporting

27. Sexual Assault Every 45 seconds a women is Sexual Assaulted. 1:5 Women
Screen ALL Trauma Patients (LOC, clothing)

28. Sexual Assault Exam
Sexual Assault is rarely suspected unless an outcry is made.
History from Patient (to diagnosis & treat)
Head-to-toe Assessment
Detailed Genital Exam
Collection of forensic evidence
Treatment for injuries, STD’s & pregnancy

31. DFSA 1/3 offenders convicted-alcohol
40% of 2,366 survivors urine-alcohol
Multiple drugs: Ethanol, Benzo’s (valium, xanax, restoril, klonopin, rohypnol) Barbiturates, GHB, Ketamine, Chloral Hydrate, Muscle Relaxants, Opiates, Sedative Antidepressants
Challenges:
Drugs uses
Reporting
Collection of evidence
Lab methodologies
Dosages

32. JPS Health Network Statistics

33. 1 hour
80 Women

34. 3. Nurse Coroners/ Forensic Nurse Death Investigators

35. Nurse Coroner/Death Investigation
The coroner is a public official who is primarily charged with the duty of determining how and why people under the coroner’s jurisdiction die (these jurisdictions vary form state to state, but typically include sudden, unexpected, unexplained, or traumatic death).

36. Nurse Coroner/Death Investigation
A licensed nurse who carries out the duties of a death investigator in accordance with the performance standards and procedures established under the medical examiner or coroner’s system of death investigating and the jurisdictional standards of practice.

37. Nurse Coroner/Death Investigation
Nurses have the educational background to understand exactly what causes death and what happens to a body after death occurs. Death may be a criminal event, but it is always a medical event. Unlike law enforcement who look at the deceased and want to know, “Who killed you?” nurses look at a dead body and ask, “Why are you dead?” If it is determined that the death was due to criminal cause then it is law enforcement’s job to determine who. Who better to determine the manner of death than medical personnel?

38. Nurse Coroner/Death Investigation
Manner of death is the circumstances in which the cause of death arose, i.e. natural, accident, homicide, suicide, and undetermined. In some cases manner of death may be difficult to determine and may appear accidental (i.e. in a suicide without a note). Forensic nurses possess the skills necessary to complete a psychological autopsy and interpret the subtle nuances of medications, health history and circumstances surrounding suspicious deaths.

39. Nurse Coroner/Death Investigation
Mechanism of death is the physiologic derangement or biochemical disturbance incompatible with life, which is initiated by the cause of death, e.g. cardiac arrest. Forensic nurses are well educated in physiology and are therefore prepared to accurately distinguish between the cause and the physiologic mechanism of death.

40. 4. Nurse Attorneys/ Legal Nurse Consultants

41. Goals To establish a leadership role in health care policy making.
To influence health care social policy, health care legislation and nursing practice acts.
To educate the public about health law issues.
To educate the public about nurse attorneys.
To educate nurses about the legal system.
To represent the public; client advocate.

42. Nurse Attorneys/Legal Nurse Consultants
Nurses want to make fundamental change in the way healthcare is delivered, and recognizing that it needs to occur through legislation and political process is a big piece of it.
Like nurses, attorneys must interact with people who are vulnerable, who have been injured or traumatized, and who need assistance to regain their wholeness.
Client advocacy is the skill nurses bring to the profession.

43. 5. Psychiatric and Mental Health

44. Issues and Goals
The enhancement of appropriate care for the severe and persistently mentally ill.
The integration of psychiatric and addictions treatment.
Strategies for promotion of mental health and prevention of psychiatric disorders.
The provision of appropriate care within the criminal justice system.
The equitable provision of care for children and adolescents.

45. Issues and Goals
Ensuring access to care for older adults and members of minority groups.
Advocacy for access to psychiatric-mental health services as readily as access to medical services.
The development of an evidence-based approach to teaching nursing students about psychiatric-mental health nursing, at both the undergraduate and the graduate levels of education.

46. 6. Correctional Health

47. Correctional Health Nurses
Correctional healthcare is a unique specialty area.
Goals:
Facilitate an improved working relationship between the private sector and the correctional staff in jails, adult and juvenile detention centers, prisons to meet the needs of the inmate patient.
Promote correctional healthcare as part of the public health continuum.

48. 7. Domestic Violence

49. Intimate Partner Violence is an Epidemic

50. The Surgeon General of the United States recently declared:
“Domestic Violence is the number one health issue facing the country today”

51. Domestic Violence
DV is the leading cause of injury to women in the world.
DV is the leading nonobstetric cause of death to pregnant women.
Every 9 seconds a women is battered.
1:3 women are a victim of domestic violence

52. Cycle of Violence Intensity Frequency Physicial Assault Severity Abuse
Emotional
Abuse

53. Eva’s Top 5 Domestic Violence Myths/Facts
Poor/unemployed
The victim spends a lot of time running to the doctor
He would never hurt the children
He only does this when he drinks
He wouldn’t kill her
FACTS
<15% unemployed
Only 2/3 will seek medical assistance
There is an increased incidence of child abuse
67% report alcohol abuse only 1/5 drinking at the time of abuse
2 women die each week at the hands of their husbands/Texas

54. 3-10 Million Children Witness DV Violence in Their Homes Each Year

55. 63% of Young Men Ages 11 to 20 Who Are Serving Time for Homicide Have Killed Their Mothers’ Abusers

56. The Leading Cause of Injury to 14 Year Old Boys

57. More Facts..
DV kills as many women every 5 years as the total number of Americans killed in the Vietnam War…54,000
Approximately 50% of all homeless women and children in the U.S. are fleeing DV.
There are 7 animal shelters for every 1 DV shelter.

58. DV & Healthcare Costs 3-5 billion dollars in health care claims
100 million dollars in absenteeism, high turnover and lost productivity
Employee’s miss 1,175,000 days of work per year because of DV alone
DV in the US costs an estimated $67 billion/year
13,000 acts of DV against women occur in the workplace every year
Up to 52% of victims of DV have lost their jobs because batterers typically engage in behavior that makes it difficult to work

59. Types of Abuse Physical Emotional/psychological Financial
Hitting, kicking, strangulation, weapons
Emotional/psychological
Threats, destruction of self worth, isolation
Financial
Work, advancement, access to finances, credit,

64. Lack of identifying victims of Domestic Violence is consistent in community hospitals and trauma centers.

65. 1 hour
400 women

66. Break The Silence
Make the Call
SAFE

67. 8. The Role of the Forensic Nurse in the Medico-legal Death Investigation

68. Death Investigation Systems in the United States

69. Three Types
Medical Examiner
Coroner
Mixed
DiMaio, (2001), p. 9-18

70. Medical Examiner vs. Coroner
A licensed physician in the state in which she/he practices forensic pathology and has been hired by the jurisdiction to investigate sudden and unexpected deaths
Coroner
An elected official in the jurisdiction who investigates sudden and unexpected deaths. May or may not be a physician
DiMaio, (2001), p. 9-18

71. MEDICAL EXAMINER AND CORONER JURISDICTIONS IN THE UNITED STATES - 2002
State ME, mixed county ME and Coroners
State ME, coroners in every county or district
Mixed ME and Coroners
Coroners in every county or district
State ME, no coroners
District ME, no coroners
County ME, no coroners
Source: Centers for Disease Control. (2004).

72. What is Forensic Nursing?

73. Forensic Nursing
Application of the nursing process to public or legal proceedings
Application of the forensic aspects of health care to the scientific investigation of trauma and/or death related to medicolegal issues
Lynch, (1993)

74. Roles within Forensic Nursing
Clinical Forensic Nurse
Sexual Assault Nurse Examiner (SANE)
Pediatric Forensic Nurse
Forensic Psychiatric Nurse
Nurse Death Investigator/Coroner
Correctional Nurse
Legal Nurse Consultant
Nurse Attorney
Lynch, (1993)

75. The Forensic Nurse Death Investigator

76. What is a Forensic Nurse Death Investigator?
A Registered Nurse who:
applies the nursing process to death investigation across the life span
collaborates with interdisciplinary agencies
identifies trends
conducts and/or participates in research
promotes health and safety through community education.
IAFN, FNDI Standards of Practice, 2004, (draft)

77. What can a nurse add to the death investigation?
Apply nursing knowledge which includes anatomy, physiology, pharmacology and family interaction
Questions are formulated based on a medical knowledge base
Aid families and survivors in terms of the grieving process
Vessier-Batchen, (2003)

78. Role of the Forensic Nurse Death Investigator at the Harris County Medical Examiner’s Office

79. Role in the ME Office Obtain death reports per state code
Augment the natural death and infant/child death investigation
Conduct post mortem sexual assault/child abuse examinations
Provide case management for pathologists
Collaborate with organ/tissue procurement agencies
Harris County Medical Examiner’s Office, (2004)

80. Role in the ME Office
Provide link between pathologists and lay investigative staff
Communicate COD and MOD with families
Educate the community regarding death investigation and forensic issues
Assist with external examinations
Harris County Medical Examiner’s Office, (2004)

81. Augmenting the Natural Death Investigation
Normally, only uniformed officers attend the natural death scene
Other types of death may present as a natural death
Conduct a more thorough investigation
Understand subtle signs of abuse and neglect

82. Case Management
Collaborate with pathologist to determine the appropriate medical records
Review medical records once received
Obtain follow-up information
Organize interagency meetings as necessary

83. External Examinations
Thorough physical examination
Review of medical records
Description via diagrams and dictation
Document pathological findings

84. Evolution of the Forensic Nursing Program at the Harris County Medical Examiner’s Office

85. Prior to Forensic Nursing
In 2002, 80% of deaths that were reported were natural deaths
Investigators had limited medical knowledge
80% of cases brought in to HCME were autopsied
Requests/receipt of medical records were inconsistent

86. Prior to Forensic Nursing
Incomplete records were received and multiple requests had to be made
Medication lists often did not correlate with the medical history
Few inquiries into circumstances that lead up to the death
Information between pathologists and investigators was fragmented at times

87. Forensic Nursing Integrated in Harris County, Texas
After extensive lobbying by Dr. Joye Carter, the Harris County Commissioner’s Court approved 1 Forensic Nurse position
Job description:
Adjunct to pathologists and investigative staff
Oversee medical record aspect of the medicolegal examination
Member of Child Fatality Review Team

88. Community Focus
Improve the natural and infant/child death investigations with better history gathering and assessments
Contact family members in order to provide information on cause and manner of death
Discuss medical and familial implications of cause of death, if applicable
Provide education regarding the medicolegal death investigation

89. Role Begins to Expand
Three positions approved by Commissioner’s Court at the end of 2002
Expand coverage of nursing services to evening and night shift
Assist with review of organ/tissue procurement recovery requests with the pathologist
Assist with natural death and infant/child death scene investigation

90. Expanding Role Provide case management for infant/child deaths
Respond to scenes and take reports
Conduct the forensic gynecological examination and evidence collection
Community education

91. Increasing Nursing Staff
By end of 2003, identified that additional positions were necessary
Conducted survey of selected medical examiner/ coroner offices throughout the United States regarding use of nurses in this setting
Proposal developed to justify additional positions

92. New Positions Are Granted
In September 2003, Commissioner’s Court authorized nine (9) new nursing positions!
Once all positions are filled, there will be twelve (12) nurses!

93. References
Centers for Disease Control. (2004). Medical Examiner and Coroner Jurisdictions in the United States. Found at:
DiMaio, V.M. (2001). Forensic Pathology. (2nd ed). Boca Raton: CRC Press.
Harris County Medical Examiner’s Office. (2004). Forensic nurse/ Physician assistant investigator II. Job description. Found at

94. References
International Association of Forensic Nurses. (2004). Forensic Nurse Death Investigator Standards of Practice. Draft copy.
Lynch, V. (1993). Forensic nursing: Diversity in education and practice. Journal of Psychosocial Nursing, 31(11), p
Vessier-Batchen, M. (2003). Forensic nurse death investigators. The Web Mystery Magazine. Found at:

95. “Justice will only be achieved when those who are not injured are just as indignant as those who are.”
King Solomon

96. Thank you !