Meliss Vessier-Batchen, DNS, RN, CFN

 The death of a loved one (spouse, significant other, parent, child, close relative, close friend) is one of life’s most traumatic events  Death of a loved one by homicide or by suicide challenges the survivors of these decedents beyond their abilities to cope  The development of complicated grief may develop as a result of the death of a loved one by any sudden and/or traumatic manner. 2 M. Vessier-Batchen, DNS, RN, CFN

 Death investigator at every homicide or suicide scene (LSA R.S. 33:1563)  No minimum standard of education, training, or knowledge (USDOJ, 1999)  Many forensic science practitioners are recognizing potential positive impact of nurses in the role (Pyrek, 2003)  FNDIs currently in practice in Texas, Oregon, South Caroline, Colorado (St. Germain & Vessier- Batchen, 2004) 3 M. Vessier-Batchen, DNS, RN, CFN

 Coping Strategies  Lazarus & Folkman (1984) - problem- focused and emotion-focused  Moos (1993) approach and avoidance  Complicated Grief  Rando (1993)  Prigerson & Jacobs (2001) 4 M. Vessier-Batchen, DNS, RN, CFN

 Homicide – criminal taking of a life (manslaughter, murder) of one human by another human by act or omission (Duhaime Canadian Law Dictionary, 2004)  15,980 homicide in the US in 2002  Approximately 95,000 to 159,000 survivors yearly  In Louisiana, 15% of all deaths recorded for 2002 were homicides  Homicides in St. Tammany, Tangipahoa, Orleans, & Jefferson comprised 51% of all homicides in the state 5 M. Vessier-Batchen, DNS, RN, CFN

 “Self-murder”  Approximately 30,000 suicides reported in US in 2002  Louisiana reported over 12% of all deaths as suicide; St. Tammany, Tangipahoa, Orleans, & Jefferson Parishes reported 28% of all deaths attributed to suicides  Stigma associated with suicide not present with any other form of death 6 M. Vessier-Batchen, DNS, RN, CFN

7  Identify & compare coping strategies used by survivors of homicide and suicide decedents during the initial discovery or notification of the death of a loved one by homicide or suicide.  Explore development of symptoms of complicated grief as more prevalent in survivors of suicide decedents rather than survivors of homicide decedents.  H 1 There are differences between coping strategies used by survivors of homicide decedents and suicide decedents.  H 2 Survivors of suicide decedents are more likely to develop complicated grief than survivors of homicide decedents. M. Vessier-Batchen, DNS, RN, CFN

8  Understand relationships between initial coping strategies and the development of symptoms of complicated grief  Knowledge of coping strategies would benefit other survivors by aiding in developing interventions to aid these survivors at the scene  Earlier and positive interventions by first- responders may decrease the incidence of development of symptoms of complicated grief in survivors M. Vessier-Batchen, DNS, RN, CFN

 Coping Strategies  Theoretical Definition  A constantly changing cognitive & behavioral effort to manage a specific external and/or internal demand that is appraised as taxing or exceeding the resources of the person (Lazarus & Folkman, 1984)  Operational Definition  Approach coping (problem-focused) determined by higher scores on the subscales 1-24, or avoidance coping (emotion-focused) determined by higher scores on the subscale items on the CRI-Adult (Moos, 1993) 9 M. Vessier-Batchen, DNS, RN, CFN

 Complicated Grief  Theoretical Definition  Grief that is considered more complex, enduring, & association with lasting mental health problems, including major depressive disorder, depression, anxiety, PTSD, & substance abuse (APA, 2000). Additionally, decreased social functioning, & physical illness (Prigerson & Jacobs, 2001)  Operational Definition  A total score of 41 or higher on the ICG-R – Short Form (Prigerson & Jacobs, 2001) 10 M. Vessier-Batchen, DNS, RN, CFN

 Uses 48 questions to measure approach coping (Questions 1-24) and avoidance coping (Questions 25-48)  Designed to measure coping responses to stressful life circumstances  Cronbach’s alpha = 0.67  Reliability will be reported for these two populations  Developer states that incomplete responses decrease strength of data 11 M. Vessier-Batchen, DNS, RN, CFN

 Measures the development of complicated grief  Measurements are most accurate if participant is 6 months or more after death  Includes a demographic form which has been modified (with permission) in order to extract necessary information  Must be complete in order to use data 12 M. Vessier-Batchen, DNS, RN, CFN

 Confidentiality maintained through sequential number system for monitoring only on each instrument and response sheet  Informed consent obtained for each participant  Instruments completed in privacy of participant’s choice of location  A grief support resource list provided to each participant  Two free counseling sessions available for any participants unable to afford fee for counseling related to participation in the study 13 M. Vessier-Batchen, DNS, RN, CFN

 Search engines used from June 2002 to April 2007  CINAHL  Medline  PsychINFO  ERIC  Questia 14 M. Vessier-Batchen, DNS, RN, CFN

15  Sample n =21 in each group with an effect size of 0.89  Unique opportunity – n =32; n =10; N =42  Decreased statistical significance but practically and clinically rich and meaningful data indicative of trends M. Vessier-Batchen, DNS, RN, CFN

16  Demographics  Descriptive and 2-sided Chi-square or Fisher’s exact test  composition of and differences ~ each group  Hypotheses  Mann-Whitney U tests and descriptive analysis for median values  check for significant differences in coping strategies and median scores ~ groups  Fisher’s exact tests  compare frequencies of development of complicated grief ~ survivor and event groups M. Vessier-Batchen, DNS, RN, CFN

18  66.7% ( n =28) Female  81% ( n =34) Caucasian  85.7% ( n =36) Some college  88.1% ( n =37) < 65 years of age  45.2% ( n =19) Catholic  66.7% ( n =28) Professional  69% ( n =29) Live with immediate family M. Vessier-Batchen, DNS, RN, CFN

19  52.4% ( n =22) Immediate family relationship to decedent  40.5% each ( n =17; n =17) 25 to 60 months and > 61 months elapsed since death  9.5% ( n =4) Symptoms of complicated grief present  100% ( n =4) Immediate family relationship to decedent  75% ( n =3) 6 to 24 months elapsed since death  75% ( n =3) Survivors of suicide decedents M. Vessier-Batchen, DNS, RN, CFN

20  Homicide (n = 21)  52.4% ( n =11) Female  73.2% ( n =16) White  81.0% ( n =17) College  73.2% (n =16) < 65 yoa  57.1% ( n =12) Catholic  57.1% ( n =12) Professional  52.4% ( n =11) Live with immediate family  Suicide ( n = 21)  81% ( n =17) Female  85.7% ( n =18) White  90.5% ( n =19) College  100% (n =21) < 65 yoa  52.4% ( n =11) Other  76.2% ( n =16) Professional  85.7% ( n =18) Live with immediate family M. Vessier-Batchen, DNS, RN, CFN

21  Age and household occupancy were significant factors in coping for survivors of homicide and suicide survivors  These variables are supported in extant literature as significant factors in coping M. Vessier-Batchen, DNS, RN, CFN

22  Homicide (n = 21)  66.7% ( n =14) Other relationship to the decedent  47.6% ( n =10) 26 to 60 months elapsed since death  Suicide ( n = 21)  71.4% ( n =15) Immediate family relationship to the decedent  47.6% ( n =10) > 61 months elapsed since death M. Vessier-Batchen, DNS, RN, CFN

23  Relationship to the decedent was significant for differences ~ homicide and suicide survivor groups M. Vessier-Batchen, DNS, RN, CFN

24  Pre-Katrina ( n =32)  75% ( n =8) Female  87.5% ( n =28) Caucasian  43.8% ( n =14) Some college  28.1% ( n =9) 46 to 55 years of age  46.9% ( n =15)Catholic  25% ( n =8) Professional; 25% ( n =8) Health Care worker  31.3% ( n =10) Live with a spouse  Post-Katrina ( n =10)  60 % ( n =6) Male  60% ( n =6) Caucasian  60% ( n =6) College degrees  30% ( n = 3) 36 to 45 years of age; 30% ( n =3) 46 to 55 years of age  60% ( n =6) Baptist  40% ( n =4) Professionals  60% ( n =6) Live with a spouse M. Vessier-Batchen, DNS, RN, CFN

25  Religious affiliation differed significantly between event groups, pre- and post- Katrina M. Vessier-Batchen, DNS, RN, CFN

26  Pre-Katrina  21.9% ( n =7) other relationship to decedent  43.8% ( n =14) reported time elapsed as months  Post-Katrina  50% ( n =5) were immediate family members  40.6% ( n =4) reported time elapsed as > 61 months M. Vessier-Batchen, DNS, RN, CFN

27  No significant differences between event groups M. Vessier-Batchen, DNS, RN, CFN

28  Absent ( n = 38)  63.2% ( n =24) Female  81.6% ( n =31) Caucasian  86.8% ( n =33) College  86.8% (n =33) < 65 yoa  50% ( n =19) Catholic  68.4% ( n =26) Professional  68.4% ( n =26) Live with immediate family  76.3% ( n =29) Pre-K  Present ( n = 4)  100% ( n =4) Female  75% ( n =3) Caucasian  75% ( n =3) College  100% (n =4) < 65 yoa  50% each ( n =2 ;n =2) Baptist & Other  50% each ( n =2 ;n =2) Professional  75% ( n =3) Live with immediate family  75% ( n =3) Pre-K M. Vessier-Batchen, DNS, RN, CFN

29  Significant differences between participants assessed with and without symptoms of complicated grief for religious affiliations M. Vessier-Batchen, DNS, RN, CFN

30  Absent( n = 38)  52.6% ( n =20) Other relationship to the decedent  44.7% ( n =17) > 61 months elapsed since death  52.6% ( n =20) Homicide  Present ( n = 4)  100% ( n =4) Immediate family relationship to decedent  75% ( n =3) 6 to 24 months elapsed since death  75% ( n =3) Suicide M. Vessier-Batchen, DNS, RN, CFN

31  Relationship to the decedent and time elapsed since the death differed significantly for participants assessed with and without symptoms of complicated grief M. Vessier-Batchen, DNS, RN, CFN

33  H 1 There is a difference between approach and avoidance coping strategies as identified by the Coping Responses Inventory-Adult (CRI-Adult) used by survivors of homicide and suicide decedents during the initial discovery or initial notification of the death of a loved one. M. Vessier-Batchen, DNS, RN, CFN

34  Problem Seeking  p =.016 SOH Mdn = 7.0 SOS Mdn = 12.0  Cognitive Avoidance  p =.009 SOH Mdn = 6.0 SOS Mdn = 11.0  p =.023 SOH Mdn = 6.0 SOS Mdn = 11.0  Emotional Discharge  p =.041 SOH Mdn = 5.0 SOS Mdn = 8.0  p =.032 SOH Mdn = 4.5 SOS Mdn = 7.5 M. Vessier-Batchen, DNS, RN, CFN

35  Statistical significance was achieved for Problem Seeking, Cognitive Avoidance, and Emotional Discharge with median values indicating that the suicide survivor group indicated these strategies as more important than the homicide survivor group  Hypothesis 1 was supported for three of the eight coping strategy subscales M. Vessier-Batchen, DNS, RN, CFN

36  Avoidance coping strategies Acceptance or Resignation (pre only) and Seeking Alternative Rewards (pre and post) were used as more primary by survivors of homicide decedents than survivors of suicide decedents in the Pre- and Post-Katrina groups M. Vessier-Batchen, DNS, RN, CFN

37  Logical Analysis  p =.084 (Total Sample)  p =.091 (Pre-Katrina)  Seeking Guidance & Support  p =.075 (Pre-Katrina)  Problem Seeking  p =.075 (Pre-Katrina)  p =.091 (Post-Katrina) M. Vessier-Batchen, DNS, RN, CFN

38  H2 Survivors of suicide decedents are more likely to develop symptoms of complicated grief than survivors of homicide decedents. M. Vessier-Batchen, DNS, RN, CFN

39  Survivors  Homicide Suicide Sig  n = 1 (5%) n = 3 (15%).303  Events  Pre-Katrina Post-Katrina  n = 3 (9%) n = 1 (10%) M. Vessier-Batchen, DNS, RN, CFN

40  Hypothesis 2 was not supported as statistical significance was not reached  Findings did indicate that survivors of suicide decedents may develop symptoms of complicated grief more often than survivors of homicide decedents  Field observations were supported by these findings M. Vessier-Batchen, DNS, RN, CFN

41  Incorporate coping and attachment concepts and theories as they relate to survivors of trauma such as survivors of homicide and suicide decedents throughout generic nursing programs to better prepare nurses to care for these vulnerable individuals and families.  Direct a designated portion of didactic and clinical experiences to include coping and attachment concepts and theories as they relate to forensic populations promoting application of the concepts and interactions with the populations through formal preceptorship M. Vessier-Batchen, DNS, RN, CFN

42  Replication of study with larger samples over wider geographic areas.  Exploration of initial coping strategies using qualitative methods based on the findings of this study.  Development of longitudinal research studies that specifically identify initial coping strategies.  Development and testing of interventions designed to limit or prevent further trauma in survivors of homicide and suicide decedents, based on the findings of this study.  Initiation of longitudinal research studies that isolate and identify time frames for the onset of symptoms of complicated grief in survivor groups. M. Vessier-Batchen, DNS, RN, CFN

43  Explore collaborative development of standards of clinical nursing experiences that will support and provide care for survivors of homicide and suicide decedents using the findings of this study.  Develop clinical nursing affiliations that formally integrate clinical knowledge with field observations and practice that promote positive interactions between nurses and survivors of trauma. M. Vessier-Batchen, DNS, RN, CFN

44  H 1 was supported in three of eight strategy subscales.  Differences in use of coping strategies ~ groups  Median values indicated greater variety of use and greater importance of most coping strategies in suicide survivor group than homicide survivor group  H 2 was not statistically supported.  Field observations were supported. M. Vessier-Batchen, DNS, RN, CFN