1. FORENSICS In Nursing “Current Trends in Forensic Science” Medical Examiners Sixth Annual Conference December 14, 2005 Eva Murray, RN, SANE-A JPS Health Network’s SANE/DV Program Manager

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

6. 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. 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). 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).

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

8. ER/Trauma

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

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

11. SANE/FNE/SART

12. 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. 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.

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

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

15. 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.

16. SART Provide victim centered services Provide victim centered services Provide compassionate care Provide compassionate care Provide community awareness Provide community awareness Where to come Where to come How we will treat you 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

17. Sexual Assault Every 45 seconds a women is Sexual Assaulted. Every 45 seconds a women is Sexual Assaulted. 1:5 Women 1:5 Women 1:10-20 Men 1:10-20 Men Screen ALL Trauma Patients (LOC, clothing) Screen ALL Trauma Patients (LOC, clothing)

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

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

22. JPS Health Network Statistics

24. Nurse Coroners/ Forensic Nurse Death Investigators

25. 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). 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).

26. 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. 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.

27. 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? 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?

28. 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. 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.

29. 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. 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.

30. Nurse Attorneys/ Legal Nurse Consultants

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

32. 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. 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. 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. Client advocacy is the skill nurses bring to the profession.

33. Psychiatric and Mental Health

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

35. Issues and Goals Ensuring access to care for older adults and members of minority groups. 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. 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. 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.

36. Correctional Health

37. Correctional Health Nurses Correctional healthcare is a unique specialty area. Correctional healthcare is a unique specialty area. Goals: 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. 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. Promote correctional healthcare as part of the public health continuum.

38. Domestic Violence

39. Intimate Partner Violence is an Epidemic

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

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

42. Cycle of Violence

43. Eva’s Top 5 Domestic Violence Myths/Facts MYTHS MYTHS Poor/unemployed Poor/unemployed The victim spends a lot of time running to the doctor The victim spends a lot of time running to the doctor He would never hurt the children He would never hurt the children He only does this when he drinks He only does this when he drinks He wouldn’t kill her 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

44. 3-10 Million Children Witness DV Violence in Their Homes Each Year 3-10 Million Children Witness DV Violence in Their Homes Each Year

45. 63% of Young Men Ages 11 to 20 Who Are Serving Time for Homicide Have Killed Their Mothers’ Abusers

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

47. More Facts.. DV kills as many women every 5 years as the total number of Americans killed in the Vietnam War…54,000 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. 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. There are 7 animal shelters for every 1 DV shelter.

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

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

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

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