CRC - Forensic Nursing

Organization: CRC
Publication Date: 13 January 2006
Page Count: 667


Forensic science might be at the apex of its popularity among members of the general public who have demonstrated a keen curiosity, satiated by a growing amount of forensic-related television programming. At the time of writing in 2005, no less than half a dozen forensic-themed shows appeared on network and cable television. The studious Forensic Files shares space and time in America's living rooms with the three "Hollywoodized" permutations of CSI: Crime Scene Investigation, and millions of people are tuned in to the exploits of the men and women who work as investigators, forensic scientists, and crime scene and lab technicians. From gritty to glamorous, from realistic to ridiculous, these shows have raised significant awareness of forensic science. Articles in the lay press have documented the "CSI factor," in which an increasing number of juries know about and expect to examine the forensic evidence involved in criminal and even some civil cases; think Twelve Angry Men of today. This is a Law & Order generation; undergraduate and graduate programs are filled to capacity with eager young people dreaming of an exciting career in forensic science or criminal justice. Are expectations of the field romanticized and unrealistic? Yes, but big dreams and high hopes can turn into the next big theories that continue to propel forensic science from the rudimentary to the refined, as history has already demonstrated. There is a significant dearth of forensic practitioners to keep pace with growing investigative demands on the criminal justice system stemming from criminal activity, violence, injury, and death, so we must grow a new crop of highly trained, astute professionals versed in medico-legal principles and practices.

It is this heavy investigative workload that, in part, opens the door for the heroes and heroines of forensic nursing. Nurses are not detectives, yet they possess an investigator's sense of curiosity and intuition, as well as keen observation and analytical skills. Nurses are not forensic laboratory technicians, but they execute evidence collection and preservation with impeccable precision. Nurses are not scientists per se, but they endeavor to meet the same exacting standards, and to satisfy the rigors of science-based study within the confines of nursing practice. Nurses are not prosecutors, yet in some small way they share a desire to see justice served. Conversely, investigators, forensic scientists, lab technicians, and prosecutors do not have the in-depth medical knowledge and psychosocial skills inherent to nursing. However, with increasing admiration of the contributions forensic nurses are making, these professionals appreciate nurses' ability to understand and integrate nursing practice into medico-legal cases.

Forensic nursing is the intersection of nursing and medical practice as applied to the law, hence it is very much a medico-legal discipline. In their forensic capacities, nurses assess, treat, and refer victims and perpetrators of violence, whose situations define the very essence of medico-legal investigation. These acts of violence include sexual assault, interpersonal violence, child and elder abuse, and assault of just about every sociodemographic group; they also see victims of motor vehicle accidents, product tampering, acts of terrorism, and other types of trauma. When serving as medico-legal death investigators, forensic nurses extend the nursing purview from the living to the dead, in investigating natural and suspicious or sudden death. Forensic pathologist Michael Baden, MD, once said to me, "Forensic nursing is a discipline whose time has come," and forensic scientist Henry C. Lee once told me that forensic nurses were "absolutely essential." Additionally, forensic laboratory directors Paul Ferrara and Barry Fisher have long respected forensic nurses for their professional prowess. These are noted and famed individuals whose opinions carry weight in the forensic science community; nurses must embrace these words of encouragement and cling to them as they continue to navigate uncharted territory in the clinical realm and bring their forensic skills to bear on health care cases of all dispositions.

Besides championing forensic nurses, this book is designed to make a strong case for the important emerging specialty of forensic nursing and its contributions to the medico-legal community. The preponderance of violence and trauma, both accidental and intentional, issues new clinical mandates for the health care industry as these medico-legal cases present in increasing numbers. The World Health Organization (WHO) defines violence as "the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation" (Krug et al., 2002). In a 1996 resolution declaring violence a leading public health problem, the World Health Assembly called on the WHO to develop a typology of violence that characterized the different types of violence and the links between them (WHO, 1996). This typology divides violence into three broad categories according to characteristics of those committing the violent act: self-directed violence, interpersonal violence, and collective violence. This categorization differentiates between violence a person inflicts on himself or herself, violence inflicted by another individual or by a small group of individuals, and violence inflicted by larger groups such as states, organized political groups, militia groups, and terrorist organizations. In addition, the nature of violent acts can be physical, sexual, psychological, or involve deprivation or neglect. Forensic nursing is the most appropriate response to the challenge of violence and its impact on public health, and its practitioners are in an ideal position to not only treat its victims and perpetrators, but also to assist in the collection and cataloguing of data. The government is recognizing that it needs to track epidemiologic information related to violent deaths. In fact, the federal Centers for Disease Control and Prevention (CDC) are calling violence-including the approximately 50,000 homicide and suicide deaths annually-a significant public health issue (CDC, 2004a). According to the CDC's National Vital Statistics System, in 2001, almost 21,000 homicides and 31,000 suicides occurred, and almost 1.8 million people were assaulted. About 323,000 harmed themselves and were treated in hospital emergency departments. Additionally, in 2001, homicide was the second leading cause of death for people ages 10 to 24, and suicide was the third leading cause of death for people ages 10 to 24.

The challenge is that current data do not provide all the information needed to accurately assess the factors surrounding violent deaths. Death certificates, for example, cannot link victim and suspect information. The CDC recognized that local, state, and national policymakers and program developers did not have comprehensive information about violent deaths, and that although state and local agencies have detailed information that answers fundamental questions about patterns and trends in violence, this information is fragmented and inaccessible. Creating a system to pool these valuable data would help answer such fundamental questions:

• Are violent deaths in schools increasing or decreasing?

• What proportion of homicides result from illicit drug deals?

• How often do murder-suicides occur?

• How frequently are homicides associated with child maltreatment?

• How serious a threat are mass killings?

To better develop answers to these questions, the CDC created the National Violent Death Reporting System (NVDRS), a state-based violent death reporting system designed to provide accurate and timely information to inform decision makers about the magnitude, trends, and characteristics of violent deaths, and evaluate and continue to improve state-based violence prevention policies and programs. The goals of the NVDRS are to do the following:

• Link records from violent deaths that occurred in the same incident, which help identify risk factors for multiple homicides or homicide-suicides.

• Provide timely information through faster data retrieval. Currently, vital statistics data are not available until two years after the death.

• Describe in detail the circumstances that might have contributed to the violent death.

• Better characterize perpetrators, including their relationship to the victim(s).

Using these objectives, NVDRS illustrates a more comprehensive picture of violent incidents. The linked data provide law enforcement officials and death investigators a clearer picture of violent activity in their jurisdictions and will aid program operators to design and implement potentially successful prevention plans.

Since August 2004, the CDC has been funding 17 states (Alaska, California, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin) to implement the NVDRS, and has also piloted the collection of data from state child fatality review teams in four of the states to better understand the value it adds to NVDRS.

In late April 2005, the CDC released the first data from the NVDRS. Data reported by the first six participating states (Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia) show increases in suicide and homicide rates for the years 2000 through 2003. These data are in contrast to decreases in violent deaths reported in these states and nationwide from 1993 through 2000. Because this system only contains the first year of data in a small number of states, CDC officials say it is too early to determine how risk factors and trends might have changed in recent years. In 2003, homicide increased 4 percent and suicide increased 5 percent above 2002 rates in the six reporting states. Homicide rates among males under age 25 increased 18 percent in those states.

"NVDRS puts us on the front line to collect rapid, reliable data to better inform our prevention strategies," says CDC Director Julie Gerberding, MD, MPH. "With NVDRS, we can spot early warning trends for violent deaths and modify our prevention efforts. Among those warning signs are the role of alcohol and drugs in violent deaths, and how often a homicide is followed by a suicide."

The CDC established NVDRS in 2003 to address a crucial gap in understanding national and regional trends in violent deaths by combining relevant records into one repository of state-specific data. "This system provides states and communities valuable information that can be used to develop and implement tailored violence prevention efforts," says Ileana Arias, acting director of CDC's National Center for Injury Prevention and Control. "The data help to identify potential strategies and also allow us to evaluate our current violence prevention efforts and determine if they are saving lives."
The NVDRS will document the circumstances of suicides and homicides to help identify and evaluate prevention opportunities. Each state collects detailed information about a violent death directly from the records of state health departments, medical examiners and coroners, and law enforcement, providing a clearer picture of the circumstances surrounding violent deaths at the national, regional, and state levels. Information such as a history of depression or a family dispute, gang activity, drugs, and other circumstances surrounding the violent death are recorded.
Currently, 17 states participate in this state-based surveillance system. The next report expected late in 2005 will include the data from the initial six states as well as seven additional states (Alaska, Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin) that began collecting data in 2004. The final four states (California, Connecticut, New Mexico, and Utah), which began data collection in 2005, will not release any data until 2006. The CDC hopes to expand NVDRS to all 50 states so data can be compared across states and regions of the country, and to establish national violence-related data. Forensic nurses might one day become instrumental in assisting local jurisdictions in this data-collection process, especially as they continue to investigate regional and national violence-related trends, apply forensic nursing- driven knowledge to their interpretation of these data, and research and publish their findings for the benefit of the entire public health, forensic science, and criminal justice communities.
Colleagues who knew I was writing a book about forensic nursing had expressed joy that, finally, someone was going to chronicle this exceptional nursing specialty in a more personal way than a traditional textbook, without sacrificing any of the studious thought and research on the subject. They also pointed to the fact that I am neither a nurse nor a scholar. True. I am an old-school journalist with more than 20 years of award-winning editorial investigatory experience backing my byline. I know how to research, how to ask the right questions and elicit truthful answers, and how to get to the heart of the matter. In regional and national newspapers, magazines, and trade journals, I have interviewed hundreds and hundreds of people, both laypersons and experts, in dozens of different fields. I have written perhaps a million or more words as I pursued the stories that made readers laugh, cry, think, act, and react. Telling the stories that no one else does is important to me, and that desire is the impetus for this project.
I discovered forensic nursing in 2001. It was late at night, without fanfare or any indication of the treasure trove that was about to yield its incredible wonders to me. I was researching via the Internet an article about the hottest nursing specialties when the term forensic nursing leaped from the screen of my computer monitor. OK, I thought to myself, I certainly know what forensic means, having nurtured an interest in this field for the past decade. I knew nursing quite well, having grown up as the daughter of a career nurse. What marvelous things, I contemplated, could happen when the two words were fused together? Hours passed as I searched for every shred of information I could find on the subject. Back then, there wasn't much to be gleaned (today, however, an Internet search yields far greater and more current results, reflected in the fact more people are discovering forensic nursing for themselves), but I could fill in the blanks. I discovered that forensic nurses could, indeed, investigate medico-legal cases, and that they embraced the concept of living forensics, quickly dispelling the myth that forensic science is in the purview of the dead only. I discovered that a small, stalwart group of forensic nurses were making significant contributions to health care, law enforcement, death investigation, nursing jurisprudence, and criminal justice, to name just a few fields, and yet these nurses seemed to be the best-kept secret of the medico-legal world.

The journey began in 2002 when I launched Forensic Nurse magazine; along the way, I met some amazing individuals whose passion for and dedication to the specialty were unrivaled. If there is one thing I know, besides journalism and publishing, it's what makes nurses tick; after all, I grew up around nurses, and had a short stint in health care myself during high school and college. I know that nurses are traditionally overworked, underpaid, and continue to battle the "just-a-nurse" syndrome in their quest for personal and professional respect. They are breaking free of these stereotypical shackles, embracing the prestige of higher education and increased opportunities, demanding interesting assignments with impact, and tackling the difficult issues previously untouched by their medical and health care (and forensic!) colleagues. I know that nurses take every success and every failure very personally, and that they care very much about helping those in need, often at the expense of their own welfare. These nurses' devotion to their practice, and particularly to the unique medical needs of the forensic patient, is manifested in how hard they work on behalf of their patients, and to a large degree, how much these nurses put their own needs behind everyone else's. To this day, I can recognize a nurse from 100 paces away by that determined look on his or her face as he or she tries to make everything in the world right again.
I don't know if forensic nursing creates a new breed of super-nurses, or whether these characteristics are already inherent in the nurses attracted to this specialty; whether it's nature or nurture, forensic nurses are extraordinary for several reasons. First, they continue to champion nursing at a time when nurses are stretched thin, underutilized, not given credit for their accomplishments, or abused by health care colleagues who are still not convinced of nurses' unimpeachable status. The nursing shortage is happening for a reason, and although the majority of forensic nurses are veterans, the field is attracting a new generation of nurses. Only time will tell if they have the maturity, stamina, and skills of this specialty's pioneers. Nursing is the oldest of all professions, yet many continue to take these special health care providers for granted. Imagine the Help Wanted ads for nurses: low pay, long hours, little respect. Who would still apply? The answer is more than ever, especially with the promise of change as forensic nursing science takes hold and changes minds.
Second, these nurses are entering a specialty that is still considered to constitute vast stretches of health care frontier. Those in the know realize that all nurses are forensic nurses, and that nurses have been unwittingly practicing forensics all of their careers. Progressive thought has finally given forensic nursing a name and an identity that is still being tested, scrutinized, and questioned. Forensic nurses must consistently validate what they do and what they contribute to the health care and medico-legal communities. They are still perfecting their practice, identifying and filling voids in practice, defining and pushing the parameters of that scope of practice, and blazing new trails. It's what they do best.
Third, forensic nurses face a practice that is only for those with a strong stomach, a pure heart, and a quick mind. Daily, they face the ugliness of society, the monstrous acts humans inflict on each other, and the inconceivable actions that most see only in their nightmares. These nurses know they are speaking for the injured, the traumatized, and the dead in a time when there is an overwhelming need for the proper medico-legal process and for its most necessary by-product, justice; if not justice, at the very least, a structured, scientific approach to understanding the medico-legal aspects of the adverse, the unexpected, and the hard-to-contemplate.
The cliché of nurses as part Sherlock Holmes, part Florence Nightingale is tiring because it suggests a vaguely cartoon-like depiction of a process that is very real and very serious to these nurses. It's not a hobby or a fleeting interest; it's a vocation worthy of the same respect as any other in the medico-legal community. These nurses mean business; they are on a never-ending quest to be science-based and taken seriously. They face enormous challenges in the future, even after overcoming significant barriers to practice. They face budget crunches and funding obstacles, questions of standardization of protocol and practice, quality issues, and gaps in training and education, among other important matters central to their effective practice. They lack a clearly defined career path, and they are knocking on doors for jobs until their knuckles are battered and bloody. They also can be their own worst enemies if they allow themselves to be; nurses are said to eat their young, so even as the specialty struggles for acceptance and recognition, nurses must take great care not to internalize these struggles in the face of doubt or discrimination, or lack of leadership and vision both within and outside of the field
One would think this would be enough to scare off even the most determined of nurses, but they have a secret . . . they are addicted to the work, addicted to advocating through science for their patients, both living and deceased, because they know that no one else is as prepared and equipped to do so as they are. I should know. These nurses have welcomed this outsider journalist into their fold, and explained and discussed what they do for my professional edification and so I could better tell their stories to the world. They have taken me into their confidences, sharing their joys, their sorrows, their grievances, their worries, and their hopes for the field of forensic nursing. We have broken bread together, laughed and cried together, commiserated about the days that it felt too hard to proceed, and celebrated the times when it was easy and they could conquer the world. We have attended conferences together, enjoying a forum in which we could discuss, debate, and dream, all for the sake of advancing this wondrous nursing specialty
Detractors of forensic nursing are as plentiful as its supporters. Forensic nurses have as their champions their patients, family members, and an increasing number of enlightened members of the law enforcement, forensic laboratory, and legal communities, a trend that is hard-won and by no means complete or widespread. Until there is a forensic nurse in every health care facility, school, prison, and medical examiner's office, and until the concept of living forensics is fully understood and accepted, there is much work to be done. It is the responsibility of every forensic nurse to tell his or her story, but better yet, to demonstrate his or her capacities and capabilities. That requires getting a foot in the door, and in many cases for these nurses, continually proving their mettle once they gain that coveted entry. Until it's no longer lip service on the part of prospective employers, forensic nurses must push for equity, parity, and greater purpose and relevance in their work, seizing every opportunity to make a case for their presence
Through speaking with hundreds of nurses since 2001, and interviewing more than two dozen forensic nursing practitioners and other professionals for this book, I am convinced that this specialty will survive, thrive, and change for the better the way medicine interacts with the law. There is no limit to what forensic nurses can achieve, but they must be willing to jump those hurdles and break down those doors themselves. Arguably, in some places in this country, breaking through will be more difficult, as stereotypes, gender biases, and lack of comprehension of the importance of forensic science principles in health care delivery continue to challenge these nurses. As many nurses have revealed in one form or another, the good days are very, very good, but the bad days are enough to make you want to turn and run. May every forensic nurse who reads this book have feet of stone, not clay, and may every forensic and medical professional come to appreciate nurses' worth. Follow your convictions, and the respect will follow
Author: Pyrek, Kelly M