Subscribe | Media Kit | Testimonials | | | Contact Us | Archives


The Professional Development of Forensic Nurses
By Julie A. Jervis, MD, RN

Victimology: An Investigative Tool and Crime Component

The Forensic Nurse as an Expert Witness: Document Preparation

Editor's Letter
New Protocols Need Your Attention

News & Views
Industry Events

 

Clinical Forensic Nursing: A Higher Standard of Care
By Mary K. Sullivan, RNC, CARN, MSN, BSN

Forensic nursing, like traditional nursing practice, appears to be sharply divided into several sub-specialties. The roles linked closely to traditional clinical nursing acumen include the sexual assault nurse examiner, crime scene and death investigator, correctional nurse and forensic psychiatric nurse. Those who have found their niche in one of these areas provide necessary services for victims and perpetrators of violence. Law enforcement and the legal system realize the positive impact forensic nursing is having on case outcomes.

One sub-specialty that appears to be under-represented and difficult to implement is clinical forensic nursing within the general hospital setting. Nurses who possess forensic expertise have not been formally recognized or utilized in their hospital or clinical settings. In my opinion, using a clinical forensic nurse examiner (CFNE) would be a reasonable approach for several problems that healthcare facilities face today. Such a role requires nurses with a broad range of forensic knowledge and skills.

One major responsibility of the CFNE would be to ensure that trauma patients receive systematic assessments and that the findings are precisely documented. Identification, collection and preservation of evidence in suspicious patient events or unexpected patient death are equally important functions. The CFNE would also function as a staff educator and serving as a role model in clinical situations increasing staff awareness of the potential for forensic cases in everyday patient-care situations. An extant member of the hospital staff who can work hand-in-hand with law enforcement agencies is vital to protect victims of foul play when they are at their most vulnerable. A case that illustrates these points comes to mind. A young adult female was found in a ditch adjacent to a Texas highway. Despite multiple-system trauma and hundreds of fire ant bites, she was found alive. She was rushed to a medical center where she was taken to the OR for exploration of abdominal and chest wounds and repair of extensive wounds and fractures of her extremities. Since she was unconscious, it was impossible to determine how she sustained her injuries. As a nurse was preparing to insert a Foley catheter, she noticed that the woman had extensive tissue trauma in the perineal and perianal areas. Blood and apparent seminal drainage were noted. At this moment the patient's body became a crime scene.

Fortunately, this nurse had attended an in-service in which a CFNE had provided examples of how staff nurses in all specialty areas can identify potential forensic evidence that could impact patient care and treatment outcomes. This nurse realized the woman was probably a victim of sexual assault and special care had to be taken in collecting and preserving associated evidence. A pelvic examination was conducted. Laboratory specimens were collected and vaginal injuries were documented and photographed by a sexual assault nurse examiner (SANE) from the emergency department. Upon regaining consciousness several days later, the woman recalled being sexually assaulted by several men and thrown from a fast-moving vehicle. Eventually DNA evidence from the pelvic exam linked the assailants to the crime. If the OR nurse had not had the heightened awareness and the increased ability to recognize the obvious forensic issues in this case, vital evidence would have been lost and the crime might never have been solved.

The CFNE can be an important resource to hospital Quality Management (QM) staff, assisting them in timely and accurate incident evaluations and care process improvements. For example, George Wesley, MD, of the Veterans' Affairs Office of Inspector General, has pointed out the link between clinical quality assurance activities and forensic medicine, yet QM personnel often do not receive first-hand reports from providers with pertinent information. When they do, the data often reach them long after the event has occurred. Opportunities to capture details about the scene, circumstances surrounding the incident, and immediate personnel recall no longer exist. The trail is cold. Healthcare providers are usually hesitant to admit to activity that could be viewed as an error. Process improvement plans are often written with the best information available and are frequently directed at staff performance, when the root cause has little to do with either factor.

The CFNE role would work best if one were scheduled 24 hours each day, 7 days a week in every area in a hospital. These nurses would continue to meet whatever their usual position responsibilities might be, but be on call for forensic consultation when other healthcare staff perceived a need. Resources in most hospitals will not permit this arrangement; however, more realistically, the next best plan may be having one CFNE scheduled 24 / 7 in the emergency department and one to cover the rest of the facility. This would be similar to the way nurses function on the IV or code teams. Forensic nurses as an integral part of the hospital's healthcare team would seem to be more accepted by peers than someone "coming in from the outside." Although this dual role has inherent challenges, no one knows more about the inner workings of a hospital and what it takes to deliver quality patient care than a nurse! It is critical that QM staff, as well as investigators and lawyers, make the most of this vital link inside the "white curtain."

Besides the previously mentioned functions, the CFNE should be required to be present in specific situations occurring in every healthcare facility. For example, in the vast healthcare system in which I work, there is a mandate that there be a 100 percent review of all patient deaths. What is actually reviewed varies from facility to facility and there is no systemwide standard operating procedure for how a death is reviewed. The CFNE should respond to every patient death, expected or not. Specific real-time data would be collected and documented including a narrative report by the CFNE.

In addition to the medical and diagnostic information, the CFNE would note orders changes, visitors within the last 24 hours, and summarize the chain of events just prior to the patient's death. Further, a standard set of laboratory tests would be drawn including blood gases, electrolytes, complete blood count, drug levels, and if appropriate, a urine analysis. Results would be maintained in secure, computerized files for an indefinite time.

I envision that the CFNE and QM staff would collaborate on data collection and analyses, and would work together on identifying trends or issues that need to be addressed over time. Should a suspicious trend be identified a few years later, these archived data could become important evidence. I believe that if a CFNE had been in place to conduct such a review, it would have made a difference in the number of patients who did not survive their encounters with Dr. Michael Swango, who is now serving a life sentence without parole for the murder of three of his patients. He is also suspected of scores of other suspicious deaths in at least four other states.

If a death is considered "suspiciously unexpected" by a staff member, the CNFE should be summoned for an assessment and evaluation of what tripped the "suspicion factor" in that provider. If necessary, all evidence identification, collection and preservation procedures would be initiated immediately by the CFNE. The CFNE would also assume responsibility for proper notification of authorities and assist law enforcement, depending upon regulations and jurisdictional constraints. Having these procedures completed in a timely manner will not only assist the internal processes of a medical center with accurately identifying problem areas, but would also prove extremely useful to investigators. The lack of appropriate medical evidence, which was never collected, or has been compromised or lost, is of no value if a routine investigation suddenly turns into a criminal one.

In addition to every patient death, the CFNE should respond to every "code blue" called on every shift, whether the patient survives or not. This does not necessarily include codes taking place in the emergency department since this area needs to have a separate process for monitoring these events. The CFNE would not be part of the code team, but would be collecting and documenting information about the code scene itself, circumstances just prior to the code being called and immediately following, as well as documenting materials used from the crash cart and other medical treatment provided. If the patient does not survive, the standard laboratory specimens would be obtained, and all items in the room inventoried. All data would be documented and collaboration with QM staff will be important as trends and problem areas are identified. If a CFNE had been present fulfilling this role in the case of nurse Kristen Gilbert, I wonder how many codes would have gone unchecked before someone finally noticed the pattern that finally brought her under investigation. Gilbert was convicted of four counts of murder and three counts of attempted murder and is now serving a life sentence without parole.

Finally, I see the CFNE as an essential part of the hospital team with the responsibility to evaluate and perform the root cause analyses of adverse patient events. Adverse patient events range from those causing minimal concern to extremely serious action, but the vast majority are not criminal in nature. However, precise identification, collection, and management of facts, data, and medical evidence are critical, criminal or not. I am referring to ensuring a higher level of quality patient care and accurate delivery of our services. It is our duty as healthcare providers to be accountable for our actions and to ensure a safe environment for our patients.

Implementation of the CFNE position will require time, energy and money; however, some medical centers are fortunate to have an onsite team of SANEs who provide forensic examinations for the community's sexual assault victims. It would be of value if these nurses could expand their forensic nursing practice to either provide increased forensic nursing expertise or to assist with developing a forensic nursing program within the facility. As with most new programs and practice innovations, there is an initial cost. These costs would be quickly recouped in terms of litigation, settlements to families and insurance reimbursements. The positive outcomes in increased accuracy of in the delivery of patient care services and more cost-effective investigation processes realized from utilizing a CFNE could be easily tracked and quantified. Research utilization information would further indicate additional areas that could be positively impacted by the CFNE. Still, the bottom line remains: There is no price that can be placed on the increased feeling of safety and satisfaction of patients who count on us for competent delivery of care or for lives we may save.

Mary K. Sullivan, RNC, CARN, MSN, BSN, is forensic nurse examiner team coordinator for the U.S. Department of Veterans Affairs.

Click here to Subscribe


HOT NEWS

12/10/

Illinois Facility Disciplined for Failure to Ensure Staff Knows How to Respond to an Allegation of Sexual Abuse

12/09/

Emergency Nurses Association, Stryker Partner to Recognize Nation’s Top Emergency Departments

11/29/

Author and Rape Counselor Advises How to Assist a Victim of Sexual Assault

Wisconsin Reports Increase in Elder Abuse

11/17/

Two Illinois Long-Term Care Facilities Fined for Failing to Investigate, Prevent Alleged Sexual Abuse

11/07/

California Attorney General Bill Lockyer Announces Release of Six-Month Preliminary Crime Statistics for

Ohio Attorney General Jim Petro Announces Inmate DNA Samples Linked to 202 Unsolved Crimes, Including Cincinnati Serial Rapes

More News

 

 

 

 







related sites

EndoNurse

Infection Control Today

Today's SurgiCenter

Forensictrak