Credentialing for Death Investigation Still Lags, Nurses Say

By Kelly M. Pyrek

Part one of two articles.

Talk to just about any forensic nurse and you’ll discover what they tend to crave most is respect from their colleagues in the forensic science and criminal justice communities, especially when it comes to their pursuit of advanced training, specialized education and the widely recognized, professional credentials and certifications that designate them as bona fide members of the medico-legal elite.

Even without their detractors, forensic nurses face numerous challenges. While the specialty has been formally recognized by the American Nurses Association, forensic nursing is still a conundrum to industry, healthcare and science in general. The number of forensic nurses also is still relatively small, although nursing is increasingly beginning to recognize that all nurses instinctively have and must continue to cultivate their forensic sensibilities. Internet chat rooms are still filled with dozens and dozens of new and veteran nurses who are intrigued by forensic nursing but haven’t any idea of the responsibilities that come with the role or a proper understanding of the concept of the living forensic patient vs. a forensic nurse’s contributions to death investigation.

Just ask Meliss Vessier-Batchen, RN, MSN, SANE, assistant professor at the Charity School of Nursing at Delgado Community College in Louisiana. She frequently does death investigation as a reservist for the St. Tammany parish coroner’s office, and says breaking into this specialty can be extremely challenging. Vessier-Batchen adds that she encountered difficulties when she approached other parishes about doing ride-alongs with investigators.

“Jefferson Parish has an excellent forensic center but its senior investigator was not very receptive to nurses because of some past problematic encounters. I think I have made headway in changing his mind about what (forensic nurses) can do and how we can help, but only time will tell. There are rarely many death investigation positions available, even in large parishes. I have been told that most of the investigators leave only when forced to retire or ‘die out of the position.’ I was fascinated with the fact that these people are so committed to their work. They go to work sick or well, tired or not.’

Vessier-Batchen says the reservist program has its challenges because of low pay and politics. “The reservist program is totally voluntary, with no pay, and the reservist rides with a regular investigator. I was hired in September as a contract investigator, which means that I carry a badge and get paid.”

Since enrolling in a doctoral program at Louisiana State University Health Sciences Center (LSUHSC) with the goal of teaching more nurses about forensic science, Vessier-Batchen says she has witnessed encouraging change in the system. “Since my doctoral studies have begun and I’ve shared many of my thoughts and ideas about investigators, training, education, and registry, the office has begun looking at those very topics. The senior investigators are very interested in making the office more cohesive and ensuring consistency across the board for investigators, regular and reservist alike. The office is now looking at the American Board of Medicolegal Death Investigators (ABMDI) registry for all investigators. There is now a response team used by the office to attend scenes of suicides to help in the coping responses of survivors. I have spoken with the head of this team and she has expressed excitement in having a nurse in the death investigation role, so there is much in the works. In an informal survey I conduct every time I have the chance, death investigators across the country are not well recognized and are definitely not paid as though they do an important job. There are some exceptions, but even in the offices specifically using forensic nurse death investigators (FNDIs), pay is well below bedside salaries. This may deter many nurses from pursuing full-time employment in the field. There are also political implications, at least in the coroner systems. This hinders raising the level of professionalism and minimal requirements for investigators. This trend is disturbing to me, but I am working through many avenues to change the way it’s done.”

Vessier-Batchen says her knowledge of death investigation was key to helping her attain her SANE credential, a process she acknowledges is different from most forensic nurses. “My death investigation experiences actually helped me with the SANE training, and this may be backward for most. I’ve been told I’m very unique. I do not see forensic nursing as a branching out of SANE/SART roles. The roles of forensic nurses are very distinct and although knowledge may be similar in some aspects (evidence collection, interviews, etc.) many of the SANEs I know say they could never cross over to my area of interest and practice. By the same token, my legal nurse consultants have no desire to either do sexual assault examinations or death investigation. The FNDIs I’ve spoken with have no desire to practice SANE. I took the route of SANE training to answer a need in the community and because of the academic area I was trying to establish. We have no programs in Louisiana that teach forensic nursing. I am the first here at a doctoral level as far as I know. I felt I needed a more diverse understanding of other roles in forensic nursing but my true focus and interest has always been death investigation.”

Bobbi Jo O’Neal, RN, BSN, SANE, F-ABMDI, deputy coroner in Charleston, S.C., says that in her experience, being a nurse was an advantage. “However, the coroner with whom I needed to network was a nurse. I did not have to try to convince anyone that as a nurse, I could do a good job. In coroner systems, if a nurse will run for the elected office, I think (he or she) will have a distinct advantage. The public values and respects nurses. The public also understands that it is important to have someone with medical knowledge in the coroner’s office and that the coroner should have a medical background. Therefore, in our jurisdiction, the nurse, running against police officers, had a distinct advantage with the public. It was not necessarily a ‘political advantage,’ however, the nurse was the underdog and did not receive the support from other ‘political entities’ as did the criminal justice opponents. The public made the right choice, however. In cases where the coroner is not a nurse, then I think nurses are at a great disadvantage in trying to gain a position as a death investigator. Nurses have a reputation as being caregivers, not as investigators.”

“Being a nurse is definitely an advantage,” says Nancy Cabelus, MSN, RN, DABFN, a death investigator with the Connecticut State Police. “Having been a registered nurse and having been an operating room nurse, it was easy to get used to workplace environments such as an autopsy room or a death scene. Politically, the medical examiners in my state are very receptive to nurses. I think they prefer a nurse to a non-nurse because nurses are already trained medically and they learn very quickly.”

O’Neal says the coroner and ME systems are not created equal and forensic nurses are discovering that the welcome mat is not always unfurled for them.

“In ME systems, I think nurses are at great disadvantage. Not only do they need to convince physicians, but also law enforcement. Death investigators have traditionally been persons with law enforcement or investigative backgrounds. Many offices use criminal justice or forensic technicians, ‘just because they always have.’ Again, nurses have a difficult time overcoming that ‘caregiver’ image. Although the public respects and values nurses, they don’t have an understanding of what nurses are capable of doing, what their skills are and the many different nursing specialties. We have a perception of ‘doing what the doctor orders’ and that we don’t really assess patients ourselves and make decisions.”

In a similar vein, Cabelus says members of law enforcement can be territorial. “They will not let people into the crime scene that they do not feel are competent or qualified to be there. Forensic nurses need to get acquainted with the law enforcement agency that they will be working with. They should have an introductory meeting or send letters out to the officers who work off-shifts so that everyone can be advised that there is a new member to the team. It’s best to know the team players before the game begins; that way, there is less resistance at the scene if everyone knows who everybody is and what their role and capabilities are. Once the law enforcement officers know what the forensic nurse can bring to the table, the confrontational attitudes should diminish and the role will be respected.”

Like Vessier-Batchen, O’Neal believes nurses have a long road ahead of them.

“I think we do have a long way to go in order to earn the respect of forensic pathologists and law enforcement,” she says. “Again it is that perception of nurses; however, we as nurses have to earn their respect and at the same time respect them. I see way too many nurses try to enter this field with a chip on their shoulder and try approaching pathologists and law enforcement with an attitude that they can’t survive without them. In fact, these professionals have been functioning for years and years without nurses. We are not going to change that overnight. We have to approach this with a humble attitude. Nurses do not investigate better than law enforcement. We do it differently, and by blending the two professions we are able to, as a team, do a thorough investigation using the skills that each brings to the investigation. I think in many cases, nurses may be their own worst enemies. As a profession, nursing is not very good at networking and lobbying. We need to change others’ perceptions of us but we also must change ourselves and learn how to interact politically with these other professions.”

Knowing that small pockets of support exist, forensic nurses wanting to break into death investigation are ready to push for the jobs they want.

“I think there are adequate career opportunities out there in the area of death investigation,” O’Neal observes. “The job description may not be written for a nurse, but there are opportunities out there. It is up to the nurse to open those doors. As with any new specialty, we are plowing new ground, and this is going to be a long, tedious process. There are many areas of the country where nurses can run for elected office. The problem is that very few are willing to take that step. Instead, they want someone to open the door for them. When plowing new ground you sometimes have to open the door for yourself. However, there are many who would disagree with my last statement. In the areas where the opportunities are not available, meaning the ME, state or whoever, will not even consider using nurses as death investigators, then obviously the opportunities are not readily available. That is where nurses need to use their networking skills, become creative and start thinking outside the box. If we are going to practice in a different setting we need to also start thinking differently.”

“There are a lot of career opportunities out there but the forensic nurse must learn to network appropriately and market the role effectively,” Cabelus emphasizes. “This is a new field for nurses. A new forensic nurse will have to design her own blueprint. If the nurse does not exude self-confidence and does not promote herself for the job effectively, no one will do it for her. I strongly recommend that my forensic nursing students polish up their CV and that they have a plan. Never go into a job interview unprepared. Set your sites on the desired job and, if asked, state your price. Don’t undersell yourself or underestimate your self-worth. Keep in mind that most government- related jobs have an established salary scale. If possible, research this before the interview.”

Vessier-Batchen’s persistence has paid off. “The senior investigator in Jefferson Parish (who was unsure about forensic nurses) has softened his stance and has become my cheerleader in taking and passing registry. And I do believe that prevailing attitudes such as this do impede our entry into and development of forensic nursing roles in ME/coroner systems. I preach that there must be some standardization of education and requirements for the role. I see this as the only way to raise the level of practice. Nurses need to know their stuff. The only way this will happen is to learn what needs to be learned to function in the role and through clinical practice, practicum, and doing the ride-alongs. I always recommend to nursing students asking about my role that they do a real ride. For some, death investigation is not what they really want to do. For others, bedside was not what they were meant for. Perseverance is one of the most necessary characteristics needed by forensic nurses. We will have to continue to prove what we know, that we can learn more, and that we can apply what we know. We have some very special skills through nursing and applied to death investigation, and can continue to use critical thinking, legal charting and communication, and interaction with people.”

Concurs O’Neal, “Those nurses who practice full time in death investigation need to continue to plow ground, speak, write and share their success stories with these other professionals.”

To a forensic pathologist or a death investigator, a forensic nurse’s education, training and credentialing are areas warranting particular scrutiny, but there is still a tremendous lack of comprehensive, national standards and credentialing systems for forensic nurses who wish to work in specialties outside the realm of traditional nursing. Besides an encouraging number of new undergraduate and graduate classroom and online programs, there are a few ways that forensic nurses can gain the knowledge and experience required to work as a death investigator, one of the more popular career options, especially among younger nurses.

The ABMDI, a national, not-for-profit, independent professional certification board, has been established to promote standards of practice for medico-legal death investigators. It voluntarily certifies individuals demonstrating proven knowledge and skills necessary to perform medico-legal death investigations as established in by the National Institutes of Justice. Earning diplomate or fellow status with ABMDI and becoming a registered medico-legal death investigator shows that a forensic nurse has submitted to examination, proves that he or she adheres to high ethical standards and have attained the knowledge and skills necessary to perform quality death investigations. Most importantly, this certification can assist the courts and public in evaluating a forensic nurse’s competence, especially in the performance of practical application of knowledge in specialized, technical tasks, including initial body examination at the scene.

The good news is that the ABDMI openly welcomes forensic nurses and recognizes that their varied backgrounds can contribute to their success as a RMDI. Upcoming exams are slated for April 30, and Oct. 8, in St. Louis. (For details, visit www.slu.edu/organizations/abmdi.)

Forensic nurses can also enroll in the Certified Medical Investigator (CMI) program offered by the American College of Forensic Examiners International (ACFE). The CMI credential allows forensic nurses to meet the demand for medico-legal investigation, including crime scene investigations and preservation of evidence, homicide investigation, authenticating and presenting evidence, and expert testimony at trial. (For more details, visit www.acfei.com.) Exam dates are March 12-13, and May 21-22, .)

Membership and representation in respected forensic science and criminal justice organizations also can be critical to a forensic nurse’s professional success. According to Jim Hurley, development director for the American Academy of Forensic Science (AAFS) the academy currently has approximately 49 forensic nurses within its General Section (the academy does not yet have a forensic nursing section). AAFS membership records show that forensic nurse representation breaks down into 10 students, eight trainee affiliates, 23 provisional members, two members and six fellows. Having worked hard to get there are forensic nurses Virginia Lynch, Sharon Crowley, Catherine Dougherty, Patricia Dunn, Janet Barber Duval, Diana Faugno, Jamie Ferrell, Constance Hoyt and Georgia Pasqualone, among others.

“I don’t think enough nurses are represented in other forensic organizations,” O’Neal says. “I think this goes back to nursing as a profession not supporting itself. Nurses, for the most part, do not get involved; they want to do their job and go home. When you compare the number of nurses that are members of the ANA, as compared to the number of physicians who are members of the AMA, it is apparent.”

O’Neal isn’t necessarily advocating that forensic nurses storm the castle. “I am not sure we should ‘challenge the old guard’ unless the organization will not let nurses be members. If we challenge them too much, we will just get a bad name that is associated with a bad attitude. That will get more doors slammed shut than doors opened wide. Instead, we need to be team players, explain the skills that nurses have, how a nursing assessment can be beneficial, and how by using our skills and their skills we can better serve the public.”

Cabelus acknowledges that a few forensic nurses belong to the AAFS, ACFE and International Association for Identification (IAI) but adds, “Perhaps they are not aware of these organizations or how they can assist them in networking, learning more about the field, receiving specialized training and gaining awareness of job opportunities. It is not that nurses are not welcome into these groups, it’s that nurses have not sought them out.

What organization is going to refuse membership dues? Personally, I belong to 11 professional organizations, and annual dues payments add up to over $600 per year. Many people cannot afford to be as aggressive as I am with professional memberships and I don’t recommend that nurses join organizations without getting involved — that would be a waste of money. I have donated my time and services to the organizations that I belong to by serving on a committee, writing an article, volunteering, giving a presentation or attending the meetings. In return, I get three-fold what I put into them.”

O’Neal says she is dissatisfied with the training and credentialing offered to nurses but adds, “From a credentialing standpoint, death investigation as a whole is just beginning to certify investigators. This is a great step. The specialty of death investigation is moving in the right direction. This credentialing is not required yet, but again, it is a good beginning. It all begins with baby steps. In the same light, training is not adequate. Most people ‘learn while doing.’ Although there are some good courses out there, hands-on training is extremely valuable and needed, for nurse and non-nurse death investigators.”

It becomes more difficult to track representation by forensic nurses in other professional organizations due to imprecise record-keeping or the sheer volume of membership. The National Association of Medical Examiners (NAME) cannot report how many forensic nurses are working in ME offices around the country, but NAME president Michael Bell, MD, says forensic nurses are often put off by the demanding hours and relatively lower pay that death investigation involves. Julie Howe, a representative at Saint Louis University, recognizes “a definite trend for nurses entering the field of medico-legal death investigation” and says forensic nurses show interest in the university’s popular Medicolegal Death Investigator’s Course held three times annually. (For details, visit: http://medschool.slu.edu/mldi.) So what happens when a forensic nurse does manage to gain a foothold?

“The first thing nurses need to do if they have attained a position is to do a good job,” O’Neal says. “These nurses need to be aware that they are paving the way. If they get lazy, have bad attitudes, or are difficult to work with, that will leave a bad taste in the mouths of those they work with and will shine a bad light on all nurses. Just as with our internship, we check everyone before they are accepted into the program. We want to be proud of those individuals that we teach. I don’t want them going back to their home state, getting a job and doing a terrible job.

That sheds a bad light on us and on nurses, which will only make it more difficult for those following behind them. Those in death investigation positions need to also continue to teach, write and speak. It is only through our experiences that we share with our profession that will allow others in the profession be able to learn and grow. By hoarding our information we are not helping our profession at all, in fact we are hindering it.”

The sentiment that classroom curriculum is no substitute for hands-on experience is frequently heard among forensic nurses discussing training and education needs for new nurses and even veteran nurses wishing to change a career course. O’Neal says that despite the overwhelming popularity of Charleston County’s hands-on death investigation internship, it has not been expanded to include more nurses’ participation due to strained resources.

“We wish we could; however, we can only accommodate so many nurses each year and still provide the quality of service that our constituents deserve,” O’Neal adds. “We hope that more nurses will fill these roles and can begin teaching as well. We do have a long list of nurses interested in the internship, with more calls and e-mails coming in each week. We have been asked to partner with one graduate forensic nursing program to assist them in providing hands-on opportunities for their students. It is important that nurses seeking a master’s degree in forensic nursing complete programs with hands-on experience. Right now, that experience is limited. The advanced education is a starting point, however we must remember that this traditionally a criminal justice specialty, where hands-on investigative experience is valued just as much if not more than advanced degrees.”

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