Chapter 1: Evolution of Forensic Nursing Science

Scientific Foundations of Forensic Nursing

• The science of nursing has merged with the forensic sciences and the justice system to create forensic nursing science.
• This scientific discipline combines the concepts and principles of the traditional forensic sciences and those of nursing in the clinical investigation of trauma and the recovery of medical evidence.
• It provides direct services to victims, suspects, perpetrators, and those who witness violence.
• The forensic nurse scientist identifies, assesses, intervenes, and evaluates trauma, disease, and death while documenting findings, preserves and secures evidence to determine legal outcomes and improve patient care.
• As interdisciplinary partners in healthcare and law-related agencies, the specialist in forensic nursing science has become a potent influence in the rule of law and provides a collective intelligence for practice and research.

Violence and Healthcare

• Violence is no longer considered solely within the purview of law enforcement but rather is viewed as a mutual responsibility of healthcare and the law.
• All trauma patients are considered forensic cases until suspicion of abuse or questions of liability are confirmed or ruled out.
• In 1979, the U.S. Surgeon General's Report “Healthy People” outlined a strategy for addressing priority areas for improving the health of the nation, which included addressing interpersonal violence, an important contributor to morbidity and premature mortality.
• In 1989, U.S. Surgeon General C. Everett Koop challenged healthcare professionals to assume accountability, along with law enforcement, for the problems associated with violence.
  • The surgeon general's workshop on violence and public health addressed domestic violence, child abuse, elder abuse, rape, homicide, murder, and traumatic accidents as pervasive threats to the fundamental public health principle of population exposure.
  • This perspective emphasized that no segment of society can be considered immune from the effects of violence.
• Forensic nurses must be able to identify injuries from weapons or human abuse and to skillfully interview patients and evaluate the nature and scope of these injuries.
  • Nurses interface with law enforcement and the medical examiner/coroner and provide excellent resources for expert testimony when these cases are tried in a court of law.
  • Forensic nursing demands superb assessment skills, second only to a high degree of suspiciousness.
• Public health and criminal justice must be collaborative partners when seeking solutions to violence.

Overview of Forensic Sciences

• The Code of Hammurabi, created by the King of Babylon, established legislation governing the field of medicine and is generally regarded as the oldest known legal code. It was not until the twentieth century that certain specialty disciplines emerged, including forensic science, which eventually gave rise to contemporary forensic pathology and clinical forensic medicine.
• Forensic nursing, as a scientific discipline, also evolved from these historic roots.
• The term forensic comes from the Latin adjective forensis meaning of, or before the forum.
• During the time of the Romans, a criminal charge meant presenting the case before a group of public individuals in the forum in order to achieve social justice.
• The term forensics now refers to the %%application of a broad spectrum of sciences used to elucidate questions of interest to the courts in relation to a crime or to a civil action.%%
• Until the 1990s, the American public had little or no knowledge of the disciplines or practices of the forensic sciences.
• The recognition of forensic science has been increased due to high-profile cases televised in court and popular media programming.
• This has raised awareness of the various disciplines and tools of the forensic sciences, such as DNA analysis, footwear impressions, fingerprinting, and geometric interpretation of blood spatter patterns.
• As scientific and technological developments escalated in the twentieth century, the basis for forensic science and applications to medicine was firmly established.
• There are multiple organizations of specialists dedicated to the forensic sciences, embracing many disciplines and spanning the globe.
• Dr. R. B. H. Gradwald, a founder of the American Academy of Forensic Sciences in 1948, stated that there is %%no fixed border for any forensic science, each having more than necessity to rely on the others.%%
• The International Association of Forensic Nurses (IAFN) has been instrumental in promoting the global exchange of knowledge and education in the science of forensic nursing.
• Together with the American Academy of Forensic Sciences (AAFS), the IAFN represents and serves the forensic specialty in nursing.
• In 1983, the Journal of Forensic Science published the first article addressing the issue of living forensic medicine by William Eckert and several other forensic pathologists.
• In 1986, the American Academy of Forensic Sciences (AAFS) formally recognized forensic nursing as an emerging discipline in the forensic sciences.
• Since then, forensic nursing has become one of the most rapidly growing specialties in the forensic sciences.

Forensic Science and Public Health

• Public health and forensic science have been intertwined to address notable public health achievements in the twentieth century.
• Public health is responsible for assuring conditions in which people can attain optimum health, while forensic science addresses crime and the security of public health.
• Forensic nursing science applies scientific knowledge and skills to identify threats to public health and safety and to intervene and prevent morbidity and mortality.
• The major mission of public health is to %%identify and control biological and environmental threats%% to the health and safety of community populations.
• Traumatic injuries from accidents and interpersonal violence produce even larger numbers of disabilities and deaths, and these unnatural, untimely deaths must be addressed.
• Understanding the sociocultural climate and population demographics of a community can be invaluable in predicting the incidence of communicable diseases or acts of interpersonal violence.
• The forensic nurse must be a contributing partner in gathering statistical data to predict health crises and develop preventive and interventional strategies.
• Public health is one sector of government at local, state, and national levels that is charged with the legal requirements associated with health and safety.
• The forensic nurse is well positioned to identify and report information to public health authorities as well as to social service or law enforcement representatives.
• Those who function on the front lines in the emergency department, as a sexual assault examiner or death investigator, or who deal with those suffering from abuse and neglect must take ownership of their public health responsibilities.

Forensic Medicine

Forensic Pathology

• Forensic medicine is a specialty that interprets or establishes the facts in equity or criminal law cases and is also referred to as medical jurisprudence. It is primarily practiced within the subspecialties of forensic pathology and clinical forensic medicine.
• Forensic pathology specifically addresses the determination of cause, manner, and mechanism of death and incorporates gross anatomical pathology. It provides insight into why death occurs and makes recommendations for the reduction and prevention of threats to public health and safety.
• Without consistent determination of the cause of death, preventive practices cannot be initiated.
• The role of the forensic nurse examiner in death investigation provides this long needed and overdue partnership in forensic pathology services as well as in clinical forensic medicine.
• Any medical treatment case reported to a legal agency has forensic implications, and may require testimony involving the healthcare professional who provided forensic intervention and recovery of evidence.

Clinical Forensic Medicine

• The practice of clinical forensic medicine is defined as the application of forensic medical knowledge and techniques to living patients.
• This practice has existed in Europe and Great Britain for more than two centuries and has been referred to as forensic medical examiners (FMEs) or forensic medical officers (FMOs).
• Root and Scott (1973) and Eckert (1983) published “Forensic Sciences: The Clinical or Living Aspects” and Eckert became the driving force behind bringing clinical forensic medicine to the forefront of contemporary American medical practice.
• Harry C. McNamara, chief medical examiner for Ulster County, New York, may have attributed clinical forensic concepts to living forensics.
• McNamara defined clinical forensic medicine as the %%application of clinical medicine to victims of trauma involving the proper processing of forensic evidence.%%
• This definition emphasizes the importance of healthcare providers maintaining an awareness of evidentiary materials and legal issues associated with their patients or clients to preserve national welfare.
• Before the evolution of the clinical forensic specialist in the United States, victims or perpetrators of crime who required a forensic evaluation and collection of evidence had to have died from catastrophic circumstances or unknown causes.
• Few medical schools in the United States offer courses in forensic medicine, leading to a shortage of forensic physicians and state-of-the-art skills in developing countries.

Forensic Nursing

• Nursing advancements have been influenced by the strong foundations of forensic medicine in the United Kingdom, Europe, Asia, and the Orient.
• Before the French Revolution, midwives testified regarding sexual assault and pregnancy.
• In the UK, forensic psychiatric nurses have been important associates of the clinical forensic team for centuries, and as their value was recognized, a trend towards the clinical forensic disciplines was ignited in North America.

Comparative Practice Model for Forensic Disciplines

Chronology of Forensic Nursing

• Forensic nursing is an integral component of public health, focusing on the civil and criminal investigation of traumatic injury or patient treatment with law-related issues.
• Forensic nurse examiners (FNEs) apply concepts and strategies of the forensic sciences in their specialty practices, such as death investigators, sexual assault nurse examiners, forensic psychiatric nurses, correctional nurse specialists, legal nurse consultants, forensic geriatric and pediatric specialist forensic clinical nurse specialists, or forensic nurse practitioners.
• Forensic nursing science is defined as the application of the forensic aspects of healthcare combined with the bio/psycho/social/spiritual education of the registered nurse in the scientific investigation and treatment of the trauma or death of victims and perpetrators of violence, criminal activity, and traumatic accidents.
• The International Association of Forensic Nurses (IAFN) defines forensic nursing as the %%global practice of nursing where healthcare and legal systems intersect.%% It combines the forensic aspects of heathcare with the scientific investigation and treatment of crime or liability-related cases.
• An innovative graduate program at the University of Texas at Arlington (UTA) in 1986 set the pace for further examination and the development of a new discipline in the forensic and clinical sciences. Courses focus on sensitivity to victims and families.

Specialty Recognition

• To receive specialty status, a practice area must be defined distinctly from other areas of nursing in regard to its purpose and functions, and the rationale for the need for the specialty must be well outlined.
• Graduate education, evidence of a research-based body of knowledge, and a means of disseminating this research to nurses engaged in the specialty are essential components.
• The presence of the IAFN and its code of ethics, along with a network of publications and scientific meetings, were vital preludes to petitioning the Congress of Nursing Practice for formal recognition.
• Nursing's Social Policy Statement requires that a specialty delineate a core of practice including roles, responsibilities, functions, and skills of a unique body of knowledge.
• Dimensions, boundaries, and intersections must be outlined to justify the placement of the specialty practice within the broader collegial and collaborative interfaces with other healthcare and social groups related to the discipline.
• The Scope and Standards of Forensic Nursing Practice is designed as a living document, subject to revision, because forensic nursing's structural framework is based on dynamic factors that are reactionary to the multiple components of healthcare, social justice
• The forensic nursing process is client-centered and collaboration is essential for successful interventions. Evaluation is multifaceted and occurs when the victim returns to society.
• Perpetrators of abuse and violence are also subjects of the process. The major tools and techniques of forensic nursing specialists include forensic assessment and clinical investigative or pathological procedures.
• The process is a collaborative one, encompassing a wide array of physical, psychological, social, and legal interventions from both healthcare and jurisprudence domains.

Framework for Accountability

• The nursing process is a scientific method that nurses use to provide care, beginning with an initial patient assessment and the establishment of a nursing diagnosis. Planning, intervention, and evaluation activities complete the process.
• The ANA Congress of Nursing Practice requires specific criteria to be recognized as a formal specialty of nursing.
• The core of forensic nursing has been established to support the nursing process, including assessment, analysis, nursing diagnosis, outcome identification, planning, and implementation of interventions and evaluation of responses to its nursing practices.
• Rules, regulations, and a variety of public policies influence and confirm the validity of forensic nursing as a specialty.
• The Scope and Standards of Forensic Nursing Practice is expected to provide basic direction to educators, researchers, administrators, as well as to forensic nurse practitioners.

Framework for Practice: Nursing Process

• Assessment
  • The first step of the nursing process is patient assessment, which includes a head-to-toe inspection, history taking, and review of clinical records.
  • Skilled assessments are essential to evaluate patients and ensure they receive the appropriate treatment and follow-up care.
  • All data must be documented and the environment must ensure visual and auditory privacy.
• Planning
  • Planning to meet the needs of forensic patients involves both simple and complex activities, such as providing visual and auditory privacy during a confidential forensic interview and placing a "Do Not Disturb" sign on the room door.
  • A nursing care plan may involve other nurses, disciplines, and outside agencies or resources.
  • The ideal forensic examination is carefully implemented to decrease emotional trauma and increase optimal forensic evidence recovery.
• Intervention
  • Nursing interventions are the core of the nursing process, but forensic nurses operate with standing orders, protocols, algorithms, or other directives based on law enforcement or judicial processes.
  • They must be continually evaluated and revised if the patient dies.
• Evaluation
  • The process of evaluation must take into account all data generated in the nurse-patient encounter. Feedback must be derived from the patient and from other members of the care team, such as advocates, attorneys, therapists, law enforcement officers, and counselors.
  • The standard for measuring patient progress and current status is based on established goals and outcomes, which are stated in concrete, measurable terms and written to ensure that other members of the healthcare team understand and affirm them.
  • The forensic nurse examiner often overlaps with other sub-specialties of forensic nursing to effectively evaluate a rape victim who is also the focus of a death investigation inquiry.
  • All steps of the nursing process are vital to every patient encounter.

Nursing Diagnosis: Basis for Nursing Care Plans

• Nursing diagnoses are clinical judgments that provide the basis for nursing interventions to achieve outcomes.
  • They relate to physiology, behavior, family, health system, and safety, with domains such as functional health status, homeostatic regulation, psychological functioning, lifestyle change, family support, healthcare delivery system use, and safety.
• In 1990, the North American Nursing Diagnosis Association (NANDA) stated that nursing diagnoses provide the basis for the selection of nursing interventions that will achieve outcomes for which the nurse is accountable.
• In instances of domestic violence or human abuse, pertinent diagnoses might include the following:
  • Ineffective coping related to an inability to manage situational crises
  • Fear related to a perceived inability to control the situation
  • Sleep pattern disturbances related to anxiety
  • Anxiety related to discussions of intimate information, diagnosis, and concern for partner
• The establishment of an appropriate nursing diagnosis is important for forensic nurses, as it promotes professional accountability and autonomy by defining and describing the independent area of nursing practice.
  • Diagnostic statements also provide an effective way for nurses to communicate among themselves and with other health professionals and are included in the framework for forensic nursing research.

Prevention of Violence

• Forensic nursing practice is the nursing care of individuals of all ages with perceived physical or emotional alterations, which may require immediate or long-term intervention with implicit legal implications.
• It is episodic (domestic violence, drug abuse) and acute (gunshot wounds, sexual assault), as well as primary, secondary, and tertiary in nature.
• As a public service profession, nursing has a responsibility to maintain standards of practice in processing cases involving patients associated with human violence.
• The National Victim's Center has recognized forensic nursing as a contemporary movement in forensic advocacy, whether victim or suspect.
• The forensic nurse must remain an unbiased, objective clinician throughout the scientific evaluation of injury and documentation of evidence in order to refrain from projecting a preconceived opinion or conclusion before the defendant is adjudicated.
• Prevention is a key aspect of traditional nursing care and an imperative one for forensic nursing practice.
• The healthcare system should educate nurses to think more about the legal issues surrounding patient care and have a working knowledge of forensic responsibilities.
• This will help stem society's escalating crime patterns and prove to be costeffective for governments.
• Nurse educators must assume the responsibility for establishing formal education programs in this nursing specialty that will assist in confronting violence in our society and alleviate the human suffering that results from global violence and abuse.