CHAPTER 16. Forensic Nursing in the Emergency Department
Daniel J. Sheridan, Katherine R. Nash and Heidi Bresee
FORENSIC NURSING DEFINED
Every day in emergency departments (EDs) worldwide, skilled nurses provide care to patients presenting with injuries sustained by trauma and violence. These injuries occur from a wide variety of mechanisms, including motor vehicle crashes, missile injuries, burns, interpersonal violence, mass disasters, and bioterrorist acts. Most of these patients survive; some do not. ED nurses are uniquely positioned to identify, evaluate, and medically treat these patients and to preserve and collect any potential forensic evidence that may be on or with the patient.
When an ED nurse provides care to victims of violent events, that ED nurse is providing forensic nursing care. Based on writings by Lynch, 17.18.19. and 21. the person most often credited for coining the phrase “forensic nursing,” the International Association of Forensic Nurses (IAFN) defines forensic nursing as follows:
The application of nursing science to public or legal proceedings; the application of the forensic aspects of health care combined with the bio-psycho-social education of the registered nurse in the scientific investigation on and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity and traumatic accidents. 10
More succinctly, forensically trained nurses provide care to patients whose reasons for being in the ED have the likelihood of ending up in a civil or criminal proceeding and/or a legal hearing or arbitration.
In addition, experienced ED nurses may choose to offer their skills to a legal process by being expert witnesses or content expert consultants. This area of forensic nursing is called legal nurse consulting. A growing number of experienced nurses are being trained and hired to be death scene investigators, yet another forensic nursing subspecialty.
HISTORY OF FORENSIC NURSING
Lynch20 tracks the origins of forensic nursing to the early 1980s and links it to the development of improvements in the science of clinical forensic medicine. However, the origins of forensic nursing began at least 10 years earlier with the development of the rape victim advocate (RVA) movement and the creation of the first sexual assault forensic evidence kits. The first three victim assistance programs in the United States began in 1972, of which two were rape crisis centers. 37
In 1974 Burgess and Holmstrom, 3 a nurse researcher and sociologist, respectively, coined the phrase “rape trauma syndrome.” They developed an intervention and treatment schema involving crisis intervention counseling that is still routinely taught in sexual assault nurse examiner (SANE) training programs.
The first three nurse-run SANE programs were developed in the late 1970s in Memphis, Tennessee, 33 Minneapolis, Minnesota, 14 and Amarillo, Texas. 1 Today, there are over 530 SANE programs (mostly ED-based) in hospitals throughout America, Canada, and other countries around the world.
Drake6 and Parker and Schumacher24 were the first to conduct nurse-based research in domestic violence that guided future intervention studies. Campbell5 began to look at domestic homicide and misogyny (hatred of women) and developed a tool, the Danger Assessment (DA), that could be administered by nurses to help identify women at risk for being killed by an intimate partner. In 1986, Hadley in Minneapolis and Sheridan in Chicago created the first ED-based family violence intervention programs. 31
A growing number of SANE programs are expanding their forensic nursing services to include assessment and documentation of intimate partner violence; elder and vulnerable person abuse and neglect; and assaults, shootings, and knifings not related to family violence. For any hospital-based violence intervention program to succeed, it must have a multiprofessional component. 30 Within the hospital, ED nurses who work within a violence intervention program must develop collaborative relationships with such professionals as physicians, physician assistants, nurse practitioners, social workers, mental health professionals, and chaplains. Externally, ED nurses need to develop referral, networking, and consultative relationships with adult and child protective service agencies, law enforcement personnel, local prosecutors, and the state’s attorney general’s office.
ROLES AND RESPONSIBILITIES OF THE EMERGENCY DEPARTMENT NURSE WITH FORENSIC TRAINING
Reporting Suspected Abuse/Neglect
All states within the United States, including the District of Columbia, have statutes mandating health professionals to report suspected child maltreatment, and most states have statutes mandating health professionals to report abuse/neglect of elder or vulnerable adults. Fewer states have statutes that require mandatory notification of authorities of intimate partner violence or crime victims in general. ED nurses, mental health professionals, social workers, and medical examiners are examples of mandatory reporters. ED nurses need to know the mandatory reporting requirements for where they work and must have readily available the appropriate hotline or reporting numbers.
Physical, emotional, and educational neglect are types of maltreatment or neglect, as are refusal of health care, delay in medical care, abandonment, expulsion from home, inadequate supervision, inadequate nutrition or clothing, permitted chronic truancy, inattention to special education needs, exposure of the child or vulnerable individual to domestic violence, permitted drug or alcohol abuse, and refusal or delay in obtaining psychiatric care. It is essential for the ED nurse caring for patients experiencing these forms of maltreatment or neglect to make the appropriate referrals to child or adult protective services.
Once the ED nurse has identified a case of potential abuse or neglect, he or she must involve other members of the multidisciplinary team to assist in conducting a thorough assessment and to plan post-ED case management. Acquiring and documenting a comprehensive history is a critical step in the assessment of abuse/neglect. Patients should be interviewed separately, and if the person(s) accompanying the patient attempts to block the patient’s privacy, the ED nurse must intercede on the patient’s behalf.
Documentation as Evidence
Thorough nursing documentation is part of excellent patient care, but one cannot understate its importance and value as forensic evidence. Nursing documentation should provide an accurate and forensically useful picture of what the trained ED nurse hears, sees, and smells when assessing the patient. Because wounds heal and histories of events may change over time, most ED nurses have a single opportunity to provide investigators and jury members an objective and detailed account of the patient’s experience, sometimes minutes after a traumatic event.
ED nurses should maintain consistent organization in their writing to prevent the likelihood of forgetting any one section. One example of organizing style is the classic SOAP format: Subjective history, Objective data, Assessment with diagnosis, and Plan for further testing or follow-up. All handwritten documentation should be legible to laypeople.
When documenting the patient’s history, one should provide sufficient and forensically useful detail, using direct quotations from the patient whenever possible. 29 Patient statements recorded in the medical record may be admissible in court as exceptions to hearsay. Nursing documentation of a patient’s history may be admissible under the medical exception to hearsay as long as it is relevant to the treatment of the patient’s physical or psychologic condition. 29
Another exception to hearsay is an “excited utterance,” which is a spontaneous statement made under duress. An example of excited utterance is when a trauma patient being wheeled into the ED by paramedics yells, “My husband shot me! He said he’s going to kill our kids. You’ve got to find my kids before he does.” Such spontaneous utterances should also be documented even if the patient is cognitively impaired from alcohol, drugs, medications, dementia, or psychologic conditions. The ED nurse should document the history of any injuries and pre-ED treatments. Any delay in treatment should also be noted. If a caregiver is responsible for the patient’s care, the ED nurse should document his or her explanation of any injuries or delays in medical treatment.
When documenting a patient’s report of events, one should be careful not to sanitize statements or “medicalize” terms. If a patient’s spouse threatened him or her, document the entire threat in quotation marks. Document verbatim what the trauma patient says, such as “My husband said, ‘If I can’t have you, you fu%$ing bitch, no one is going to have you.’ Then he shot me and laughed when I begged him to call 911.” Not only will that documented statement be valuable and powerful in court, it is also very significant for nurses and medical providers in planning interventions to address the patient’s psychologic response to being shot.
A 5-year-old child may not describe his genitalia using the medical or adult term penis. Instead the nurse should use the patient’s term, clarifying with the patient its location. For example, a child may report, “He touched my pee-pee [penis].”
ED nurses must remain objective in their documentation, limiting bias and subjectivity. If a patient presents to the ED reporting chest pain, the ED triage nurse would never consider writing “alleged chest pain” as the chief complaint. Similarly, the ED nurse should never document in the medical record “alleged sexual assault, alleged child abuse, or alleged domestic violence.” The use of the word “alleged” or documenting that the patient “claims” he or she was assaulted is pejorative (biased) and sends a message that the ED nurse does not believe the patient. Replace the words “alleged” and “claimed” with “reported” or “suspected.”
Another example of judgmental and biased documentation frequently found in medical records is the use of the word “refused,” such as “The patient refused medication.” To be more objective in one’s charting, replace the word “refused” with “declined” or use the words “said,” “stated,” or “reports.” For example, “Patient declined medications” or “Patient said she does not want to make a police report.” ED nurses should not document their feelings and emotions.
Collecting Evidence in the Emergency Department
Because ED nurses are often the first individuals to come into contact with victims of violence, they have the important responsibility of recognizing, collecting, and preserving key forensic evidence. Ultimately, the first priority for these patients is their medical stability. However, nurses often overlook crucial forensic evidence that can be forever lost as they cut off the patient’s clothing and clean/dress their wounds. Later in this chapter there will be a discussion of simple procedures that can be used to maximize evidence collected by a forensically trained ED nurse while not inhibiting lifesaving medical treatments.
Emergency Nurses Association Position Statement
The Emergency Nurses Association (ENA) 7 identifies forensics as a part of conscientious emergency nursing practice. The comprehensive nature of ED nurses’ care of forensic patients lends itself to the inclusion of evidence collection procedures in daily practice. Even though nursing schools do not traditionally teach evidence collection and associated documentation, the ENA position statement Forensic Evidence Collection outlines the importance of ED nurses’ having the knowledge and skills in collecting evidence and documenting appropriately using both written and photographic techniques (Box 16-1). A multidisciplinary approach should also be used by an ED to create its own evidence collection procedures. Finally, the ENA also emphasizes the importance of maintaining chain of custody, where appropriate.
Box 16-1
E mergency N urses A ssociation P osition S tatement on F orensic E vidence C ollection
• ENA believes that it is the emergency nurse’s role not only to provide physical and emotional care to patients, but also to help preserve the evidence collected in the emergency department.
• ENA supports collaboration with emergency physicians, social service, and law enforcement personnel to develop guidelines for forensic evidence collection and documentation in the emergency care setting.
• ENA encourages emergency nurses to become familiar with the concepts and skills of evidence collection, photographic and written documentation, as well as testifying in legal proceedings.
ENA, Emergency Nurses Assocition.
From Emergency Nurses Association: Position statement: forensic evidence collection. Retrieved June 1, 2008, from http://www.ena.org/position/pdfs/forensicevidence.pdf.
What Is Evidence?
Forensic evidence is defined as anything presented in court to support or refute a theory or statement. 21 Evidence may be presented by the prosecution (criminal case), plaintiffs (civil case), or defendants. Evidence may be tangible, such as a medical record, DNA, clothing, bullets, and photographs, or intangible, such as the patient’s reported history, excited utterances, and odors. Trace evidence involves small, minute quantities of physical material that has transferred from one location to another due to contact. 4 Such evidence is not always easily visible to the naked eye. Therefore everything that arrives with the patient will need to be preserved for closer scrutiny in the crime laboratory, as will be subsequently discussed.
Gloves should be worn at all times when collecting or handling potential evidence to prevent contamination. According to Locard’s principle of exchange, when two objects come into contact, a mutual exchange of evidentiary material occurs. 4 ED nurses need to be aware of this principle and protect evidence as described in the following sections.
Identifying/Collecting/Preserving Physical Evidence
In a criminal case the person ultimately responsible for physical evidence in the legal system is the police officer. Sometimes the police are not yet involved at the time the patient is receiving care. Without ED nurses’ first recognizing, preserving, and collecting physical evidence, its potential value may be lost forever. The police may have difficulty in effectively investigating the criminal matter. This can result in an inability to prosecute or the prosecution of the wrong person. Ultimately, the person responsible for the violence and suffering may go unpunished, capable of causing more harm.
SEMEN AS EVIDENCE
A 2006 study found that forensic evidence collection from body sites in children and adolescent victims of rape were unlikely to generate semen more than 24 hours after the incident. 36 Items of clothing and linens proved to have a greater yield of DNA, highlighting the significant role the ED nurse can play in collecting and securing potential evidence.
However, semen can be found in adult sexual assault patients many days after the reported assault. In a growing number of jurisdictions, the cutoff time for collection of DNA evidence in adolescents and adults has been extended from 72 hours to 120 hours (5 days) to 168 hours (one week). 35 Ensuring the evidence is in a locked or secured environment is essential to proving chain of custody. An example of a secure environment for evidence storage would be a locked closet with numerous shelves, each dedicated to one patient. Another example would be a locked multidrawer metal file cabinet that has had air holes drilled for ventilation. Access to the keys to evidence lockers needs to be restricted. Evidence should be released to law enforcement with proper documentation included to establish each person involved in the chain of custody.
CLOTHES
Clothing can tell an important story of the violent event. Consideration must be taken to properly collect clothing that may include DNA, patterned injuries such as bullet holes, or other valuable evidence that can prove crucial in abuse cases. For example, gunpowder residue can help experts determine the firearm distance, whereas blood or other body fluids may identify the individuals involved. Shoes can also be linked to footprints at the crime scene or display imprints from the brake pedal before a vehicle collision.
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