According to the Bureau of Justice Statistics National Crime Victimization Survey, in 2007 approximately 5,177,100 violent crimes were reported (U.S. Department of Justice/Bureau of Justice Statistics [USDOJ/BJS], 2007). These crimes ranged from vandalism and theft, to rape and sexual assault, to aggravated assault and murder. The estimated medical and productivity economic burden of interpersonal and self-directed violence (suicide, homicide, child maltreatment, youth violence, intimate partner violence, and other assaults) is estimated at $70 billion per year (Corso, Mercy, Simon et al., 2007). Because of the prevalence of violence and violent crimes in society, health care professionals are required to identify and assess victims of trauma, abuse, and/or neglect and provide proper care and referrals as needed. Indeed, screening for violence is now considered to be a minimum standard of care for all clients (American Association of Colleges of Nursing, 1999; Sekula, 2005).

The term forensic means “pertaining to the law; legal” (Venes, 2001). It refers to instances, activities, or information used in or suitable to courts of law. Health care providers, especially nurses, frequently care for both victims and perpetrators of crime (American Association of Colleges of Nursing, 1999).

Forensic nursing combines the disciplines of nursing science, forensic science, medical science, sociology, and psychology with law enforcement and the criminal justice system. Forensic nursing is one of the newest specialty areas recognized by the American Nurses Association (ANA) and is growing nationally and internationally. It was officially recognized by the ANA in 1995, and the Scope and Standards of Forensic Nursing Practice was published in 1997 (Burgess, Berger, and Boersma, 2004).

The International Association of Forensic Nurses (IAFN) defines forensic nursing as “the application of forensic science combined with the bio-psychological education of the registered nurse, in the scientific investigation, evidence collection and preservation, analysis, prevention and treatment of trauma and/or death medical-legal issues” (ANA, 1997, p. v). Thus the forensic nurse’s role provides a vital link between the health care system, the investigative process, and courts of law (Lynch, 2006).

Forensic nurses practice in multiple areas and settings of the public health system. Their responsibilities may include screening, assessment and collection of evidence, and also include the documentation and expert testimony from victims and perpetrators in settings such as hospitals, community clinics, or death scenes. In addition to working with victims and perpetrators, forensic nurses may be involved in paternity disputes and cases involving workplace injuries, malpractice, vehicle accidents, food or drug tampering, and medical equipment defects (Burgess et al., 2004). The Healthy People 2020 box lists some objectives related to this highly specialized practice area.

Sexual assault forensic examiner (SAFE) is the most widely recognized subspecialty in forensic nursing. In the 1970s, emergency department (ED) registered nurses identified a special client population—sexual assault or rape victims—who were not receiving the appropriate, compassionate care after a terrifying traumatic event (Ledray and Arndt, 1994). They observed that the sexual assault victim would enter the ED, and in many cases the staff did not know how to compassionately approach the client, properly assess and collect evidence, or testify in court; therefore the SAFE role was developed.

A SAFE is a specially trained registered nurse who applies the nursing process during forensic examinations to victims or perpetrators of sexual assault. The SAFE collects forensic evidence related to a reported crime and frequently testifies as an expert witness at subsequent trials (Girardin, 2001; IAFN, 1996; Ledray, 2006). SAFEs are usually employed in EDs, labor and delivery departments, and community clinics dedicated to victims of interpersonal violence.

If the client is medically stable, the SAFE is responsible for conducting a thorough examination including obtaining a history, performing the physical assessment, and collecting forensic evidence (Box 31-2). If the client is medically unstable, he or she will be assessed and stabilized by a physician prior to the forensic examination (Antognoli-Toland, 1985). Other responsibilities of the SAFE are crisis intervention referral, evaluation for sexually transmitted infection, pregnancy risk assessment and interception as needed, and client referral for additional support (Ledray, 2006).

SAFE is the only forensic nursing subspecialty with a certification currently offered through the IAFN. Both adult and pediatric certifications are available. The requirements for a registered nurse to be eligible for the SAFE certification examination are that the nurse must (1) be in practice for a minimum of 2 years, (2) have successfully completed 40 hours of didactic instruction or 3 semester hours of academic credit from an accredited nursing program, and (3) demonstrate competency in sexual assault examinations (IAFN, 1998).

According to Hanzlick (2007) there are four different types of death investigation: medicolegal, institution-based, private, and public health. Medicolegal death investigations are usually conducted to clarify the unnatural circumstances in which death occurred. Institution-based death investigations are usually those that occur in the hospital or nursing home setting. Private death investigations are family initiated and are focused on answering questions the family may have surrounding the death. Public health investigations are frequently conducted in cooperation with the medicolegal and/or are retrospective studies. An example of public health death investigation would be elderly mistreatment–related deaths. Typically the forensic nurse will be employed in the medicolegal death investigation or public health setting. The medicolegal death investigation system falls within the purview of the public health system as defined by the Centers for Disease Control and Prevention. One of the outputs of death investigation is death certificates. In the United States, medicolegal death investigation systems are characterized as either medical examiner, coroner/justices of the peace, or mixed (Fulton, 2003; Hanzlick, 1996; Hanzlick and Combs, 1998; Lynch, 2006; Prahlow and Lantz, 1995).

Typically, medical examiners are licensed physicians who are board certified in anatomic and forensic pathology (Hanzlick, 2007). Usually medical examiners are appointed for an unspecified term and serve a county, district, region, or state as determined by law. The coroner/justices of the peace are usually elected laypersons; that is, persons who have little or no training in medicine or science who conduct medicolegal investigations and certify cause and manner of death. A mixed medicolegal system is a combination of medical examiner and coroner/justices of the peace systems, depending on state law (Hanzlick, 2007).

Most medicolegal death investigation agencies are responsible for issuing death certificates that state the cause and manner of death. These data are collected at city, county, state, and national levels and used to determine the health of the nation and how best to allocate financial resources. The cause of death is the event that initiated the progression of events that ended in death (Lynch, 2006). The manner of death is categorization that relates to the conditions in which the cause of death occurred (Hanzlick, 2007). The National Association of Medical Examiners (NAME) identifies five acceptable options for recording manner of death: natural, accident, suicide, homicide, and “undetermined” (Hanzlick, Hunsaker, and Davis, 2002).

Legal nurse consultants (LNCs) and nurse attorneys are nurses who provide assistance within the legal system using specialized nursing knowledge and expertise when interaction of law and health issues arise (Geissler-Murr and Moorhouse, 2006; Saunders, 2000). Among many activities, LNCs evaluate, analyze, and render informed opinions on the delivery of health care and its outcomes (American Association of Legal Nurse Consultants, 1999). LNCs are hired by attorneys and insurers to review and interpret medical records and charts, provide objective opinions based on standards of care, and possibly to testify in court (Burgess et al., 2004; Raymond, 2002; Saunders, 2000).

Nurse attorneys are educated in both law and nursing. They may practice in health care, public health, or criminal or civil law, which would include malpractice cases. Malpractice cases may be from a plaintiff’s or defendant’s perspective, may involve licensure disciplinary action, or may involve agency oversight (Collins and Halpern, 2005). Some practitioners have differing opinions regarding LNCs and nurse attorneys. They may be perceived as either defending the profession or prosecuting peers by testifying against professional colleagues. Haas and Bradshaw (1999) observe that by providing services as experts and testifying, nurses serving as legal consultants help hold accountable poor practitioners who are dangerous to clients. In contrast, meticulous practitioners who are wrongfully accused of negligence will be defended.

The number of LNCs is growing and totals around 4000 (Raymond, 2002). According to the American Association of Legal Nurse Consultants (1999), LNCs perform many different services and activities, including the following:

LNCs read reports and records and determine whether the standards of care were met or breached. In general, if working for a plaintiff in a malpractice case, the LNC will look for breaches in the standards of care; if working for the defense, the LNC will look for nursing care that is given within the standards of care related to the complaint. It is essential that the attorneys be kept informed of all findings—even those that might negatively affect their case (Meiner, 2005).

When providing services, the LNC may submit an affidavit, which is a written statement explaining the expert’s credentials, background, and licensing or certification(s). It also provides a list of the materials read and considered in the case, and the findings of the review are summarized into a case analysis. Following the submission of an affidavit, the LNC may be asked to provide a deposition. The deposition is a pretrial discovery process that allows the attorneys on both sides to learn more about what the courtroom testimony will be. It is given to a court reporter, and the respondent is under oath.

During the deposition, the LNC will present the facts of the case and be questioned by attorneys from both sides. This process may be quite lengthy and stressful. It is essential that the LNC be prepared, having reviewed the case and all related materials very thoroughly. Following this process, the LNC will be given a written transcript of the deposition; this needs to be carefully reviewed for accuracy. If the case goes to trial, the LNC will then testify in court (Meiner, 2005; Ruiz-Contreras, 2005).

In some cases, the forensic nurse will be called on to testify in court, not as an expert witness as described above, but as a factual witness—one who has firsthand knowledge of the case in question. In these cases, the forensic nurse is present to provide factual statements about the evidence collected and what was observed (Ruiz-Contreras, 2005). Box 31-3 lists tips that will be helpful for nurses to review prior to testifying in court.