Trends and patterns in crime and criminal justice have historically impacted vulnerable populations affected by social violence and violations of human rights; among them are the aboriginal tribes indigenous to Australia as well as those who have immigrated throughout centuries. Victimization rates for human abuse and sexual assault continue to rise, but even with the diligent work of forensic nurses, many interpersonal crimes are not being reported (Australian Institute of Criminology, 2009).

Australia has been a world leader in forensic nursing education. There are several key programs throughout Australia for educating forensic nurses at both the undergraduate and graduate levels. Flinders, Perth, and Victoria have developed certificate courses and degree programs in basic and advanced education as well as implemented roles within the healthcare and legal community. Australia hosted the southern hemisphere’s first forensic nursing scientific meeting in 2000. This meeting brought together nurses from nearby countries as well as from North America. Those of prominence include Flinders University in Adelaide, the University of Notre Dame in Perth, and the Institute of Forensic Medicine in Victoria. Queensland is also investing in the training of forensic nurse examiners (FNEs).

In 2010 a new clinical forensic nursing role is to be piloted in South Australia. Flinders University, in collaboration with the South Australian Police Department, has been working to establish a role for registered nurses to collect forensic evidence from arrested suspects within associated legal frameworks. This is a new initiative to Australia that will complement the newly established SANE role in the eastern states. This move has led to a review and redevelopment of the curriculum with a more practical approach that includes skill acquisition in evidence collection, court procedures, and witness examination to support this new role.

Crime is a prominent issue in twenty-first-century South Africa, identified in 2002 as the most dangerous country in the world not at war (news.bbc.org). However, by 2009, South Africa’s status as perhaps the world’s most dangerous country had been challenged by Somalia, the Democratic Republic of the Congo, Pakistan, Israel, and Sudan. Crime, often cultural and superstition based, remained at an alarming rate in the immediate post-apartheid era and continues to intimidate a country struggling to resolve conflict without violence. Dangers include bombing, looting, murder, rape, farm attacks, carjacking, and armed incited fear and increased victimization during decades of apartheid violence. The media speculates that much of the violence is regarded as a means for dissidents to avenge social inequalities among the people. Feelings of inadequacy are believed to contribute to hopelessness and acts of anger. The long-standing apartheid, of course, is also a major factor in the ongoing unrest among Africa’s people.

In 1996, South Africa adopted a National Crime Prevention Strategy, which aimed to reduce and prevent violent crime by reinforcing community structures. This historic document included the Proposal for Reconstruction of Forensic Services in South Africa, drafted by Dr. J. E. Els, Kimberley’s forensic medical officer (FMO). He envisioned the role of the forensic nurse as one step forward in the reduction and prevention of crime during these early endeavors and established the Northern Cape Institute in Forensic Studies in Nursing (NCIFS). Students of the NCIFS were challenged to address issues of homicide, rape, domestic violence, and alcohol abuse as a primary focus. Graduates received diplomas as FNEs and were employed in the newly developed Thuthuzela Care Centres (TCC) for forensic patients and in medicolegal death investigation (Duma, 2006; Lynch, 1999; National Prosecution Authority pamphlet, undated). Since that time, numerous programs have spread across Southern Africa and adjacent countries.

Zimbabwe became the second African country to address forensic nursing as an emerging specialty. The first FNE training program became operational in 2001 in Harare, the nation’s capitol. IAFN member Emilia Hlatywayo, an FNE and graduate of the first training program in South Africa, was employed by Amani Trust to provide forensic care and evidence collection for the survivors of torture in Zimbabwe’s political unrest. The Amani Trust is a Zimbabwean nonprofit, nongovernmental organization dedicated to preventing organized violence and torture, advocating for the rights of victims, and rehabilitating victims through community-based care. Hlatywayo was instrumental in bringing a U.S. team of forensic nurses to Zimbabwe to teach the 24 registered nurses who graduated as FNEs (Amnesty International, 2003) (www.amnesty.org/en/library/info/AFR46/015/2003).

Kenya, an East Africa country with a long history of sexual and gender-based violence, has more than a million children who have been orphaned by AIDS (www.UNICEFUSA.org). In 2009, Nancy Cabelus (DNP, RN), a U.S. FNE, established residency in Nairobi as an employee of the U.S. Department of Justice. Cabelus’s designated project spans law enforcement, nursing, and forensic development. Cabelus works with the Jordan Foundation in an effort to improve forensic laboratory facilities for Kenya. She has provided valuable assistance to the U.S. Embassy in Nairobi in compiling information for its annual report on trafficking in persons. Much of Cabelus’s work relates to a pilot program to combat sexual/gender-based violence. An enthusiastic response indicates that Kenyans are eager to learn about the ways that forensic science can aid their citizens and improve conditions within their communities. The University of Nairobi, School of Nursing has requested that Dr. Cabelus assist in the development of a master’s degree and postmaster’s certificate in forensic nursing.

Nonhlanhla Dlamini, a member of Parliament (MP) from Ludzeludze Constituency in Manzini, Swaziland, Africa, became the first FNE in Swaziland. She has been a strong advocate for the rights of women and children and a member of Swaziland Action Group against Abuse (SWAGAA), an organization that works to incorporate men in the fight against gender-based violence. SWAGAA provides several types of educational programs and has trained 25 FNEs to provide services to victims of rape. Dr. Dlamini has been a strong advocate for including forensic nursing as a curricular component in schools of nursing in the southern regions of Africa. She has affirmed that she will use her influence in Parliament to campaign for the successful adoption of this proposal (Phakathi, 2008).

In July 2007, the Canadian Nurses Association (CNA) recognized the Forensic Nurses Society of Canada (FNSC) as an emerging special interest group, according to Sheila Early, a prominent FNE in Surrey, British Columbia. This is an initial step to achieving specialty recognition. The FNSC was developed as a Canadian organization for forensic nurses.

Although the Canadian forensic nurse death investigator (FNDI) was the first in North America to be identified as a forensic role as early as 1975, other subspecialties of forensic nursing science have expanded the scope and practice of the discipline. Sexual assault nurse examiner (SANE) programs were initiated in 1993 at two locations. Currently there are 46 programs throughout Canada. The University of Saskatoon (Saskatchewan) is the center for forensic psychiatric and forensic corrections nursing, which has long filled a vital role in national forensic services. Legal nurse consultants (LNCs) are also emerging from within the general forensic nursing framework and becoming established in independent practice throughout Canada. This is a significant trend, as 10 years ago, very little was known about legal nurse consulting in Canada.

Major issues that have become barriers to the evolution and expansion of forensic nursing practice within Canada include limited educational opportunities and public acceptance. It remains difficult to establish any kind of program for sexual assault outside of larger centers. For example, five sites in British Columbia have expressed interest in specialized programs but are unable to secure funding from their health regions or other sources, due in part to the lack of physician support for forensic nursing. Fortunately, however, the established programs appear to have enthusiastic support from the medical community.

The Ontario Coroner’s Service for Death Investigation has yet to accept registered nurses as coroners based on provincial law, which requires all coroners to be medical doctors; however, in British Columbia, Saskatchewan, and the Yukon Territory, nurses frequently hold this position. The provinces with a medical examiner service, such as Alberta and Manitoba, were first to employ registered nurses as investigators. However, Ontario leads Canada with a network of 35 sexual assault/domestic violence treatment centers that care for forensic patients of sexual assault, domestic violence, elder abuse, and child maltreatment. This network is by far the most advanced in the country and can serve as a role model for the rest of the provinces and territories if developmental and support funds can be obtained. Healthcare is a provincial and territorial matter, and the federal government does not mandate the destiny of funds given to each province/territory.

A major initiative is the development of a national sexual assault evidence recovery kit by the Royal Canadian Mounted Police (RCMP), soon to be available for FNE services. In spite of the benefits of an official evidence recovery kit, Ontario and Quebec will not be included, as they have forensic centers outside the RCMP mandate. This means that the protocols for forensic evidence collection and the supplies used will be standardized for eight provinces and three territories. In the greater Vancouver, British Columbia area, Surrey Memorial Hospital in Surrey is now in the process of adding the care of human trafficking victims to its mandate. This is a newly established process that is now evolving under the direction of the Office to Combat Trafficking in People (OCTIP), which was established in British Columbia in 2007.

Larger cities in Central America have begun initiatives in forensic nursing. Several hospitals and community agencies have established special programs related to sexual assault, domestic violence, and child/elder abuse screening. Because there is a lack of a qualified forensic nursing faculty, they have relied heavily on the United States for education and training resources. Physicians and nurses are routinely receiving basic forensic indoctrination within their basic and graduate curricula in the healthcare professions. The Roman Catholic churches throughout the country are also active in providing domiciliary care and victim services.

Dr. Juan Geraldo Ugalde Lobo, Presidente Asociacionde Derecho Medico de Costa Rica, became the first in Latin America to recognize the significance of a forensic specialist in nursing and the need to bring this new concept in forensic services to Costa Rica. The First Latin American Congress on Forensic Medicine and Science (Association Latinoibero Americana Del Derecho a La Salud) was held in San Jose, Costa Rica, in 1998. At the meeting, a delegation of U.S. forensic nurses introduced the role of forensic nursing and assisted in the founding of the organization Forensic Nurses of the Americas. The following year, a 40-hour forensic nursing training program was offered in El Salvador, and indoctrination was provided for law enforcement officers, prosecutors, and defense attorneys. Jamie Ferrell, an FNE employed by the Texas Office of the Attorney General, presented an extensive educational offering designed to provide Salvadorian justice officials with a contemporary perspective on sexual assault. Other initiatives of El Salvadorian forensic physicians and nurses include identifying the remains of thousands of “missing” children who were extricated from their families during the civil wars that persisted from 1980 through 1992. The organization U.S. Physicians for Human Rights has also participated in this effort, as well as the quest to reunite missing children with their families (PHR Update, 2008).

Honduras, like other countries in Central America, experiences high incidents of interpersonal violence, especially since the 1990s when wars in neighboring countries raged, fueling the proliferation of military weapons, police corruption, and political unrest. The country continues to be challenged by human rights abuses, high homicide rates, substance abuse, human trafficking, and conflicts between criminal bands (NotiCen Publication, August 31, 2000). These concerns were a great burden to the chief medical examiner of Honduras as he attended the FNE training program at the Department of Legal Medicine in El Salvador in 1998. Although initially doubtful of the value of a forensic nurse, he became a convert and invited the U.S. team to present this program in Tegucigalpa for his medical staff and a number of nurses in 1999. In the interim, a hurricane demolished the entire forensic facility in Tegucigalpa and the program was relocated to San Pedro Sula. With support from U.S. forensic pathologists and the American Academy of Forensic Sciences, forensic services in the Honduran capital were eventually restored and revitalized.

In 2008 the International Justice Mission (IJM) contracted with forensic nurse examiner Ruth Downing, MSN RN CNP SANE-A, to establish the role of the forensic nurse in sexual assault examination in Peru. The IJM is a human right agency that works in Peru with partner organization Paz y Esperanza (Peace and Hope) to provide investigative, legal and aftercare services to victims of sexual assault. After time working in the field, the IJM found a lack of forensic capacity among local law enforcement and medical practitioners to be a regular obstacle to securing perpetrator convictions. Downing provided education in evidence collection for sexual assault patients to law enforcement, lawyers, forensic physicians, nurses, teachers and social workers in Huánuco, Peru. This central providence is located in the Andes Mountains, one of the poorest regions, with a high rate of sexual abuse. In 2009, Downing returned to Huánuco with a team of professionals from The River Church Community in San Jose, California, to continue education and support for Paz y Esperanza. This faith-based mission continues to be well received by the local community, and in 2009 the District Attorney, local law enforcement and Paz y Esperanza agreed to form a sexual assault response team to increase collaboration as they continue to address child sexual abuse in their community. Since 2003, when IJM and Paz y Esperanza began their work in Huánuco, the forensic community has greatly increased their response to child sexual abuse. Currently, the health and justice partners share the highest prosecution rate in Peru, and are committed to their mission to bring justice to victims despite frequent threats on their lives and numerous struggles in dealing with government corruption and lack of resources.

Since International Justice Mission began their work in 2003 in Huánuco, Peru, the community has greatly increased their response to child sexual abuse. Future plans include a collaborative partnership between the Hermilio Valdizan National University in Huánuco and the University of Tennessee Health Science Center, College of Nursing for the purpose of training and education to forensic physicians and other professionals in the areas of sexual assault. Patricia M. Speck DNSc, APN, FNP-BC, SANE-A, SANE-P, DF-IAFN, FAAFS, FAAN and Margaret T. Hartig, PhD, APN, FNP-BC, FAANP will be developing curriculum and SAFE classes. This initiative will create opportunities for telehealth and provide distance education through the Doctorate in Nursing Practice (DNP) located at the University of Tennessee Health Science Center in the College of Nursing.

There is a misconception in England that forensic nursing refers only to mental health/psychiatric nursing within institutional care units and prisons. This is not the case. In fact, women have been practicing forensic type services as early as the fourteenth century when they were involved in examinations to confirm the virginity of women who were marrying royalty or to evaluate sexual assault victims. Nevertheless, in the 1990s FNEs expanded their roles, not only within the mental health arena, but as custody nurses (nurses working in police stations), SANEs, and nurses working in accident and emergency units.

Forensic nursing science within England is a rapidly developing new subspecialty for the profession. Custody nursing, for example, was developed, piloted, and implemented with the Kent Police Constabulary in 2000 and is now being practiced in many other police forces. The SANE role was developed in 2001 and is currently practiced in Greater Manchester, Lancashire, and London. Despite these tentative and innovative developments, few members of other professions allied to the medicolegal system, including nursing at present, acknowledge these roles or analyze its benefits to any great extent. Forensic nursing services, with the exception of forensic psychiatric nursing, remain somewhat unrecognized in the United Kingdom. This, however, is beginning to change.

The United Kingdom Association of Forensic Nurses (UKAFN) was founded in March 2007 at King’s College Hospital, an NHS Foundation Trust in London. Support from Scotland Yard and the Metropolitan Police has been the major driving force in the development of forensic nursing in the United Kingdom. Jo Delaforce, chair of the UKAFN, is a forensic clinical nurse specialist (FCNS) in London and has been instrumental in developing a designated Centre of Excellence for the care of victims of sexual violence. The UK’s first Custody Nurse and Sexual Assault Nurses Conference was held in May 2009 in Liverpool, and it was attended by nurses, forensic medical examiners, physicians, law enforcement officers, and other forensic personnel (www.ukafn.org).

Academia in England is rapidly gaining momentum in the education of forensic nursing. Professor Jane Rutty, PhD, designed and developed a curriculum module for postregistration nurses entitled “Medico-legal Healthcare and Safeguarding People.” This offering focuses on the care of vulnerable populations and managing the associated forensic cases. As part of a European Commission grant, Professor Rutty has been designated to assume a leading role in strategic mass casualty and forensic planning associated with the XXX Olympiad.

Scotland has recognized the need to address forensic nurse specialists in light of a United Nations report that has labeled it as the most violent country in the developed world. There are considerable opportunities for FNEs within death investigation, sexual assault services, and child abuse evaluations in the wake of political and religious violence. Considering the fact that Scottish law often requires corroboration of findings by two examiners, forensic nurses could assist in meeting the need for quality forensic resources, as they could assume the role of one of these two examiners.

Northern Ireland also experiences social issues that have prompted interest in improving its forensic services. The recent release of an investigative report outlined the extent of pedophilia and child abuse within Northern Ireland (Peel, 2009). Amnesty International and other groups have been critical of its lack of services to support victims of rape and domestic violence. As part of the End Violence against Women Coalition, the state of mind in Ireland is changing. There is concern for intimate partner and sexual violence that was illuminated in the results of a 2008 survey of young adults, which shed light on disturbing attitudes indicating a general acceptance of aggression against women (Amnesty International, 2008). This report was in part responsible for the development of the first FNE program in Dublin (news.bbc.org, 2008). In January 2009, the first eight nurses in Ireland completed the year-long pilot program and obtained the Higher Diploma Nursing in Sexual Assault Forensic Examination. These nurses are registered as clinical nurse specialists in sexual assault forensic examination and are employed in a new Sexual Assault Treatment Unit (SATU) in Mullingar County, Westmeath, and the other seven nurses are based in different SATUs throughout Ireland. According to leading nurse educators, the main concern in Ireland is to have well-established programs for sexual assault forensic examiners. They believe that there will be advancement into areas such as child sexual abuse and other subspecialties when a cohort of expertise is firmly in place. In 2008, the Journal of the Irish Nurses Organization published an article regarding the development of the original eight nurses who were sponsored to undertake the Higher Diploma in Nursing in Sexual Assault Forensic Examination. This, along with reports in other publications, is expected to stimulate interest in forensic nursing within Ireland.

In Germany, great concern for the lack of forensic nursing services remains an active debate. In 2007, Andrea Lambe, a nurse at the Institute of Legal Medicine and Nancy Gage-Linder, Esq. Section Head of Violence Prevention and Intervention, challenged the German healthcare and legal system to develop an innovative, cost-efficient, and competent plan of forensic nursing practice based on the World Health Organization’s proposal (2002). Since the new plan has been in place, the German Federal Law Enforcement Agency has identified and recorded many acts of violent crimes that would have previously not been noted, including homicide, manslaughter, sexual assault, rape, aggravated assault, and robbery, as well as lesser charges of assault with intent to harm (Lambe & Gage-Linder, 2007).

Exemplary federal laws and adequate resources were developed in 2001 to the ensure safety and well-being of victims of interpersonal crimes. However, mandatory reporting of child abuse does not exist in Germany. Screenings for interpersonal and domestic violence are also not mandatory, and many cases go unnoticed within the country’s healthcare system. Although it is recognized that FNEs could provide a valuable resource in these cases, the German judicial system prefers the opinions of forensic medical examiners (FMEs) as the standard for legal recognition and reporting of crimes. Currently, Germany and other European countries are in the process of adapting their current nursing educational model to that of the United States, perhaps paving the way for the integration of forensic nursing science into the curricula (Lambe & Gage-Linder, 2007).

Turkey has been positively impacted by forensic nursing practice since the 1990s, and the need for advancing both education and practice for these specialty roles has been recognized. The Institute of Legal Medicine and Forensic Sciences (LEMFOS) of the Istanbul University teaches graduates of diverse disciplines the forensic aspects of their field. LEMFOS is the only institution in the field of forensic science available to graduates of various disciplines to enroll nurses in 1995 as a general education and public service project. The focus of this program is to address the reduction and prevention of sexual violence. The lack of experience and insensitivity to victims was associated with physicians who were reluctant to conduct the examination. This reaction often occurs because specific education in sexual assault evaluation is typically not provided for general practitioners. Victims wait several hours for an examination, and in some regions, they have to travel to another city to find a hospital where the examination can be accomplished. After making a legal statement, the victims are sent to the Council of Forensic Medicine to have another examination by court order (Lynch, 2006). In 2006, LEMFOS introduced the Section of Sexual Assaults (SSA) to ensure a more timely, thorough, and precise collection of forensic evidence. In the process, the SSA developed procedures for the physical examination and collection of evidence, as well as a variety of report forms. Educational literature was also written covering topics such pregnancy and cessation, sexually transmitted diseases, and suggestions for providing support to the victim. This program was developed and directed by the faculty of the Istanbul University and the Public Health Department, the Ministry of Justice, and the Ministry of the Interior and was lauched within the College of Nursing at Istanbul University during the 1997-1998 academic year. Currently, forensic nurses are trained as specialists who will apply their dual expertise in nursing and forensic sciences to assist in the administration of justice to complete complex forensic investigations (Gorea, Jasuja, Lynch, et al., 2003). Through the work of forensic nursing specialists and the support received from the forensic physicians, scientists, police, and attorneys, FNEs have secured their place within the forensic science community in Turkey.

In Eastern Europe, the sequelae of war-related violence resulting from the Bosnian/Serb War in 1992-1995 included the atrocities of Muslim mass murders and incarcerating women in rape camps for the purpose of ethnic cleansing (sexual genocide). In the southern Serbian province of Kosovo, sexual violence and trafficking of persons continues to be a serious concern. In the past, women seldom voluntarily reported rape, and historically this war crime has gone unpunished. However, international tribunals have now declared it to be a crime of war, stemming from the Bosnian civil war and the Rwanda genocide. This action has effectively paved the way for involvement of the FNE in international bodies such as the United Nations and the International Committee of the Red Cross, who identify such atrocities and provide care and treatment of the victims.

In 2002, the Kosovo Department of Justice and the Office on Missing Persons and Forensics implemented an initial SANE training program for the adult and child victim. Venera Mehmeti and Valbona Keqekolla started to work in January 2003 at the Office of Missing Persons and Forensics in the Office of the Medical Examiner and Department of Justice as FNEs. In addition to sexual assault case management, initial duties include assisting the forensic physician and forensic technician during autopsies of the recently dead and assisting the forensic anthropologists during the autopsy on the remains of the war dead. When requested, the FNEs respond to the scene of a crime as representatives of the Office of the Medical Examiner and work with the police officers to document and collect evidence (Mehmeti, V., personal correspondence, 2009).

Northern Europe is struggling to develop a forensic nurse specialist role in the Netherlands. In spite of many difficulties, Piet Machielse, who studied forensic nursing science in the United States in 2005, has brought this issue to the forefront. Machielse, a highly experienced emergency department nurse at the University Hospital of Rotterdam, used his acumen to introduce the science of forensic nursing and to bring attention to its contribution to healthcare. He presented a paper at the Dutch Forensic Institute in an endeavor to promote the need for forensic nursing services in the Netherlands. “Yet, as in Germany, there is no existing policy related to forensic evidence collection in Rotterdam or elsewhere in the Netherlands healthcare systems while a growing number of patients continue to present as a result of forensic scenarios,” acknowledged Machielse (IAFN, 2008).

The southern region of Europe has taken the lead in the development of forensic nursing in Puglia, Italy under the direction of Dr. Giancarlo Di Vella, a prominent forensic pathologist. In 2007, the University of Bari awarded master’s degrees to 42 nurses who completed requirements of its rigorous curricula in forensic nursing. Forensic nurses from the United States supplemented their faculty resources, teaching selected subject matter in forensic nursing and providing academic advice to the Bari faculty, and assisting in career mentoring for the students. In addition to gaining clinical experiences within Puglia, selected students also had a unique opportunity to participate in extensive forensic nursing initiatives of the Harris County (Houston, Texas) Medical Examiner’s Office to better understand the several roles of the forensic nurse in the United States. Such cooperative international endeavors are characteristic of the collaboration required to maximize scarce educational resources required for basic and advanced nursing education. In 2010, the University of Bari expects to also award doctorates in this specialty.

To illustrate the unique contributions of the professional nurse in death investigation, Michele Stallone, a graduate of the master’s program in forensic nursing at the University of Bari, presented his work at the 2009 American Academy of Forensic Sciences meeting in Denver, Colorado. Stallone demonstrated how nurses are utilized within the Office of the Medical Examiner in Bari as on-scene investigators. He stated that the use of forensic nurses has positively impacted the forensic science community by demonstrating the unique contributions of the professional nurse in solving cases (AAFS Proceedings, 2009). The University of Bari has chosen to give major emphasis to forensic nursing in the advanced education degree (magisterial bachelor degree). The educational program addresses forensic topics such as elder abuse and child abuse, domestic violence, mass disasters, evidence collection and preservation, and death investigation. A master’s program on postmortem findings and crime scene investigation provides additional information and advanced clinical training in the field.