Forensic psychiatric nursing
L. Kathleen Sekula and Alison M. Colbert
1. Define forensic nursing, forensic psychiatric nursing, and correctional nursing.
2. Describe the educational preparation required for the forensic nurse generalist and the advanced practice forensic nurse.
3. Identify the functions of forensic nurses.
4. Discuss the specialized roles in forensic nursing.
5. Identify three roles of psychiatric nurses in the specialty of forensic nursing.
6. Discuss the roles of the forensic psychiatric nurse within the legal system.
7. Compare and contrast the roles of forensic psychiatric nurses and corrections nurses.
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In the United States, crime accounts for more deaths, injuries, and loss of property than all natural disasters combined (Disaster Center, 2007). Approximately 13 million people (5% of the U.S. population) are victims of crime on a yearly basis, and of those crimes 1.5 million are violent. Violence has been targeted as a goal in Healthy People 2020 to prevent injury and violence in the United States (U.S. Department of Health & Human Services [USDHHS], 2012) (Box 32-1).
Forensic nursing
The International Association of Forensic Nurses (IAFN) (2006b) defines forensic nursing as:
• 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 and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity, and traumatic accidents.
Forensic nurses provide direct services to crime victims and perpetrators of crime and consultation services to colleagues in nursing, medicine, social work, rehabilitation, and law, just to name a few. Forensic nurses can offer expert court testimony in cases related to their areas of practice and expertise, input on policy changes within the corrections settings, and evaluation services regarding specific medical and psychiatric diagnoses for inmates, among other services.
The IAFN was formed in 1992 when 74 nurses—most of whom were sexual assault nurse examiners (SANEs)—came together to create an organization to represent nurses whose practice overlapped with key areas of forensic science and law (IAFN, 2006a). The group currently represents nurses who are forensic nurse generalists, SANEs, forensic psychiatric nurses, death investigators, coroners, correctional nurse specialists, and those in other forensic nursing specialties that continue to evolve. A year after its creation, the organization had more than tripled in size, and by 2012, the IAFN’s membership had grown to more than 3000 nurses (IAFN, 2006a). The ANA officially recognized forensic nursing as a specialty practice area in 1995 and combined efforts with the IAFN to develop the Scope and Standards of Forensic Nursing in 1997.
The goals of the IAFN (2006a) are to:
• Incorporate primary prevention strategies into our work at every level in an attempt to create a world without violence.
• Establish and improve standards of evidence-based forensic nursing practice.
• Promote and encourage the exchange of ideas and transmission of developing knowledge among its members and related disciplines.
• Establish standards of ethical conduct for forensic nurses.
• Create and facilitate educational opportunities for forensic nurses and related disciplines.
While there is no advanced practice certification at the master’s level in forensic nursing, a portfolio recognition process has been established by the IAFN through the American Nurses Credentialing Center (ANCC). Various entry-level certifications, such as Sexual Assault Nurse Examiners (adult and pediatric) through the IAFN, Death Investigator through the American Board of Medicolegal Death Investigation, and the Legal Nurse Consultant through the American Association of Legal Nurse Consultants, are offered.
Education
Educational programs have been developed to prepare nurses for a career in forensic nursing. The IAFN calls for the incorporation of forensic content at all levels of nursing education. As students become more knowledgeable about forensic issues in the care of all patients, more graduate programs are offered that focus the nurse on forensic practice as a specialty area. Forensic education is offered at all academic levels.
Forensic nurse generalist
To be called a forensic nurse generalist, the nurse with a baccalaureate or associate degree or diploma may acquire additional knowledge and skills by completing a certificate program that comprises continuing education in an area of forensic nursing. Nurses can also gain expertise by taking secondary education electives and/or pursuing a minor in legal topics.
The role of the forensic nurse generalist may vary according to clinical setting, but consistent within this role is the need to be proficient in assessment and treatment of victims of violence, evidence collection and preservation, proper documentation, the legal system, and setting standards of care for victims and perpetrators. A forensic nurse generalist may work in a specialty area, such as on a trauma team or in an emergency department, critical care, or outpatient women’s health clinic, or may serve as a general resource person for colleagues in the clinical setting. The forensic nurse generalist may also serve as a resource for the care provider who is working with a patient who has been a victim or perpetrator of violence. In addition to addressing patients’ physical and psychological needs, forensic nurse generalists are prepared to identify and care for victims of violence and know when evidence should be collected and preserved.
Forensic nurse in advanced practice
A forensic nurse in an advanced practice role (advanced practice forensic nurse) has completed graduate education with a broad focus in forensic nursing and may have obtained credentials as a clinical nurse specialist, certified nurse-midwife, or nurse practitioner. The education provides clinicians with nursing, medical, and legal content and focuses on the collaboration among disciplines in the care of victims and perpetrators. The advance practice registered nurse in forensics also has an educational background in psychiatric assessment and intervention skills, death investigation, forensic wound identification, evidence collection, family violence, sexual assault of all types and in varied populations, introductory law, and principles of criminal justice and forensic science.
Other advanced training takes place after the completion of a master’s degree. Individuals who are prepared with a doctor of nursing practice (DNP) may evaluate and apply evidence-based forensic practice for the improvement of education, clinical practice, systems management, and nursing leadership. A doctor of philosophy (PhD) prepares nurses to initiate and conduct research in the area of forensics to ultimately enhance the practice of forensic nursing. Most forensic nursing researchers have completed a doctoral degree or have another advanced degree.
Postdoctoral education or fellowships are also available as additional coursework in the specialty of forensics and clinical experiences to enhance terminal nursing degrees.
Roles and functions
Regardless of the preparation level of the nurse, the goal of forensic education is to provide nurses who are knowledgeable in the care of all victims and perpetrators of violence.
In forensic nursing, the nurse-patient relationship occurs based on the possibility that a crime has been committed, but it is not the role of the forensic nurse to make a decision as to guilt or innocence or whether a victim is being candid in reporting what happened. Basic roles of the forensic nurse include the following:
2. Creation of appropriate treatment plans
3. Collection, documentation, and preservation of potential evidence.
The forensic nurse possesses expertise in assessment and treatment roles related to competency, risk, and danger. Forensic nurses are educated in theories of violence and victimology, legal issues, and nursing science that enable them to objectively assess the circumstances of the case.
An understanding of both the victim and the perpetrator enhances evidence collection. Forensic nurses may apply medical-surgical knowledge to the care of victims and perpetrators or may function in the legal role primarily as they collect evidence, testify in court, or collaborate with law practitioners with relationship to a victim or perpetrator.
Sexual assault nurse examiner
The sexual assault nurse examiner (SANE) was the first specialized forensic role for nurses, and it represents the largest subspecialty in forensic nursing. SANEs are forensic nurse generalists who seek training in the care of adult and pediatric victims of sexual assault (SANE-A and SANE-P respectively). The IAFN has established clear guidelines for the preparation of SANEs and provides certification for nurses although not all nurses who work in this capacity have certification. A SANE training course is typically 5 days (40 contact hours) and is available online or in the classroom setting. Completion of the course is followed by a period in which the nurse is preceptored by an expert SANE until the nurse is deemed proficient in conducting the exam herself. At this point the nurse can then sit for the national certification exam through the IAFN. Chapter 29 addresses the role of the SANE nurse in more depth.
Nurse coroner/death investigator
The nurse coroner/death investigator for nurses was first recognized in the mid-1990s. Traditionally, the coroner is a public official primarily charged with the duty of determining how and why people die. Increasingly, nurses are prepared as death investigators or deputy coroners. Nurses can practice as death investigators in medical examiners’ or coroners’ offices or independently in private offices. This expanding nursing role involves assessing the deceased through understanding, discovery, preservation, and use of evidence.
Nurses who work as nurse coroners/death investigators possess medical knowledge that allows them to make expert judgments regarding the circumstances of death based on observations of history, symptomatology, autopsy results, toxicology, other diagnostic studies, and evidence revealed in other aspects of the case. Their knowledge of anatomy and physiology, pathophysiology, pharmacology, grief and grieving, growth and development, interviewing, outcomes measurement, and many other areas of nursing practice bolsters the value of nurses serving in this capacity. Nurses are able to expand the role of the coroner and improve services provided to families, health care agencies, and communities by employing the basic principles of holistic nursing care.
Forensic psychiatric nursing
A forensic psychiatric nurse is one who is prepared as a generalist or at the advanced practice level. In the generalist role, nurses are prepared at the entry level as a college/university degree, associate degree, or diploma graduate, which prepares them to function as direct care providers and patient advocates. At this level a nurse who enters a forensic psychiatric setting is expected to advance her education through continuing education or certificate programs that provide education in caring for the forensic patient, usually in a corrections setting. At the advanced practice level, graduate education is required, which prepares nurses to function as psychiatric clinical nurse specialists or psychiatric nurse practitioners. Additional graduate work in forensics at the master’s and post-master’s levels provides the knowledge needed to practice with forensic populations. This specialty requires skills in psychiatric mental health nursing assessment, evaluation, and treatment of victims or perpetrators. Combining the skills of medical and psychiatric nursing with a thorough understanding of the criminal justice system is pertinent to expert practice (Lyons, 2009).
Evidence collection is central to the role of the forensic psychiatric nurse. For example, evidence is collected by a careful evaluation of intent or diminished capacity in the perpetrator’s thinking at the time of the crime. This evaluation aids in determining the degree of crime and may later influence the sentence. Forensic psychiatric nurses who work as competency evaluators collect evidence by spending many hours with a defendant and carefully documenting the dialogue. In this capacity, the role of the forensic psychiatric nurse is not to determine guilt or innocence but to provide assessment data that can help make a final diagnosis within the multidisciplinary forensic team (Sekula & Burgess, 2006).
Roles and functions of the forensic psychiatric nurse
The forensic psychiatric nurse may function as a psychotherapist, forensic nurse examiner, competency evaluator, fact or expert witness, consultant to law enforcement agencies or the criminal justice system, hostage negotiator, or criminal profiler. These roles may involve providing therapy, witness testimony, services to a prosecutor or defense attorney, and criminal profile reports. Roles of the forensic psychiatric nurse may be examined in relationship to the outcomes for which the nurse is contracted to accomplish. These nurses may be contracted by the legal system to interface with the perpetrator for a variety of services. They may also be contracted by the correctional system or a private entity to offer direct services to the perpetrator. Or they may provide services to the victim in a variety of settings. A list of role functions of forensic psychiatric nurses is presented in Box 32-2.
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