Forensic clinical nurses in emergency departments: An emerging need for New Zealand

Andrea Donaldson About the author: Andrea Donaldson, RN, MSc, PhD, CATE, is an academic staff member at the Centre for Health and Social Practice, Waikato Institute of Technology, Hamilton, New Zealand. Her correspondence address is: [email protected] This article was accepted for publication in September 2019.	ABSTRACT Aim: This article reports on a systematic review of the literature, undertaken to gather evidence to support the establishment of clinical forensic nurse specialist roles in New Zealand emergency departments. Background: Violence is a significant and increasing health problem in New Zealand. One consequence of this is the need for New Zealand nurses to be able to recognise forensic situations in emergency departments and to apply clinical forensic principles and practices. Method: A systematic review of the literature was undertaken, using the Medline, Ovid, EBSCOHost and Proquest databases, to synthesise the findings of 23 internationally published articles on the role, function and purpose of the clinical forensic nurse in emergency departments. A thematic approach was used to analyse the information in the articles. Findings: Themes that emerged focused on the qualities and skills forensic nurses possess, and the level of specialist knowledge required to ensure patients receive the best medico-legal care. Key qualities and skills clinical forensic nurses possess include effectively identifying, collecting, documenting and preserving evidence from patients who are victims of violence, as well as educating and mentoring nursing colleagues and other health professionals about forensic evidence. These nurses require specialist knowledge to enable them to care for some of the most challenging patients, many with complex psychosocial, psychological and physical health-care needs, all while upholding ethical and legal principles. Conclusion: A role for clinical forensic nurse specialists in New Zealand emergency departments is clearly indicated. Emergency departments also lack protocols to support nurses caring for and treating victims of violence or unexplained death. The review also found that nurses lack the confidence, skills and education needed to meet medico-legal obligations to their patients and to fulfil their duty to “do no harm”.
KEYWORDS forensic nursing, forensic nursing skills, forensic nursing education, forensic nursing specialization, emergency department

INTRODUCTION

EVERY DAY, IN EMERGENCY departments around the world, skilled nurses provide care to patients presenting with injuries caused by trauma and violence. Violence is a major public health problem worldwide. Each year, millions of people suffer permanent disabilities, live with physical and psychological scars and die from injuries related to violence (Butchart & Mikton, 2014). The World Health Organization (WHO) cites violence and crime as a significant health issue and the fourth leading cause of death among adults (Butchart & Mikton, 2014). Trauma and violence injuries occur in a wide variety of ways, including through motor-vehicle crashes, burns, interpersonal violence, mass disasters and terrorist acts. Victims of violence require complex care from health professionals with trauma-informed, evidence-based expertise which is medically and legally sound. People who experience intimate-partner violence, child and elder maltreatment, strangulation, physical assault, and sexual violence, often face substantial short and long-term health and legal consequences (Anda, 2018; Fanslow & Robinson, 2004; Koss & Heslet, 1992; Loxton et al, 2017; SAMHSA, 2014). The hospital emergency department is the first place a victim and/or perpetrator of violence is brought for medical treatment. Most of these patients survive; some do not. Emergency nurses are uniquely positioned to identify, evaluate and treat these patients. They are also obliged to preserve and collect any potential forensic evidence that may be on or with the patient, as well as maintain the chain of custody (documenting the handling of evidence) and notify the appropriate authorities.

When an emergency nurse provides care to victims of violent events, that nurse is providing forensic nursing care. In New Zealand, violence is a significant and increasing health problem (Boshier, 2011). One result of this growing problem is the need for New Zealand nurses to recognise forensic situations and apply clinical forensic principles and practices in emergency departments. Currently there are few, if any, nurses specifically trained in forensic skills working in emergency departments in New Zealand (Williams, Richardson, O’Donovan & Ardagh, 2005), nor is there any current postgraduate education in forensic science principles for nurses in this country.

This article reviews the literature describing the clinical forensic nurse’s role and offers reasons why they are needed in New Zealand.

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BACKGROUND

The rate of domestic violence in New Zealand has risen (Boshier, 2011) and has seen described as “an epidemic” (Hand et al, 2001). In fact, New Zealand has the highest rate of family violence in the developed world (New Zealand Herald, 2016). In 2014, 60 percent of all female homicides in New Zealand were committed by a family member (New Zealand Family Violence Clearinghouse, 2017). One in three (35 percent) ever-partnered New Zealand women report having experienced physical and/or sexual intimate partner violence in their lifetime. When psychological/emotional abuse is included, 55 percent report having experienced intimate partner violence in their lifetime (Fanslow & Robinson, 2011).

One in three New Zealand women and one in 10 men report having experienced child sexual abuse. Twenty percent of female secondary school students and 9 percent of male secondary school students report having experienced unwanted sexual contact in the previous 12 months. “There were 2163 reported events involving the sexual victimisation of a child aged 16 years or under in 2016”. (New Zealand Family Violence Clearinghouse, 2017). On average, 525,000 people are harmed each year due to domestic violence, with 80 percent of these cases going unreported to authorities (New Zealand Herald, 2016).

It seems inevitable that both victims and perpetrators of violence will be assessed and treated in this country’s emergency departments. This supposition is supported by research showing that those who experience abuse access the health-care system two to 2.5 times as often as those not exposed to abuse, and that care could be improved if health professionals were able to identify the signs of abuse underlying the patient’s presentation (Fanslow & Robinson, 2004; Koss & Heslet, 1992). Additionally, research has shown that women with a lifetime experience of moderate or severe physical intimate partner violence were more likely to have consulted a health-care provider within the previous four weeks, more than twice as likely to have been hospitalised within the previous 12 months, and more than 2.5 times as likely to report current symptoms of emotional distress and suicidal thoughts in their lifetime, compared to women who had not experienced any violence (Fanslow & Robinson, 2004; Fanslow & Robinson, 2011). These findings have considerable implications for health-care delivery, highlighting the need for specialist skills in identifying current and past victims of violence and abuse in the health sector.

Violence is also becoming more visible in other ways, with front-line health-care staff, such as doctors and nurses, being assaulted (Swain, Gale & Greenwood, 2014; Wilson, 2009), ethnic groups being victimised, and ordinary people under threat from terrorism (Hawi, Osbourne, Bulbulia, & Sibley, 2019). Despite violence becoming more visible, health professionals, like the general public, are reluctant to report violence against themselves at work. Failure to report has the potential to influence cultural norms by hiding the true extent of violence in society (Richardson, Grainer, Ardagh & Morrison, 2018). Not reporting violence reinforces the notion that violence is acceptable. If violence is not reported, how can nurses and other health professionals work to reduce the impact of it for people in our communities? It is this question that prompted this review of the literature on the role of the clinical forensic nurse and the potential for such a role in emergency departments.

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AIM

The aim of this systematic review was to gather evidence to support the establishment of clinical forensic nurse specialist roles in New Zealand emergency departments.

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METHOD

A search of the literature was conducted using digital databases, including Medline, Ovid, EBSCOHost and ProQuest. Manual searches were also made using the reference list from recovered articles and textbooks. Key words used for the database searches were “forensic nursing”, “forensic nursing education”, “forensic nursing research”, “forensic nursing specialization”, “emergency department”, “forensic medicine” and “forensic science”. The search located 121 studies from 80 different journals, books and theses. Only literature that discussed forensic nursing in emergency departments was included in the review. Literature which discussed forensic nursing in general, or in other areas such as forensic mental health, was excluded. This narrowed the suitable studies down to 23 journal articles or textbooks.

A thematic approach (Braun & Clarke, 2012) was used to analyse the information in the articles. This approach uses six levels of analysis: familiarising oneself with the data, generating initial codes from the data, searching for themes, reviewing potential themes, defining and naming themes, and producing the report. Descriptive themes covered the qualities and skills forensic nurses possess, and the level of specialist knowledge required to ensure patients receive the best medico-legal care.

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FINDINGS

The following section identifies the key themes identified by thematic analysis of the 23 reviewed studies.

Clinical forensic nurses possess specialist skills and knowledge, allowing them to identify, collect, document and preserve evidence from patients who are victims of violence. They also educate and mentor nursing colleagues and other health professionals on dealing with evidence associated with such patient presentations. Such evidence could include the circumstances surrounding the injury, the type of weapons involved, the length of time between the injury and treatment, the nature of the injury and whether there were any witnesses. Clinical forensic nurses also give legal testimony in court and write policies and guidelines on the collection and documentation of forensic evidence in public health services. Their specialist knowledge must equip them to care for some of the most challenging patients, who may have complex psychosocial, psychological and physical health-care needs, all while upholding ethical and legal principles.

Defining forensic nursing

The term “forensics” is derived from the Latin word “forensis”, meaning “forum”, which described the marketplace where lawyers met to debate (Saunders, 2000). In modern use, “forensics” is a synonym for “legal” or “related to courts”. Today, the term is used to describe the field of forensic science. Forensic science principles have become intertwined with other professions, including those in health care. These professions include forensic medicine, forensic pathology, clinical forensic practice, and – the most recent addition – forensic nursing science (Lynch & Duvel, 2011; Lynch, 1996; Lynch, 1997).

The concept of forensic nursing emerged from the practice of clinical forensic medicine (Lynch, 1996). Clinical forensic medicine is defined as a medical specialty that applies the principles and practices of clinical medicine to the elucidation of questions in judicial proceedings for the protection of the individual’s legal rights before death (Eckert et al, 1986, cited in Lynch, 1997). Until recently, practitioners of clinical medicine had largely ignored forensic issues in the care of the living patient (Lynch & Duvel, 2011; Smock, 2006). This lack of recognition led to the development of clinical forensic practice, which is defined as the application of medical and nursing sciences to the care of living victims of crime or liability-related accidents, as opposed to forensic pathology, which focuses upon the deceased (Lynch, 1993; Lynch & Duvel 2011).

Forensic nursing was first established in the United States (US) in the 1970s (Lynch & Duvel 2011; Sekula, 2016). It is now a growing nursing specialty in many other countries around the world (Lynch, 2011). Recognition as a nursing specialty was first acknowledged in 1995 by the American Nurses Association, after the International Association of Forensic Nurses (IAFN) was formed (Kent-Wilkinson, 2013). Canada very quickly followed with recognition in the late 1990s. In Australia, forensic nursing is a small but established specialty that is beginning to expand, thanks to the growing number of courses being developed and recognition of the role nurses can play in helping victims of crime and assisting the course of justice (Michel, 2008; Prebble, 2001; Saunders, 2000).

According to Lynch and Duvel (2011), there is now a greater focus on the needs of forensic patients, and not just the incarcerated, the mentally ill or the deceased. This is occurring as the public become more aware of their medical and legal rights, which adds pressure on hospital staff. Health-care staff struggle to manage the collection and documentation of forensic evidence when few hospitals have guidelines on how to do so (Williams, Richardson, O’Donovan & Ardagh, 2005) and there are no forensic nursing specialists to guide the process and ensure patients’ legal rights and needs are met.

The clinical forensic nursing role

Forensic nursing in the emergency department is a nursing specialty that focuses on the identification of patients whose illness, injury or death stems from acts of violence. It involves providing the best medical and legal care, through effectively identifying, collecting, documenting and preserving evidence that can be handed over to law enforcement authorities, to be used in the investigation and prosecution of a case. Roles for clinical forensic nurse specialists in the area of interpersonal violence have become the norm in the US. There, nurses lead multidisciplinary teams in assessing child abuse, elder abuse and spousal abuse, and advise on related laws and policies (Kent-Wilkinson, 2011).

Forensic nurses also liaise between the emergency department and law enforcement authorities and give expert testimony in court (Goll-McGee, 1999; Kent-Wilkinson, 2009; Lynch & Duvel, 2011; McGillivray, 2005; Pyrex, 2006; Sekula, 2016). They not only provide life-saving management, resuscitation, and health care, which is the primary focus of the emergency nurse (McCracken, 1999; Pyrex 2006; Sullivan 2005); they also identify and collect evidence, including the circumstances surrounding the injury, the type of weapons involved, the length of time between injury and treatment, the nature of the injury and whether there were any witnesses (Lynch & Duvel, 2011; Kent-Wilkinson, 2009; McGillivray, 2005; Pyrex, 2006; Sekula, 2016).

One of the basic concepts of clinical forensic nursing is the idea of the “body as a crime scene” (Pyrex 2006). Sullivan (2005) describes the importance of recognising and collecting evidence, and accurate documentation. More recently, Foresman-Capuzzi (2014) stressed the importance of evidence collection in the emergency department and introduced the basic skills of collecting evidence and preserving the chain of custody for that evidence. Given the necessity of these skills, it is important that clinical forensic nurses practise in emergency departments, and that they have access to specialist postgraduate education (Lynch & Duvel, 2011; Kent-Wilkinson, 2009; Lynch, 1996; McGillivray, 2005; Pyrex, 2006; Sekula, 2016; Sullivan, 2005). Research has shown that emergency nurses are aware of forensic patients in their departments, but lack the knowledge, training or confidence to adequately care for them (Cucu et al, 2014; Michel, 2008). In some cases, there may be a legal mandate to gather evidence, eg in the case of motor-vehicle accidents or abuse of a child, and ethical considerations must always be considered, especially in relation to consent, invasiveness of evidence collection and loss of privacy. Williams et al (2005) discuss ethical considerations in forensic nursing, explaining how not collecting evidence could be to the detriment of the ethical principles of beneficence and non-maleficence, as well as to the pursuit of justice.

Another part of the role of the clinical forensic nurse involves educating and supporting other nurses and health professionals on how to identify living forensic patients and how to provide these patients with specialised medico-legal care. This care requires the collection and preservation of forensic evidence, and meticulous documentation and legal processes (Goll-McGee, 1999; Kent-Wilkinson, 2009; Lynch, 1996; Lynch & Duvel, 2011; McGillivray, 2005; Pyrex, 2006; Sullivan, 2005). Shapiro (2011) notes that when emergency nurses are educated about, and trained in, basic evidence collection, the practice can become an automatic and integral part of patient care that does not delay treatment.

To help clarify forensic nurses’ responsibilities in the emergency department, McCracken (2001) devised a mnemonic for clinical forensic nurses, based on the well-known and internationally accepted ABC of trauma care (see Table 1). This works by applying logical steps to each letter of the alphabet to ensure safe, standardised, effective care.

Table 1: Forensic ABC mnemonic

Trauma ABCs	Forensic ABCs
Airway	Assessment
Breathing	Bridge the gap (involving other agencies)
Circulation	Chain of custody
Disability	Documentation
Expose	Evidence
Farenheit	Families
Get vital signs	Going to court
History and head to toe	Hospital policies and guidelines

While forensic victims of violence present at emergency departments in increasing numbers, it should not be forgotten that sudden or unexplained death may also require specialised clinical forensic nursing input, especially in terms of evidence collection, documentation and legal testimony (Lynch & Duvel, 2011; Pyrex, 2006; Sullivan, 2005).

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DISCUSSION

The need for a clinical forensic nursing role in New Zealand

Nurses have a role in communicating, educating and acting as catalysts for change in public health (Castledine, 2002). They are educated to use evidence-based practice and can help design and implement specific interventions to give the best care to victims of domestic violence (Hegarty & Taft 2001; Spangaro, 2017). Nurses and doctors increasingly report that they lack the knowledge to deal with domestic violence issues with their patients (Biresch, 2011).Clinical forensic nurses have the skills to provide the specialised care these patients need.

Sadler (2002) says health professionals who work in emergency or acute care are more likely to find forensic or legal situations a cause of considerable uncertainty and anxiety. This is true in the New Zealand context, where Fanslow, Norton, Robinson and Spinola (1998) and Spangaro (2017) describe how New Zealand health-care professionals are concerned with addressing the issue of abuse due to fear of “opening Pandora’s box”, fear of offending, a sense of powerlessness, time constraints and privacy issues.

Lynch (1997) also describes nurses as lacking knowledge about and awareness of forensic issues. Research by Hinderliter, Doughty, Delaney, Pitula and Campbell (2003) supported this point – they identified a lack of nursing competence and confidence in their ability to screen patients for domestic violence. The American Nurses Association and Sadler (2002) both highlight a lack of education and clinical preparation, in both undergraduate and postgraduate education, on dealing with violence and legal investigations. This is also true in New Zealand nursing education, where education and clinical preparation on violence and legal investigations is limited in both undergraduate and postgraduate nursing programmes.

Another barrier to nurses screening patients for family violence is the nurse’s own experience of the issue. If one in every three females in New Zealand is affected by family violence (Ministry of Health, 2016), the predominantly female nursing workforce is likely to include a significant number who are themselves victims of abuse (Davis, 2007). It is essential, therefore, that the nursing profession take the guesswork out of forensic patient care for emergency department nurses (and other health-care professionals), to ensure appropriate and effective interventions, justice and professional accountability. Therefore, forensic education and resources are needed to prepare nurses for the specialist clinical forensic role.

Once nurses were educated for this specialty, the role could expand to include liaising with law enforcement, developing hospital forensic protocols, and serving as onsite role models in providing the best medical and legal care for patients in the emergency department.

The need for forensic nurses in New Zealand emergency departments was recognised nearly a decade ago, but has not been acted on (Williams, Richardson, O’Donovan & Ardagh, 2005). With the New Zealand Government announcing additional funding for family violence services for the first time in 10 years, and stating that the money will be split between “stabilising current services and filling gaps in service delivery” (New Zealand Family Violence Clearing House, 2019), the time is right for nurses to demand specialised postgraduate forensic nursing education. The development of a specialist clinical forensic nurse role in hospitals will help promote safer communities, address inequality and lower the significant health effects of violence, all while assisting the course of justice.

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CONCLUSION

From this literature review, it is apparent there is a significant need for clinical forensic nurse specialists in New Zealand emergency departments. Violence is a significant health concern and New Zealand has among the highest rates of domestic violence in the world. Emergency departments lack protocols to support nurses and other front-line personnel to care for and treat the victims of violence or unexplained death. Currently, the medico-legal needs of these patients are not being sufficiently addressed. This review also indicates nurses may lack the confidence, skills and education to meet medico-legal obligations to forensic patients and to fulfil their duty to “do no harm”. Tertiary education needs to offer clinical forensic nursing training. Also, emergency departments need to develop the clinical forensic nurse specialist role, not only as a resource and role model for other emergency department nurses, but also to help develop forensic protocols, to liaise with law enforcement and to ensure patients’ legal rights and the needs of justice are met.

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