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OTE Volume 14 Number 3 - Fall 2008 Forensic Emergency Nursing
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Forensic Emergency Nursing - Role Integration

By Pi
et MImage of Piet Machielse, RNachielse, RN

On The Edge - Fall 2008
This paper outlines the need to develop a specialised nursing role, that of the Forensic Nurse. Awareness of the importance of forensic evidence collection, appropriate storage, and disposal of material is growing (Williams T, 2005). It is necessary not only for the legal implications but also for the psychological outcome of response to traumatic events. However, there is no existing policy related to forensic evidence collection in the Emergency Department environment in Rotterdam as well the Netherlands. It is an accepted feature of emergency care to deal with serious injuries and death. While the physical and emotional care of the patient is the primary focus of such nursing care, the collection of forensic evidence is a logical step in the development of holistic healthcare. (McGillivray, 2004)
Where the role of emergency nurses in the recognition, collection and preservation of forensic evidence is established more knowledge of their role and responsibilities is needed. In addition departmental and organisational policy and the need for more specific educational preparation in this area have to be developed. The emergency nurse must be proactive in recognising that any patient admitted to the emergency room with potential liability-related injuries, whether victim or victimiser, living or dead, is a clinical forensic patient (Lynch, 1995).
This paper gives an overview of the essential knowledge related to the recognition, collection and preservation of forensic materials by emergency nurses. It also discusses the importance of using an ABC kind of structure by emergency nurses in caring for patients who present as victims of violence. Transparent and systematic procedures are described to maintain quality guiding and professional standards. In this way the role and responsibilities of emergency nurses can be clarified.
Forensic nursing is a new idea in the Netherlands, but has long been established in the U.S., England, Canada, and Australia. Clinical forensic practice is derived from forensic medicine originating in England. It focuses on the investigation of traumatic injury or patient treatment with legal-related issues. Where the pathologist was concerned with the deceased and the investigation of death, the newest forensic experts, forensic nurses, is concerned with the living and called living forensics (James and Norby, 2005). The identification and collection of evidence is from living patients. Moving out the morgue into the ER or clinical area will pave the way for nursing involvement (Mary K Sullivan, 2005 ).. In the Netherlands, medical experts working at the Dutch Forensic Institute (NFI) only practice forensic science. Forensic nursing is an unknown. In trying to make a change, my starting point will not be “ground zero”, (Vegghi, 2004) but far below that. After my meeting with employers from the NFI, I was able to show them the need for collecting evidence from the patient, both for the patient and for use in court. It can be used by the police medical examiner as well.
The ER as forensic area:
Due to the shifting need in healthcare in the Netherlands, the emergency nurse is moving into a new area where more autonomy is required. This is why the emergency nurse wants to move towards a more holistic approach. In this way the emergency nurse becomes responsible for building bridges between other healthcare organisations or departments. This requires an active and assertive attitude.  Not only can advice be given to the patient, but also can build in checkpoints at certain moments if adequate help is to be accurately realised. Communication with other agencies, departments and organisations, for instance mental health care or the police department, is necessary. Emergency nursing care will always be the provision of physical and emotional care. However, we are seeing an increased number of victims of violence in our ED.
A growing number of patients present as a result of assault or in suspicious circumstances. Collecting forensic evidence is necessary, not only for the legal implications but also for the outcome of response to the traumatic events for the victim. However, there is no existing policy related to forensic evidence collection in the ED in my own working area as well as other EDs in the Netherlands. There is an upcoming change in all kind of training and education programs are offered and in development by universities and high schools in Forensic Science. This is occurring because of TV programs like CSI (USA) and Silent Witness (UK). There is still none for the “living patient”. A quick survey counting the numbers of patients suspected of being a victim of violence visiting the ED of the University Hospital Rotterdam, I discovered I was seeing 2-4 patients per day. Those patients were well treated (in a technical way, including good evidence collection) but only a few of them had follow-ups by the police medical examiner, detectives, outpatient units or other health/victim care agencies.
Recognising and collecting evidence:
Preservation and collection of evidence will slowly become a daily practice for emergency nursing practice. As a result it is important to educate nurses and other health care workers regarding this important step in the process of examination and investigation. The first step in the collection of forensic evidence is the ability to recognise the patient populations that require it. Patients who are victims, survivors, suspects, or perpetrators of violence can be referred to the ED. It is important to consider the wide range of patients for whom this collection is needed. For example, motor vehicle crashes; attempted homicide or suicide; injuries involving firearms, knives or other weapons; accidents, including fires, falls or electrocution; work-related accidents; damaged or improperly used equipment; unidentified persons; poisonings, overdoses, or illegal drug use; assaults, sexual or nonsexual; public health hazards; anyone in police custody for any circumstance; or sudden, unexpected death. (LindaMcCracken, 2003). The recognition of these patients is important, as rape and domestic violence are grossly under-reported.
An important skill for an emergency nurse concerning forensic evidence collection is the recognition that evidence may exist. The ER nurse is the first to see the patient, the first to talk to the family, first to handle the potential evidence; therefore, it is essential that ER nurse becomes proactive in collecting forensic evidence. Evidence collection needs to be done during primary assessment but should never compromise the vital signs. A role of the ER nurse is to be aware of their prime position in collecting evidence which later may be used for forensic investigation. The life, health, and safety of each patient are, however, of higher priority than forensic considerations (ENA, 2003). Another role of ER nurses is that they can refer patients to authorities.
The emergency nurse is in the unique position to make the “story complete.” Most trauma charts include a body map page where the charter can document visible injuries. (LindaMcCracken 2003). Visual material is better that the spoken word. Visual material doesn't forget or stretch the truth. “A photograph continues to testify from the moment it is put into evidence until the verdict is rendered” (LindaMcCracken 2003). While trauma team members are performing the initial assessment of the patient and intervening in any life-threatening injuries that they come upon, one nurse, with a camera in hand, can take quick shots of patterned injuries and/or identifying markings such as tattoos should the patient be unidentified. During the log-rolling of the patient, to `inspect the back' for injuries, that same nurse can attain photos of abrasions, contusions, stab wounds or other injures before the patient is log-rolled back to a supine position. (LindaMcCracken 2003). Photographing injuries does not delay patient care, nor does it delay documentation.
While examining and taking care of the wounds it is easy to ask more detailed questions., For the patient it is less harmful to talk about the traumatic event when the questions are aimed at an objective focus. It’s like building a structure to organise the overwhelming facts and memories. It is well known that the process of healing depends largely on the ability to get order in the relations between the events.
System required:
ER nurses are used to working within a standard system, called the ABCD’s. Like in all worldwide courses ATLS, TNCC, etc. we use the same kind of mnemonics in the ER. During the development of forensic nursing education it would be easy to use the same mnemonic. Linda McCracken wrote in “On the Edge” and presented on her web site, it is an easy system to transfer.
A         Assessment of/ advocate for the victim/victimiser
B         Bridge the gap – liaison with outside agencies (police/ med. ex)
  C         Chain of custody – know the methods of evidence collection; establish continuity of evidence possession and disposition of that evidence; maintain confidentiality
D         Documentation of findings (include diagrams, photos)
E          Evidence – physical/potential evidence (gross, trace, informational)
F          Families – remember them and keep them informed
G         Going to court – be prepared for written or verbal testimony
H         Hospital (other institutional) policies – know where to access guidelines
I           Index of suspicion – keep it high! Be cognisant of sexual abuse, child abuse
Hospital policy is needed:
Caring for trauma victims and gathering evidence in the ED is a dilemma. Adequate documentation is a must in the collection of forensic evidence. The ER nurse is in a unique position to document evidence; it is still a principle that what is documented has occurred (McGillivray, 2004). We need an official authorised status - in law and in hospital policy- for the forensic nurse.
Competent handling of forensic evidence may be a deciding factor in a verdict. Forensic evidence may be compromised if appropriate precautions are not used when collecting evidence (Sharma, 2003). Problems in collecting evidence are often due to the lack of proper storage and preservation. These include principles of processing clothing, a uniform way of describing wound characteristics, and for performing a forensic medical examination. Inaccurate terminology may result in the perpetrator being released.
Use of gloves, papers bags, one bag for each item of clothing; careful removal of clothing without losing, removing, and/or contaminating the evidence is essential. Diagrams and/or photographs may be helpful in documenting wound characteristics. Each envelope, container, or photo must be dated and signed by the nurse or clinician. ED or hospital policies and guidelines should guide collection of forensic evidence.
Forensic nursing does not yet exist in the Netherlands. Because of the increase in patients visiting the ER as a victim of violence, the need for the development and implementation of forensic nursing is a great need. The emergency nurse is moving towards working with a professional standard. He or she uses a transparent and systematic way of handling. In this respect an ABCD structure can be helpful as a policy within the emergency department. In the end easy to handle protocols must be developed to guarantee that the right people make the correct decisions. Some of the goals of the forensic nurse must be responsible collection of evidence, documenting (e.g. Digital or Polaroid photographs) the victim’s wounds and injuries, developing protocols and standards for ED evidence and statement collection, securing evidence, maintaining the chain of evidence, and referring patients to other resources.
In the Netherlands there is no currently published literature concerning medico-legal aspects, collecting evidence, etc. However, there is much more information available from the USA, Canada, England, Australia, and New Zealand. There is currently a void in the health care system in the Netherlands in treating victims of violence and the inclusion of an expert forensic nurse can and will be an improvement of total patient care.
Piet Machielse, works and lives in the Netherlands, Europe. He has worked for 25 years as a Senior Emergency Nurse in the Emergency Department of the University Hospital of Rotterdam, Erasmus Medical. Introduced TNCC, ENPC and Triage, was a Board member of the Dutch Society on Trauma nursing for more than ten years, and instructor of TNCC, ENPC and Triage. In two years I hope to become a Master in ANP. Using these skills and knowledge needed in changing and introducing a new role for nurses – forensic nursing.


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