FORENSIC NURSING

CHAPTER 32: FORENSIC NURSING

According to the Bureau of Justice Statistics National Crime Victimization Survey, in 2015 approximately 5 million violent crimes were reported; this was a slight decrease from the number of violent crimes in 2011 (U.S. Department of Justice/Bureau of Justice Statistics [USDOJ/BJS], 2015). These crimes ranged from vandalism and theft, to rape and sexual assault, to aggravated assault and murder. The estimated medical and productivity economic burdens of interpersonal and self-directed violence (suicide, homicide, child maltreatment, youth violence, intimate partner violence, and other assaults) are staggering. Because of the continued high prevalence of violence and violent crimes in society, health care professionals are recommended to identify and assess victims of interpersonal partner violence and provide proper care and referrals as needed. Indeed, screening for violence is now considered to be a minimum standard of care for all women, as is vigilance in looking for indications on when and where to screen for abuse among elders and vulnerable adults (U.S. Preventive Services Task Force [USPSTF], 2013).

The term forensic means “pertaining to the law, legal” (Lynch, 2011, p. 5). 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, and they should be prepared to assess for indications of violence and abuse and to intervene as needed.

Forensic nursing is defined as “application of the nursing process to public or legal proceedings, and the application of forensic health care in the scientific investigation of trauma and/or death related to abuse, violence, criminal activity, liability, and accidents” (Lynch, 2011, p. 5). Forensic nursing combines the disciplines of nursing science, forensic science, medical science, sociology, and psychology with law enforcement and the criminal justice system. Recognized by the American Nurses Association (ANA), forensic nursing is growing nationally and internationally. The specialty of forensic nursing was officially recognized by the ANA in 1995, and the Scope and Standards of Forensic Nursing Practice was published in 1997 (ANA, 2014; Amar and Sekula, 2017)) and revised in 2009 (ANA, 2009). The International Association of Forensic Nurses (Price and Maguire, 2016), recognizing the need to provide accurate and reliable knowledge, skills, and scope of practice education to the new forensic nurse, endorsed the Core Curriculum for Forensic Nurses.

The International Association of Forensic Nurses (IAFN) explains that forensic nursing is the practice of nursing where the health and legal systems intersect (ANA, 2009). Thus the forensic nurse’s role fills a gap between the health care system, the investigative process, and courts of law (Lynch, 2011).

Forensic nurses practice in multiple areas and settings of the health care and public health systems. Their responsibilities may include screening, assessment and documentation of injuries, and collection of evidence, and may also include expert witness testimony for victims and perpetrators across a variety of settings such as hospitals, community clinics, and death scenes. In addition to working with victims and perpetrators, forensic nurses may be involved in paternity disputes and cases involving workplace injuries, malpractice, transportation crashes, food or drug tampering (Fig. 32.1), and medical equipment defects (Lynch, 2011). The advanced forensic nurse or the graduate or doctoral prepared forensic nurse may assist in developing and implementing protocols and systems to help victims or perpetrators of violent occurrences, aid in research and policy changes, develop and supervise systems of care for complex health issues, and provide essential education to others (IAFN, 2004). The Healthy People 2020box lists some objectives related to this highly specialized practice area.

FIG. 32.1 A forensic nurse counting medications.

Healthy People 2020

Objectives Related to Forensic Nursing

· AH-11: Reduce adolescent and young adult perpetration of, and victimization by, crimes.

· IVP HP2020-33: Reduce physical assaults.

· IVP HP2020-38: Reduce nonfatal child maltreatment.

· IVP HP2020-40: Reduce sexual violence.

· IVP 2020-43: Increase the number of states that link data on violent deaths from death certificates, law enforcement, and coroner and medical examiner reports to inform prevention efforts at the state and local levels.

· MHMD-HP2020-7: Increase the proportion of juvenile residential facilities that screen admissions for mental health problems.

· SA HP2020-5: Increase the number of drug, driving while impaired, and other specialty courts in the United States.

· SA HP2020-10: Increase the number of Level I and Level II trauma centers that implement evidence-based alcohol screening and brief intervention.

From HealthyPeople.gov: Healthy People 2020: topics & objectives, 2013. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=24. Accessed February 21, 2018

Subspecialties of Forensic Nursing

The IAFN recognizes core specialties within forensic nursing (Box 32.1). Each of the subspecialties will be briefly discussed.

Sexual Assault Nurse Examiner

The sexual assault nurse examiner (SANE) is the most widely recognized subspecialty in forensic nursing. In the 1970s, emergency department (ED) registered nurses identified a special client population—sexual assault victims—who were not receiving the appropriate, compassionate care after a terrifying traumatic event (Ledray and Arndt, 1994). They observed that in many cases the staff did not know how to compassionately but objectively approach the sexual assault victim entering the ED; to properly assess, document, and collect evidence; or to provide testimony in a court of law. Therefore the SANE role was developed.

A SANE is a specially trained registered nurse who applies the nursing process during forensic examinations to victims or perpetrators of sexual assault. Recognizing cultural and developmental differences, as well as the impact of trauma of victims, the SANE assesses and documents detailed physical examination findings, collects forensic evidence related to a reported crime, and frequently testifies as an expert witness at subsequent trials (Office for Victims of Crime, 2017). SANEs are usually employed in EDs and community clinics dedicated to victims of interpersonal violence. SANEs may also be employed to complete forensic examinations on deceased individuals for whom sexual assault is presumed.

BOX 32.1 Specialties of Forensic Nurses

1. • Sexual assault nurse examiner

2. • Nurse coroner and death investigator

3. • Legal nurse consultant and nurse attorney

4. • Forensic nursing educator and consultant

5. • Forensic psychiatric nurse

6. • Forensic nurse examiner

7. • Correctional nurse

If the client is medically stable, the SANE is responsible for conducting a thorough examination, including obtaining a history, performing the physical assessment, and collecting forensic evidence (Box 32.2). If the client is medically unstable, he or she will be assessed and stabilized by a provider before the forensic examination. Other responsibilities of the SANE are crisis intervention referral, pregnancy risk assessment and interception as needed, and client referral for additional support (Ledray, 2011).

A registered nurse caring for sexual assault victims may receive SANE certification offered through the IAFN. Both adult and pediatric certifications are available. The requirements for a registered nurse to be eligible for the SANE adult and/or pediatric certification examinations 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 academic course equivalent, and (3) demonstrate competency in sexual assault examinations (IAFN, 2015).

Medicolegal Death Investigation

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 sudden, unexpected, and often nonnatural 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 sudden unexpected infant deaths. 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 medical examiner, coroner/justices of the peace, or mixed (Hanzlick, 2007; Lynch, 2011).

BOX 32.2 Type of Evidence Collected from a Victim of Sexual Assault

1. • Documentation of history of the event

2. • Documentation of injuries (photographic and written)

3. • All clothing worn at the time of incident

4. • Trace evidence (fiber, glass, soil, particulate matter)

5. • Biological evidence for DNA comparison (victim’s blood or hair)

6. • Fingernail swabbing

7. • Swabs and smears (from the victim’s mouth, vagina/penis, and anus)

8. • Pubic hair combings

9. • Evidence disbursement sheet

10. • Any additional evidence, as noted during examination (example: body piercings)

Data from Ferrell J, Caruso C: Sexual assault evidence recovery. In Lynch VA, Duval JB, editors: Forensic nursing science, ed 2, St Louis, 2011, Mosby pp. 144–154.

Typically, medical examiners are licensed physicians who are board certified in anatomic and forensic pathology (Hanzlick, 2007). Usually a medical examiner is appointed for an unspecified term and serves a county, district, region, or state as determined by law. The coroners/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 coroners/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 are 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, 2011). 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 identifies five acceptable options for recording manner of death: natural, accident, suicide, homicide, and “undetermined” (Hanzlick et al., 2002).

Role of a Forensic Nurse Death Investigator

Typically the forensic nurse is employed in the medicolegal death investigation or public health setting. Forensic nurses enter the death investigation arena possessing knowledge of anatomy, physiology, pharmacology, growth and development, physical examination, and health history interviewing techniques, all of which are needed to conduct a comprehensive death investigation (Lynch and Koehler, 2011; Mitchell and Drake, 2017). In most cases related to a death scene investigation, investigators are police officers or homicide detectives—members of professions without medical knowledge. The forensic nurse death investigator (FNDI) evaluates the death scene from a holistic nursing perspective and might interpret the scene differently (Clinical Example 32.1 and Fig. 32.2). The requirements for being an FNDI vary; however, most employers ask for a minimum of 2 years of experience, preferably in the setting of critical care or emergency.

FIG. 32.2 A forensic nurse plans her day.

Clinical Example 32.1

A police officer entering a house observes several pools of blood located throughout the residence and discovers a deceased male, nude and lying in bed; the police officer suspects foul play or homicide. The FNDI entering the same death scene notices the same findings as the initial police officer, but also notes bloody emesis in the toilet, blood-soaked towels in the washing machine, and empty alcohol bottles in the trash. A preliminary examination of the decedent by the FNDI reveals ascites, jaundice, and multiple contusions on the body. Through communication with family members, the FNDI discovers the decedent was an alcoholic with many health problems; the FNDI suspects that he had ruptured esophageal varices. This suspicion was confirmed by an autopsy, and the manner of death was determined to be from natural causes rather than homicide, as initially believed.

Role of Nurse Coroner

In coroner systems in which the chief medicolegal death investigator is elected and often state laws do not have specific requirements of the office, nurses may decide to run for the position of coroner or nurse coroner. The nurse coroner is responsible for ensuring that appropriate measures are taken to perform death investigations and to certify death certificates. A nurse coroner’s educational background and knowledge enables him or her to identify disease processes that the lay coroner may not recognize or may misinterpret as foul play, as in the preceding clinical example.

FNDIs and nurse coroners exhibit communication skills when dealing with grieving families. Nurses are given education in therapeutic communication and are able to practice those skills in any setting. They are acutely aware of the importance of using open-ended questions, listening attentively, and being fully present with family and friends. The use of these techniques allows family and friends to openly share the feelings and thoughts experienced with the death of a loved one (Potter and Perry, 2016). Additionally, nurses are guided by their nursing code of ethics (ANA, 2015). These codes cross all settings for the nurse and are the foundation for providing ethical values and obligations across the life span.

Nurse coroners and FNDIs may apply to become board certificated in death investigation through the American Board of Medicolegal Death Investigators (ABMDI). ABMDI requires applicants to (1) be certified at the Registry Level and in good standing for a minimum of 6 months, (2) have at least an associate’s degree from a postsecondary institution recognized by a national educational accrediting agency, (3) be currently employed at an agency with the job responsibility to conduct scene investigations, and (4) have a minimum of 4000 hours of experience in the last 6 years (ABMDI, 2017). Once an investigator satisfies these requirements, he or she may take a standardized examination and become board certified as a Fellow of the ABMDI.

Legal Nurse Consultant and Nurse Attorney

Legal nurse consultants (LNCs) and nurse attorneys are nurses who provide assistance within the legal system using specialized nursing knowledge and expertise when interaction between law and health care quality and safety issues arise (Geissler-Murr and Moorhouse, 2006; Pagliaro and Cewe, 2013). Among many activities, LNCs evaluate, analyze, and render informed opinions on the delivery of health care and its outcomes, based on their area of expertise (American Association of Legal Nurse Consultants [AALNC], 2017). Many law firms hire LNCs to review and interpret medical records and charts, provide objective opinions based on standards of care, and possibly to testify in court as expert witnesses. A forensic nurse practicing as an LNC may apply for certification through the American Legal Nurse Consultant Certification Board (ALNCCB). The candidate must have (1) a current nursing license full and unrestricted, (2) a minimum of 5 years’ experience as a registered nurse, and (3) evidence of 2000 hours of legal nurse consulting experience within the last 5 years (ALNCCB, 2017). Once the candidate meets these requirements, he or she may sit for a standardized examination, and once having passed the examination, he or she earns the Legal Nurse Consultant Certified credential.

Nurse attorneys are academically 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 require participation of a nurse attorney on either the plaintiff’s or the defendant’s side, and may involve licensure disciplinary action or 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. By providing services as experts and by testifying, nurses serving as legal consultants help hold accountable practitioners who are unsafe to the public. In contrast, meticulous practitioners who are wrongfully accused of negligence are defended by these nurses’ actions.

According to the AALNC (2017), an LNC performs many different services and activities, as follows:

1. • Identify, organize, and analyze medical records and related materials

2. • Prepare chronologies or timelines of health care events

3. • Identify applicable standards of care

4. • Evaluate causation and damage issues

5. • Conduct literature research and summarize medical literature

6. • Evaluate case strengths and weaknesses

7. • Serve as an expert witness

8. • Identify plaintiff’s future medical needs and associated costs

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 (Robson, 2009).

When providing services, the LNC may submit an affidavit, 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. After 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.

BOX 32.3 Tips for Testifying at a Deposition or in Court

Do’s

1. • Dress professionally and conservatively.

2. • Tell the truth at all times.

3. • Listen to the complete question before responding.

4. • Speak slowly, clearly, and concisely when answering.

5. • Take a few seconds to formulate an answer before responding.

6. • Minimize “ums” or “uhs” by pausing at the end of sentences.

7. • If there is an objection, stop talking and wait for the judge to make a ruling.

8. • When answering questions, make eye contact with the jury members.

9. • Remain calm.

10. • Respond confidently.

11. • Practice difficult words.

12. • Avoid nervous gestures; keep your hands in your lap.

Don’ts

1. • Avoid saying “I think” and “I believe.”

2. • Never interrupt.

3. • Do not answer a question that you do not understand; ask the attorney to repeat questions as needed.

4. • Do not become defensive or angry.

Data from Ruiz-Contreras A: The nurse as an expert witness, Top Emerg Med 27(1):27–35, 2005.

During the deposition, the LNC presents the facts of the case and is questioned by attorneys from both sides. This process may be quite lengthy and stressful. It is essential that the LNC be prepared, having reviewed everything thoroughly. After this process, the LNC is given a written transcript of the deposition, which needs to be carefully reviewed for accuracy. If the case goes to trial, the LNC will then testify in court (Robson, 2009; Ruiz-Contreras, 2005).

In some cases, the forensic nurse is called on to testify in court, not as an expert witness as described previously, but as a factual witness—one who has firsthand knowledge of the case in question. In these cases, the forensic nurse provides factual statements about the evidence collected and what was observed (Pagliaro and Cewe, 2013). Box 32.3 lists tips that will be helpful for nurses to review before testifying in court.

Clinical Forensic Nurse Examiner

Emergency and Critical Care

Registered nurses may be employed in EDs and critical care units as forensic nurse examiners. In this role they deliver care to living patients who are involved with the legal system, and their services may include several subspecialties. The term living forensics refers to individuals who are subject to forensic investigations, including but not limited to survivors of physical and mental trauma, toxicology emergencies, interpersonal violence, transportation crashes, and police detention (Lynch, 2011).

As illustrated in Clinical Example 32.2, the ED is frequently the initial location of the initial forensic nursing examination or medicolegal investigation (Doughtery, 2011). It is imperative that registered nurses identify forensic patients; initiate the proper collection, preservation, and chain of custody of evidence; and then provide accurate documentation for this unique population. The recognition, collection, and documentation of evidence collected within the ED may have an important role in the investigation of crimes and can have a major impact on legal decisions. Box 32.4 lists types of evidence.

BOX 32.4 Types of Evidence

Tangible (touchable) evidence—recognized on sight:

1. • Weapons/tools

2. • Bullets, casing, wadding, gunshot residue

3. • Matches, lighters, or other ignition sources

4. • Blood, semen, saliva, tissue

5. • Soil, paint

6. • Clothing or personal effects

7. • Notes or messages

8. • Photographs

Transient evidence—temporary and may be lost, destroyed, or damaged:

1. • Physical findings such as bruises, swelling, bleeding, tenderness

2. • Odors (e.g., marijuana, alcohol, gasoline)

Trace evidence—may not be visible; identified by microscope or alternative light sources:

1. • Fibers

2. • Biological specimens: blood, semen stains

3. • DNA

Data from Hammer RM, Moynihan B, Pagliaro EM: Forensic nursing: a handbook for practice, ed 2, Burlington, MA, 2013, Jones & Bartlett Learning; Lynch VA, Duval JB: Forensic nursing science, ed 2, St. Louis, 2011, Elsevier/Mosby; and Safertein R: Criminalistics: an introduction to forensic science, ed 10, Upper Saddle River, NJ, 2010, Pearson.

Clinical Example 32.2

A 27-year-old woman arrived at the ED with a gunshot wound of the head. Emergency medical technicians reported to the ED nurse and doctor that the client was found by her boyfriend barely breathing. The boyfriend called 911, and the client was transported to the hospital. The client arrived at the hospital in asystole and was pronounced dead within 10 minutes of arrival. The ED nurse applied her forensic knowledge and placed brown paper bags on the client’s hands, securing them with tape. This procedure is performed to preserve gunpowder or primer residue. Gunpowder or primer residue aids in the identification of the shooter and distance of the gun. When a gun is fired, residue is released and lands on the items close to the gun, specifically the hands and clothing of the person firing it.

The police agency investigated the death. The nurse’s intervention, placing paper bags over the client’s hands, preserved the presence or absence of gunshot or primer residue. The police agency performed a scanning electron microscope examination for gunpowder residue and did not find any on the client’s hands. This finding led police to further investigate the incident and discover that the boyfriend had shot the client, rather than the first presumption, that the gunshot wound was self-inflicted.

Organ and Tissue Donation and Transplantation

Forensic nurses also have a role in providing a detailed physical examination of patients who may be organ and tissue donors. This area of care is complex and requires detailed understanding of related legal and ethical issues. When a patient is declared brain dead or donation after cardiac death (DCD), federal law states that the legal next of kin shall be approached for organ and tissue donation. A forensic nurse is able to conduct and provide a detailed physical examination and to collect any evidence that may be required. A thorough death investigation at the hospital may be required for sudden, unexpected, and nonnatural deaths. This involves reviewing medical records and documenting injuries, which is essential for the medicolegal investigation agency to identify acceptable candidates and potential organs and tissues for harvest. The nurse involved in this process must be knowledgeable about legal specifications related to organ donation and be familiar with agency policies and procedures for determining brain death and DCD. The nurse must also have excellent communication skills as well as the ability to relate empathetically to grieving families. In this capacity, the forensic nurse working harmoniously with organ and tissue procurement agencies can obtain release authorization for lifesaving organs (Shafer, 2011).

Care of Vulnerable Populations

The youngest, oldest, and disabled populations are the most vulnerable to maltreatment. Nurses dedicating their practice to these vulnerable populations often are required to collaborate with other agencies to ensure adequate resources are available. Often advocacy groups are referred to for assistance.

Child Abuse and Neglect

Child abuse and neglect (child maltreatment) are major concerns for society; therefore the role of a forensic nurse examiner is especially imperative. The Federal Child Abuse Prevention and Treatment Act defines child abuse and neglect as minimum of:

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm.

(42 U.S.C.A. §5106g, as amended and reauthorized by the CAPTA Reauthorization Act of 2010)

In 2015, approximately 683,000 children were victims of child abuse and neglect, and nearly 77.7% of the perpetrators involved at least one parent. Furthermore, reported cases of child abuse or neglect resulting in death in were estimated to be 1670 children (U.S. Department of Health and Human Services [USDHHS], Administration for Children and Families [ACF], 2015).

States have varying definitions of what constitutes or determines child abuse and neglect. If a forensic nurse suspects that a child is being abused or neglected, the nurse should refer to the state’s legislation surrounding the reporting of these suspicions. The following definitions are provided by USDHHS, ACF (2015):

· Neglect: Failure of a parent, guardian, or caregiver to provide basic needs. Neglect may be physical (deprivation of adequate food, clothing, shelter, or supervision); medical (failure to provide necessary medical treatment); educational (failure to educate a child or attend to special education needs); or emotional (failure to attend to emotional needs or provide psychological care or allowing the usage of alcohol or other drugs).

· Sexual abuse: Range of activities from noncontact indecent exposure to production of pornographic materials, to incest, rape, fondling, and genital contact to actual adult–child sexual intercourse.

· Physical abuse: Intentional physical injury, including striking, kicking, burning, and biting.

· Emotional abuse (or psychological abuse): A pattern of behavior that impairs the child’s emotional development or sense of self-worth, including constant criticism, threats, and rejection.

For the well-being and safety of the child, a nurse ensures that abuse and neglect are swiftly identified and reported to the proper authorities, including the consultation of a forensic nurse examiner (Finn, 2011; Lewis-O’Connor and Latimore, 2017). The nurse obtains a thorough history and assessment, focusing on several facets of abuse and neglect. These include child–parent interaction, the child’s appearance and behavior, child–child interaction, and the environment.

A forensic nurse may be employed in a variety of clinical settings that assess, diagnose, and treat children. These settings may include pediatric or general EDs, hospitals, physician offices, schools, home health, hospice, and child advocacy centers.

Elder Mistreatment

Forensic nurse examiners caring for the geriatric population play an important role similar to that of pediatric forensic nurses. Elder mistreatment is thought to be one of the most underdiagnosed and underreported crimes in the United States (Pickens and Dyer, 2016). Unfortunately, there is no exact accounting of elder mistreatment cases, for several reasons: an absence of standardized reporting systems, no consistency in state definition of elder mistreatment, and lack of national data collection (Hammer and Hammer, 2013). Regardless, elder maltreatment is an act of violence or the nonconsented withdrawal of necessary care to sustain life (Pickens and Dyer, 2016)

There are several forms of elder abuse: physical, psychological or emotional, financial, neglect, and sexual abuse (Pickens and Dyer, 2016). Physical abuse is the intentional harm or injury of another person resulting in injury, pain, or impairment (Pickens and Dyer, 2016). In a study by Acierno and colleagues (2009), 1.6% of subjects reported physical mistreatment, and family members accounted for 76% of the mistreatment; specifically, in 57% of cases the abuser was a partner and/or spouse.

Psychological or emotional abuse occurs when there is mental or emotional anguish (e.g., verbal or nonverbal infliction of anguish, pain, or distress) (Pickens and Dyer, 2016). Acierno and colleagues (2009) reported that 4.6% of elders experienced emotional abuse, and for 25% of them, the abuse came from the partner and/or spouse. Financial exploitation occurs when the elder person’s financial assets, property, or funds are utilized for another person’s benefit without the elder’s consent. In the study by Acierno and colleagues (2009), more than 5% of subjects reported being a victim of financial exploitation.

Sexual abuse is the nonconsensual contact of any kind with an elderly person (Pickens and Dyer, 2016). The elder population is at risk for sexual abuse because of inability to resist pursuit or inability to recognize the abuse due to mental illness or other advanced disease processes. Less than 1% of respondents in the study by Acierno and colleagues (2009) reported sexual abuse, and for 40% of those who did report the abuse, the partner and/or spouse was responsible.

Lastly, neglect is the most common form of elder abuse, whether it is caregiver neglect or self-neglect. Caregiver neglect occurs when the obligated caregiver fails to provide appropriate clothing, food, or health services either via refusal to fulfill these requirements or abandonment of the elder client (Pickens and Dyer, 2016). Self-neglect occurs when the elder discounts personal well-being—this could be the result of medical or mental illnesses. Acierno and colleagues (2009) report that 5.1% of elders experienced caregiver neglect.

The elderly client may be hesitant to report abuse, ask for assistance, or acknowledge the maltreatment because the abuser might be a spouse and/or partner, child, or close relative, or because the disclosure would possibly result in litigation and institutionalization (Pearsall, 2011). Forensic nurses may be employed in any setting, treating or seeing elder clients. Some settings are EDs, hospitals, physician offices, nursing homes, home health agencies (Clinical Example 32.3), and geriatric day care centers.

Clinical Example 32.3

A home health care nurse has received a referral from the hospital for a 80-year-old female residing at her home with her son. The patient had been discharged from the hospital with the diagnosis of urinary tract infection and pneumonia. Her son reports she was confused and coughing for 2 months before he took her to the hospital. Her past medical history includes dementia, impaired mobility, and dysphasia from a prior stroke. Upon arrival at the residence, the nurse greets the patient, who is lying in bed. The home is cluttered and dirty, with visible roaches, and the refrigerator/freezer is filled with meat, cheese, milk, and beer. The nurse’s assessment findings include the following: clothing is loose fitting and adult brief is soiled, strong body and urine odor present, body is emaciated with upper and lower extremity contractures, contusions of various coloring are located on the upper thighs and posterior torso, stage II decubitus ulcers are present on the right hip and sacral areas (both are covered with soiled dressing), and dentition is poor. The son explains that the patient obtained the contusions because at times she becomes confused and strikes out, hitting things. Furthermore, this happens during times that he attempts to bathe and turn the patient.

Upon leaving the residence, the nurse contacts her supervisor to discuss the findings and her concerns about physical and sexual abuse and neglect. The supervisor agrees, and the patient is returned to the ED for a forensic nurse examination, at which time the forensic nurse places a call to Adult Protective Services for further evaluation and investigation. The hospital is also contacted to discuss why the patient was discharged back into this environment.

Disabled Population

It is well documented that children and elderly with disabilities are more likely to be mistreated. Mandatory laws addressing the reporting of abuse or neglect of a disabled person aged 18 to 64 years varies within states. Throughout their life span, the risk for one or more forms of mistreatment of individuals with disabilities is three times higher than that for individuals without disabilities (Harrell, 2012).

Forensic Psychiatric Nurse

The forensic psychiatric nurse bridges the gap between the criminal justice, legal, and mental health systems. Forensic psychiatric nurses apply the nursing process to clients who await a criminal hearing or trial while maintaining a neutral, objective, and detached position (Mason, 2011). Forensic psychiatric nurses collect evidence by determining intent or diminished capacity in the client’s thinking at the time of the incident. To do so, they often spend several hours interviewing and observing the client, carefully documenting conversations and observations.

The forensic psychiatric nurse may be called to court to testify as an expert witness in a mental health issue; therefore it is imperative that the nurse have an understanding of mental illnesses and personality disorders. Roles filled by or activities performed by psychiatric forensic nurses include the following (Mason, 2011):

1. • Sanity or competency evaluation (for legal purposes)

2. • Assessment of violence potential

3. • Assessment of capacity to formulate intent

4. • Parole and probation considerations

5. • Assessment of racial or cultural factors in crime

6. • Assistance in jury selection

7. • Sexual predator screening

8. • Provision of expert witness testimony

Active Learning

Spend a few hours working with a forensic nurse in a clinical setting. Observe the nurse’s interventions and processes related to assessment, evidence collection and preservation, documentation, and collaboration with, for example, police officers. Take note of the techniques used for interviewing and counseling.

Correctional Nursing

Correctional nursing is a specialized subset of forensic nursing. It requires a significant amount of knowledge as well as an understanding and awareness of the unique needs and perspective of the clients served. Several issues specific to correctional nursing and related issues are described in this section.

Unlike in any other care setting, clients are inmates, and care is negotiated and provided with recognition of safety and security issues for the nurse and the constitutional right of prisoners to receive adequate and timely health care. The primary goal in correctional facilities is to maintain a safe, secure, and humane environment for inmates. Health care, including nursing care, is a necessary and essential part of that environment.

Maintenance of a Safe Environment

Correctional facilities are violent environments, and nurses practicing in correctional settings must continually negotiate personal safety and nursing care (Clinical Example 32.4). Nurses in this setting must be aware that medical supplies issued to inmates can be a safety threat to the environment. For example, a simple elastic bandage can be used to improve the grip on a homemade weapon. Virtually any prescribed medication can have value on the prison “black market.” Furthermore, nurses are subject to manipulation by inmates, who may seek nursing care for reasons other than health. As the following clinical example illustrates, the nurse must maintain an escape route to use if a situation of personal violence is imminent. In addition, no nursing care in a correctional environment requires a nurse to be locked in an enclosed environment with an inmate. Although it might appear that providing humane, therapeutic nursing care in an environment of potential violence is contradictory, it is ultimately a prerequisite for nursing practice in correctional settings.

Clinical Example 32.4

Safety in Correctional Facilities

In a county jail in Michigan in 2014, a nurse was attacked by an inmate who was pretending to be sick. Deputies on duty became aware of the possible problem. The nurse was leaving the inmate’s cell when he attacked. The nurse was not seriously injured; however, this incidence illustrates the risk within the environment and the need to be alert (http://www.wnem.com/story/23782972/surveillance-video-shows-nurse-being-attacked-by-inmate).

Research Highlights

Public Health Role in Death Investigation

Drake et al. (2015) assessed the practice differences of the public health role of two death investigation systems in Texas. The authors utilized a previously validated instrument adapted from the Public Health Essential Services and sent it to 723 justice of the peace offices and 12 medical examiner offices in the 254 counties of Texas. Ten medical examiners and 112 justices of the peace responded. The study found that medical examiners are more likely than justices of the peace to fulfill the essential medicolegal death investigation services. Specifically, the researchers indicated that medical examiners have formal processes and follow set guidelines for carrying out their role versus the justice of the peace. In terms of formally evaluating or trending quality and effectiveness of their work product, no statistical differences were found between the two systems. Drake and colleagues proposed improving the Texas medicolegal death investigation system by restructuring it into a regionalization system. This could ensure optimal standards, accreditation, training, education, and quality and economy of scale service were being provided to the public.

Drake SA, Cron S, Giardino A, Nolte KB: Comparative analysis of the public health role of two types of death investigation in Texas: application of the essential services. J Forensic Sci 60(4): 914–919, 2015. https://doi.org/10.1111/1556-4029.12748.

Health Issues in Prison Populations

Today’s prison inmate often enters prison with health care issues. Nurses employed in the correctional setting are likely to see health care problems that are similar to those in an acute care setting or a community outpatient clinic. The daily operation of a correctional clinic includes management of acute and chronic illness. Most health care clinics in correctional environments screen each inmate upon entry into the facility. The health care triage process generally includes a physical and a mental health history. Many significant health care issues are recognized during the screening process, often for the first time.

Chronic and Communicable Diseases

The most critical heath care issues among the incarcerated population are chronic and communicable diseases. Of continuous concern are HIV, hepatitis, and tuberculosis. According to the Bureau of Justice Statistics, the rate of HIV infection decreased slightly from 146 cases per 10,000 inmates in 2010 to 143 per 10,000 at year end in 2012 (Maruschak et al., 2015), but remains very high. Likewise, hepatitis is a serious health care issue in correctional facilities. According to the Bureau of Justice Statistics, 6.5% of inmates reported hepatitis as a health problem in 2012 (Maruschak et al., 2015). The rate of these and other communicable diseases among the incarcerated population is associated with high-risk behaviors, including current and previous drug use, unprotected sexual intercourse, and tattooing.

Of growing concern are the increased rates of chronic conditions such as hypertension and diabetes (Maruschak et al., 2015). Additionally, in 2012 about one quarter of inmates were of normal weight, with the majority being overweight (46%) to morbidly obese (2%).

As it is for the general population, managing inmates with multiple chronic conditions, including infectious and noninfectious, will continue to be a major threat to the health of those incarcerated.

Women in Prison

By 2014, the number of incarcerated women reached 215,332 (The Sentencing Project, 2015). In 2014, women in state prisons were incarcerated for drug offenses 24% versus 15% for males (Carson, 2015). Of the estimated 74 million children under the age of 18 in 2007, 2.3% had a parent incarcerated, of which 8% were mothers (Glaze and Maruschak, 2010). Approximately 8 in 10 women with a prior mental health diagnosis reported physical or sexual abuse before imprisonment: 57.2% were physically abused and 39% sexually abused (CSOSA, 2014).

Drug use and victimization, combined with the stress associated with being separated from their children, put incarcerated women at risk for many mental and physical health problems, including the risk of HIV infection and other sexually transmitted diseases. Unfortunately, health care providers in correctional facilities have limited experience and training to meet the health care needs of women in prison, and quality of care is adversely affected. For example, women who have been sexually assaulted are often reticent about obtaining regular gynecological examinations. The National Commission on Correctional Health Care (NCCHC, 2014) confirms that routine gynecological examinations are not consistently apart of health screening for women upon entry into a correctional facility or a routine part of ongoing health care. The NCCHC (2014) offers the following to guide the provision of health care for women:

1. • Correctional institutions’ health care intake procedures should include comprehensive gynecological examinations.

2. • Comprehensive health care services should be available to incarcerated women that give special consideration to the reproductive health needs of women, the high rate of victimization among incarcerated women, counseling related to parenting issues, and accessibility to drug or alcohol treatment.

Ethical Insights

Inmates’ Refusal of Medications

An inmate’s right to refuse treatment is a legal and ethical issue that nurses working in a correctional environment sometimes experience. The right to refuse treatment and the state’s power to enforce treatment are both highly charged legal and political issues and have gained attention in state and local courts. The issue of forced medication and competence to stand trial is of particular concern. The legal and ethical principles that guide forced treatment against the will of an inmate have historically been potential safety issues toward self or others in the environment. The Supreme Court decision in Harper v. Turner in 1987 permits the violation of the rights of the incarcerated so long as the prison policy is reasonably related to repressing violence within the prison system (Black, 2008).

Unlike in nursing practice with the general population, prison inmates who refuse health care do not leave the facility and return home. Nurses practicing in correctional facilities continue to provide care and address the consequences of an inmate’s refusal of treatment. For example, an inmate who refuses to adhere to treatment protocols for schizophrenia may affect the safety of the environment and in fact create a “ripple effect,” thus undermining prisoner administration (LGIT, 2009). Nurses are obliged to treat any resultant health issues. However, individuals who are incarcerated by the state have a constitutional right to refuse and receive health care. Nurses practicing in correctional settings must recognize that involuntary medical treatment is undertaken after internal review and judicial proceedings; however, a hearing is not necessary.

Adolescents in Prison

Increasing numbers of adolescents are committing violent crimes, and many states have lowered the age limit at which adolescents may be tried and sentenced as adults. Consequently, adolescents who have been convicted of violent crimes are often incarcerated in adult facilities. Incarcerating adolescents in an adult population presents barriers to meeting the distinct developmental needs of adolescents. These developmental needs include rapid physical and emotional growth and nutritional needs, all influenced by environment, genetics, and family experiences. Adult correctional facilities are not generally equipped to deal with the challenges of adolescent development. Adolescents in an adult correctional facility are the highest at risk than any other group (Campaign for Youth Justice, 2011). Juveniles in adult correctional facilities are 36 times more likely than the adult population and more likely than juveniles in the juvenile center to commit suicide.

To ensure the safety of adolescents in an adult facility, the nurse must be aware of their individual vulnerability. A mechanism for adolescents to access medical and mental health care is essential. Services and interventions should be provided that consider the developmental stage and the experience of adolescence.

Active Learning

Spend a day in a jail or correctional facility working with a correctional forensic nurse. Pay particular attention to differences in care delivery related to legal and ethical issues unique to this subspecialty. Develop impressions into a paper.

Mental Health Issues in Correctional Settings

Approximately 34% of state inmates, 24% of federal inmates, and 17% of jail inmates received treatment for mental health problems (James and Glaze, 2006). Being in prison with a mental illness such as schizophrenia, bipolar affective disorder, major depressive disorder, or personality disorder makes adjustment to incarceration extremely difficult. The great number of inmates with mental illnesses in today’s prisons makes it difficult to meet the needs of this population.

In the late 1950s and early 1960s, deinstitutionalization moved people with mental illness out of state hospitals into communities that were often ill prepared to care for them. As a result, many people with a mental illness reside in nursing homes, residential homes, prisons, or jails. People with mental illness are more likely to encounter law enforcement than health care providers when in the midst of acute mental distress. This results in more than 2 million people a year going to jails, with the vast majority not the result of criminal activity (National Alliance for the Mentally Ill [NAMI], 2017).

According to NAMI, most jail inmates with symptoms of mental illness are charged with minor crimes. A far smaller number of inmates with severe mental illness commit more serious crimes, again frequently a consequence of either inadequate or no treatment. NAMI (2017) takes the position that many dangerous or violent acts by people with severe mental illness are a result of inappropriate or inadequate treatment. The following strategies have been proposed to address the criminal justice and forensic issues facing mental illness:

1. • Train police officers to recognize severe mental illness in the community and to respond appropriately to people who are experiencing psychiatric crises.

2. • Divert nonviolent offenders with severe mental illnesses away from incarceration into appropriate treatment.

3. • Establish “mental health courts” to hear all cases involving individuals with severe mental illness charged with misdemeanors or nonviolent felonies in order to divert as many as possible away from incarceration and into treatment and services.

4. • Create specialized units within departments of parole and probation to coordinate services for people with severe mental illness on probation.

In 2009, over half of all state offenders and nearly half of all federal offenders had acute symptoms or chronic history of mental illness (e.g., depression, schizophrenia, or bipolar disorder) (Human Rights Watch, 2009).

Nurses employed in correctional settings must always be aware of the vulnerabilities of people with mental illness who are incarcerated. Depression, schizophrenia, bipolar disorder, and other neurobiological disorders can be readily treated with newer-generation psychiatric medications that reduce or ameliorate symptoms, but the unique vulnerabilities of incarceration often remain. Nurses should also be aware that once released from imprisonment, these individuals are at substantial risk of mental illness relapse and reinstitutionalization (Perdue et al., 2016).

Active Learning

Attend a session of local or state mental health court (court proceedings to determine the status of an individual’s mental status and disposition—e.g., confinement to a mental institution or release in the care of a guardian or family member). Report on the experience to classmates.

Education and Forensic Nursing

According to Kent-Wilkinson (2011), because of the amount and depth of knowledge and skills needed by forensic nurses, whatever their subspecialty area, simply completing a continuing education course is not adequate for practice. As a result, several colleges and universities offer a variety of programs to educate practitioners, future educators, and researchers of forensic nursing. The core curriculum for forensic nursing was published recently (Price and Maguire, 2016) to provide guidance across settings. This is the direct result of the identified need and growing knowledge base for practice of this specialty area. Table 32.1 gives an overview of basic curricula for forensic nursing programs. In addition, during the formal programs of study, the student usually completes a minimum specified number of supervised clinical hours; a clinical internship or fellowship also may be required.

TABLE 32.1

Basic Curricula for Forensic Nursing Programs
Subject	Topic(s)
Fundamentals for forensic nursing	Evidence collectionDocumentationInterviewing skillsBasic criminal, procedural, and constitutional lawScope of practiceInterdisciplinary collaborationTestifying in court as an expert witness
Forensic law	Legal concepts (culpability, burden of proof, rationale for punishment, mitigating circumstance)Defense issues (justification, insanity, entrapment, duress)
Forensic science	Collection and preservation of evidenceInterpretation of DNA and laboratory reportsForensic chemistry and toxicologyCause and manner of deathBlood spatter interpretationMechanism of injury; wound identification

Data from Burgess AW, Berger AD, Boersma RR: Forensic nursing: investigating the career potential in this emerging graduate specialty, Am J Nurs 104(3):58–64, 2004.

For those interested in seeking additional education in the growing specialty of forensic nursing, Box 32.5 lists nursing colleges and universities that have programs in forensic nursing. It should be noted that some of these programs offer a certificate in forensic nursing, whereas others provide a minor or concentration, and still others grant a graduate degree (typically a master of science in nursing degree) or postgraduate certificate.

The American Nurses Credentialing Center offers an Advanced Forensic Nursing certification (AFN-BC). To become eligible to obtain an AFN-BC, a nurse must (1) hold an active RN license, (2) have practiced at least 2 years as a full-time registered nurse, (3) have obtained a graduate degree in nursing, (4) have practiced a minimum of 2000 hours within a specialty area of forensic nursing within the last 3 years, (5) have completed a minimum of 30 continuing education hours within the specialty forensic nursing area, and (6) have fulfilled two of the professional development categories specific to forensic nursing (six academic credits, presentations, publication or research, preceptor, or professional service) (ANCC, 2017).

BOX 32.5 Schools Offering Programs in Forensic Nursing (Graduate and Certificate Programs)

California

· University of California at Riverside, Riverside, California—online

Colorado

· University of Colorado at Colorado Springs, Beth-El College of Nursing, Colorado Springs, Colorado

Georgia

· Emery University, Atlanta, Georgia

Massachusetts

· Boston College, Chestnut Hill, Massachusetts

· Fitchburg State College, Fitchburg, Massachusetts—online

New Jersey

· Fairleigh Dickinson University, Teaneck, New Jersey

· Monmouth University, West Long Branch, New Jersey—online

New York

· Binghamton University, Binghamton, New York—online

Ohio

· Cleveland State University, Cleveland, Ohio—online

· Xavier University, Cincinnati, Ohio

Pennsylvania

· Duquesne University, Pittsburgh, Pennsylvania—online

· Drexel University, Philadelphia, Pennsylvania-online

· University of Pennsylvania, Philadelphia, Pennsylvania-online

· University of Pittsburgh, Pittsburgh, Pennsylvania

Texas

· The University of Texas Health Science Center at Houston School of Nursing, Houston, Texas-online

· Texas A&M, College Station, Texas

Washington

· University of Washington, Seattle, Washington

Case Study Application of the Nursing Process

Correctional Nursing

Mr. Smith is a 65-year-old African American male serving a sentence for aggravated assault. Mr. Smith has a medical history of diabetes mellitus, hypertension, coronary artery disease, and peripheral vascular disease. Three weeks ago, his right foot was amputated because of gangrene. Mr. Smith has been admitted to the infirmary six times since the procedure, stating, “I’m not feeling well; can you double-check my sugar?”

The incision site is healing well, and his diabetes mellitus is under control with medication. Mr. Smith takes his medications as prescribed, and his doctor believes he is doing well and continues with his current medication regimen.

Mr. Smith’s daughter visits him only once every 6 months because she lives out of state. His son is also in prison but at another location. Mr. Smith’s wife recently died from a motor vehicle accident, and he was unable to attend the funeral.

Assessment

Mr. Smith has a flat affect and does not make eye contact. He constantly looks at the ground and does not speak clearly when asked questions. Many times the nurse must ask him to repeat himself. According to medical records, he has lost approximately 18 pounds since surgery and he says, “I’m not hungry, that’s why I don’t eat.” When asked about his sleeping habits, Mr. Smith states he sleeps all day except when the guards make him get up. He says he has not played cards with his buddies in more than a week. He also reports that he has been buying Soma “from them” and has not taken a bath in 3 days.

Diagnosis

Individual

1. • Despair, gloom, hopelessness

2. • Inability to overcome mental and emotional difficulties

3. • Powerlessness

Family

1. • Situational crises

Community

1. • Lack of mental health services

Planning

Mr. Smith will set goals with the health care provider and will ask for assistance with communication with his daughter and son.

Individual

Long-Term Goal

1. • Client will reestablish positive relationships with fellow inmates within 2 weeks.

Short-Term Goal

1. • Client will verbalize and recognize his feelings.

2. • Client will participate in diversion activities of his choice (e.g., playing cards).

Family

Long-Term Goal

1. • Family will demonstrate coping skills appropriate to the situation.

Short-Term Goal

1. • Family will verbalize and recognize feelings.

Community

Long-Term Goal

1. • Program will be available for all individuals.

Short-Term Goal

1. • Begin mental health programs, utilizing forensic nurses.

Intervention

Individual

1. • Mr. Smith will be encouraged to express his feelings in an open and nonjudgmental environment, allowing for the development of a therapeutic relationship.

2. • The forensic nurse will schedule several visits to the clinic and encourage Mr. Smith to participate in activities, such as card playing, with his friends.

Family

1. • Mr. Smith’s daughter will be included in the plan of care and encouraged to express her thoughts and feelings relating to her father’s imprisonment.

Community

1. • The forensic nurse will arrange several activities for inmates suffering from mental illnesses, including group activities and group talk.

Evaluation

Individual

Mr. Smith slowly engaged the forensic nurse individually and in group therapy. He gained 5 pounds over 2 weeks and was able to make eye contact. Mr. Smith expressed his grief for the death of his wife. He gradually stopped buying Soma and spent more time with his friends.

Family

Mr. Smith’s daughter continued to visit only once every 6 months, but was able to fully explain her thoughts and feelings about her father’s incarceration. The time the daughter spent with her father increased and was more meaningful.

Community

A forensic nurse was on constant duty to assist inmates with mental health illnesses.

Levels of Prevention

Primary

1. • Encourage interaction with colleagues and family.

2. • Promote participation in prison activities.

Secondary

1. • Screen for depression.

2. • Provide outreach services to inmates with mental illness.

Tertiary

1. • Encourage therapy to reduce symptoms of mental illness.

Case Study Application of the Nursing Process

Forensic Nursing

Transcript of a 911 telephone call:

1. • Emergency operator: “This is 911, what is your emergency?”

2. • Caller: “My son isn’t breathing, he’s not moving, I need help!”

3. • Emergency operator: “We will send an ambulance and police to assist you.”

4. • Caller: “Thank you, please hurry!”

Emergency medical personnel arrived at the house to discover James Oats, a 14-year-old white male, lying face up on his bed. The young man was unresponsive and not breathing. Emergency medical personnel immediately began lifesaving interventions, but despite all efforts, they were unsuccessful. James Oats was pronounced dead at his house.

Police officers arrived at the residence during the rescue attempt and secured the scene. They then notified homicide detectives and the medical examiner’s office. Teresa Fernandez, a forensic nurse death investigator (FNDI), was dispatched to the residence to work in collaboration with the homicide detective, Pete Smith, to investigate the death.

The police determined that there was no indication of foul play. The house was in order, there was no evidence of a robbery, and all the doors and windows were locked. A PlayStation was attached to the television, various clothes were strewn about the room, and schoolbooks were on the desk.

The decedent’s mother, Jane Oats, informed the FNDI that James was in fine health. She explained that he had undergone a physical examination last week for athletics and that the findings were unremarkable. James had an older brother and younger sister, both in excellent health. James’s father has hypertension and a history of heart disease, and diabetes and cancer were present in grandparents.

Teresa (the FNDI) tried to comfort Mrs. Oats, who was extremely upset; she was crying and hyperventilating. Teresa turned to Mr. Oats, who was also present. In answer to Teresa’s questioning, Mr. Oats reported that other parents and teachers had been concerned about rumors of the increasing use of “bars” in area schools. Teresa was alarmed by this information and questioned him further about what he meant; he confirmed that the school kids were reportedly using the antianxiety medication Xanax.

Assessment

Teresa performed an assessment of the decedent. James was wearing blue jeans, a yellow shirt, and socks. Her findings: “Livor mortis is consistent with body position and blanchable; rigor mortis is breakable in the jaw, arms, and legs. Frothy white foam cone was present at mouth and within bilateral nares. There are no visible signs of trauma.”

The decedent was removed from the residence by the medical examiner’s office, and an autopsy was performed the next day. The pathologist reported that the physical findings from the autopsy were unremarkable. During the autopsy, toxicology samples were collected from the heart, liver, and stomach.

Toxicology results were returned and were positive for an extremely large amount of alprazolam (Xanax). The final official cause of death for James Oats was alprazolam toxicity; the manner of death was accidental.

Along with James’s parents and Detective Smith, Teresa was informed of the cause and manner of death. Mr. and Mrs. Oats were devastated by the news and, upon questioning, stated that they did not understand how James had obtained the Xanax pills. They assured the detective and the FNDI that the only prescription medications in the residence were locked in the master bedroom cabinet and that James had no access to them.

Mr. Oats reported that Mrs. Oats has not been eating and had lost 25 pounds in 3 weeks. She had not been able to return to work, cried continuously, and did not care for their other children. Mr. Oats reported that the entire family was withdrawn; the younger child was misbehaving in school and received detention several times. Mr. Oats expressed exasperation with the need to provide all child care, perform routine chores, and go to work; he admitted that he did not know how much more he could handle.

Mr. Oats told the investigators that community and church members were extremely helpful and sensitive to the family. The school officials and area churches agreed to support and offer programs to encourage children to say no to drugs; these programs were to focus more attention on prescription medications. Furthermore, the school James attended was investigating drug and alcohol abuse. The school social worker told Mr. Oats that a support group was being formed to assist students with James’s death.

Detective Smith interviewed several of James’s classmates and discovered that Xanax was used by many of them. From the information that he was able to gather, it appeared that this was the first time James had tried the drug. Detective Smith discovered that some of the students were obtaining Xanax from their parents and selling it to their peers. Furthermore, he learned that students are trying the “bars” because “it’s cool.”

Diagnosis

Family

1. • Mental and emotional distress

2. • Grief

3. • Lack of family support

4. • Excessive stress

Community

1. • Readiness for healing

Planning

Family

1. • The Oats family will initiate counseling to assist with acceptance of and coping with James’s death.

Long-Term Goal

1. • Family will identify need for outside support and seek such support.

Short-Term Goals

1. • Family will verbalize and recognize feelings surrounding the death.

2. • Family will express feelings honestly.

Community

Long-Term Goal

1. • Members of the community will establish a plan to deal with problems and stressors, including premature deaths.

Short-Term Goal

1. • Members of the community, including school personnel and students, will identify positive and negative factors affecting management of current and future problems and stressors.

Intervention

Family

Teresa Fernandez:

1. • Listened to the family’s comments, remarks, and expression of concerns, noting nonverbal behaviors and responses

2. • Encouraged family members to verbalize feelings openly and clearly

3. • Referred family to appropriate resources for assistance as indicated (e.g., counseling, psychotherapy, spiritual guidance)

Community

With police, school personnel, and community leaders, Ms. Fernandez:

1. • Reviewed the community plan for dealing with substance abuse problems among schoolchildren and assessed the related stressors

2. • Determined the community’s strengths and weaknesses

4. • Identified available resources

5. • Established a mechanism for self-monitoring of community needs and evaluation of efforts

Evaluation

Family

1. • The Oats family began family counseling and slowly accepted James’s death.

2. • James’s siblings began educating fellow classmates about the ill effects of abusing prescription medications.

Community

1. • The community implemented quarterly meetings for grieving families that included licensed counselors.

2. • The community members employed “just say no” rallies focusing on school-aged children.

Levels of Prevention

Primary

1. • Initiate drug teaching in middle and high schools, focusing on drug resistance training, social skills, and personal management.

2. • Support programs that encourage students to role-play and apply life skills to deal with peer pressure.

3. • Provide life-skills training (e.g., skills to cope with peer pressure, improve self-esteem/confidence).

Secondary

1. • Organize group sessions in school to discuss illegal prescription medication abuse.

2. • Provide information to school personnel and parents on how to identify or screen for evidence of use of drugs and alcohol among school-aged children.

3. • Provide information on area groups that provide support for students who want to avoid using drugs or want to stop using drugs.

4. • Reduce or stop harm that is done to individuals or groups while they are using drugs.

Tertiary

1. • Reduce risk that additional students will abuse prescription medication.

2. • Provide support to those who are abusing such substances.

3. • Refer to support systems (e.g., Narcotic Anonymous).

Summary

Forensic nursing is a broadly expanding specialty that combines multiple aspects of nursing science into the care of patients and families with forensic or legal concerns. Most often, the forensic nurse is employed in a hospital, clinic, correctional facility, or medicolegal death investigation setting. Specialized knowledge, competency, and skills are essential to the practice and require advanced education and training.

As mentioned previously, assessing for evidence of violence and intervening as needed are fundamental requirements of care that all health professionals must perform. Therefore every nurse has the potential to interact with a client, patient, or population with forensic needs, regardless of the client population or setting of care. Forensic nurses are faced with the challenge of meeting nursing needs while ensuring legal aspects are objectively ensured for living or deceased, and the need for practitioners in this specialty area is expected to grow.

REFERENCE

Nies, M. A., & McEwen, M. (2019). Community/Public health nursing: Promoting the health of populations (7th ed.). St. Louis, MO:

FORENSIC NURSING

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