Forensic Nursing Pioneers Ponder the Future

By Kelly M. Pyrek

Faye Battiste-Otto

Now that forensic nursing isn’t quite the obscure, unsung entity it used to be in the days before official recognition by the American Academy of Forensic Science (AAFS) and the American Nurses Association (ANA), practitioners of this unique nursing specialty can rest on their laurels, right?

The answer is a resounding “No!” according to the nurses who have seen forensic nursing grow from a tiny seed of an idea to a discipline finally coming into its own. It’s not so much a quest for validation anymore as it is the pursuit of respect from other members of healthcare and medicine. Forensic pathologists, law enforcement investigators and members of the legal community have been quicker to support forensic nursing because it augments and contributes to the medicolegal process. Other physicians, clinicians and even some nurses continue to be puzzled by forensic nursing’s insistence on fundamental tenets of evidentiary examinations, chains of custody, evidence collection, preservation and documentation, and its bigger purpose in a court of law.

“We still have a long way to go,” says Faye Battiste-Otto, RN, SANE, president and CEO of California-based forensic education and consulting firm American Forensic Nurses. “I think that with increased education and research, we will eventually gain the respect we deserve. The problem is, the community is not sure what forensic nursing is. They are afraid of it. When I started my business years ago, people said, ‘You are involved in forensic science so you must be involved with dead people.’ They did not know about living forensic patients.”

Forensic clinical nurse specialist Virginia Lynch, MSN, RN, FAAFS, FAAN, considered by many to be a pioneer of forensic nursing and the first to identify this specialty with that moniker, concurs, adding that some of the greatest opposition has come from nursing itself.

“It was such a foreign concept to nursing,” she says. “Understanding came first from forensic pathologists and forensic scientists, then from law enforcement, and finally nursing. But once nursing recognized the value of what I was trying to do, they embraced it wholeheartedly. It was such a strange evolution because generally, medicine is the last to be the first to support nursing; however, forensic pathologists were the only specialists in the entire history of medicine that didn’t have their own nursing specialists. Pediatricians had pediatric nurses; oncologists had oncology nurses; critical care physicians had critical care nurses; and even neurosurgeons wouldn’t consider going into surgery without their skilled surgical nurses. But the forensic pathologist only had non-medical police officers to assist them.”

Lynch credits Dr. Thomas Noguchi as being one of the first to recognize a specific role for nurses in forensic science. “Dr. Noguchi was the famed coroner in LA who autopsied John Belushi, Natalie Wood and Marilyn Monroe, among other high-profile cases. Almost 20 years ago, when I introduced forensic nursing at the Academy, he told me he had always believed that a nurse would be the ideal clinician to work with families of sudden infant death syndrome. He felt that police officers and traditional death investigators didn’t have the psychosocial skills necessary to communicate with families who were so emotionally traumatized.”

Lynch says there were many others who saw and believed in the value of nurses in forensic pathology. “The very first was Dr. John Butt from Canada as long as 35 years ago. At that time he did a five-year study to see who made the best death-scene investigator. He used paramedics, lab techs, police officers and registered nurses, and came to the conclusion it was the registered nurse who made the best death scene investigator. Among their greatest skills cited was their ability to communicate, their psychosocial intervention. The chief forensic pathologist in Dallas, Dr. Charles Petty, opened the door of the Southwestern Institute of Forensic Science for me as a nursing student. He allowed me free reign to study in all of the departments of the Institute, not even knowing at that time what I would do with it. And, of course, it was Dr. Patrick Besant- Matthews who took me through my first autopsy there ... who today still is one of the greatest champions of forensic nursing. Dr. Nizam Peerwani gave me my first job as a medical examiner’s investigator, the job that led me to realize what nurses needed to know and were capable of doing.”

It has only been a little more than a decade since a group of about 70 nurses founded the International Association of Forensic Nurses (IAFN), to give shape to what was emerging as one of the newest nursing specialties. Battiste-Otto says the early days were filled with hope, enthusiasm and determination, not unlike the emotions that fill today’s newest crop of nurses breaking into the field.

“When I became interested in forensic nursing I was an ER nurse and I thought, ‘Hmmm, forensic science, that’s interesting. Let me get into that.’ During her time in the ER, Battiste-Otto says she would see numerous police officers waiting to interview victims and thought there had to be a better way to handle the situation. Those early glimmerings of understanding were cemented when she realized evidence handling was a nurse’s perogative, too — even though nursing care frequently compromised the very evidence they should have been protecting.

“If we encountered a chest injury caused by a bullet, for instance, the first thing we would do is clean the chest really well and throw away the bullet,” Battiste-Otto recalls. “I started to think, ‘We really shouldn’t do that,’ so I began looking for education and there was little or none in the early 1990s. I think that’s how we became involved in the IAFN; there were 74 of us and we all had the same vision — we would have no choice but to become involved in legal issues in forensic science. It did feel like me against the world for a while. I think there were probably about six of us here in California. We were so enthusiastic but we knew it would be a challenge. We have come a long way but we still have a tremendous amount of distance to go.”

Forensic nursing was slowly growing and infiltrating emergency rooms as sexual assault nurse examiners (SANEs) were being trained and certified, and nurses working in corrections, psychiatry and death investigation — among other disciplines — began identifying with the forensic-nursing umbrella designation. Talented, dedicated individuals were working tirelessly to spread the word about the medicolegal process, and important inroads were slowly and quietly being made, until suddenly, forensic nursing was “tried” in the courtroom and the media got wind of it.

This watershed moment in forensic nursing had its beginnings in late 2000 in a Virginia circuit court where a sexual assault case, Commonwealth v. Johnson, was underway. Suzanne Brown, RN, a SANE considered to be an expert by the presiding judge, was allowed to testify about injuries she observed in a rape victim. Brown’s testimony that physical injuries detectable by gross visualization are not found in individuals in whom the “human sexual response” had been triggered. The prosecutor said that injuries visible without magnification indicated to Brown that the sexual activity occurred without consent, while the defense said Brown’s opinion was scientifically unreliable. The court consulted various studies and ruled that none of them supported Brown’s opinion that genital injuries detectable by gross visualization do not result from consensual sexual intercourse. The court said that because the medical literature did not support Brown’s opinion about the human sexual response relating to genital injury, there was no foundation to admit evidence and Brown’s testimony about the human sexual response was excluded.

While portions of Brown’s testimony were thrown out of court, forensic nurses celebrate the significance of the court’s recognition that Brown, as a SANE, was an expert witness.

In 2002, the status of the SANE — due to the individual’s training and experience — was established, but the breadth and depth of what the nurse can say was narrowed by the Virginia Supreme Court in a different case. The court said nurses who examine alleged rape victims may testify in court but cannot offer their opinion that a victim’s injuries were caused by sexual assault. Through issuance of the ruling, the court ordered a new trial for a man convicted of rape in 1999 because the jury heard improper testimony from Barbara Jean Patt, a SANE called by the prosecution. Patt testified that the victim had injuries “consistent with non-consensual intercourse,” while the defense argued only a licensed physician could diagnose sexual assault. The court upheld Patt’s expertise and said, “In essence, all that is necessary for a witness to qualify as an expert is that the witness have sufficient knowledge of the subject to give value to the witness’s opinion.”

The Challenges

Forensic nursing is sometimes an uneven landscape, its broad stretches of smooth terrain punctuated by hidden pitfalls and sheer cliffs. Traversing this path, sojourners will encounter not only the need for professional recognition, they face education and training challenges, barriers to employment, and perhaps most significantly, fighting for the right to call themselves forensic nurses. Lynch says it’s a matter of semantics, really, since nurses have already been serving in this capacity for a hundred years.

“Many nurses were already working in a variety of forensic roles, but no one called it forensic nursing,” she explains. “Nurses had long been working with the criminally insane, the suspects, and the accused who were remanded while waiting to stand trial.

Nurses had just started doing rape exams in the mid-1970s, about the same time as nurses in death investigation. Nurses had been managing forensic cases in the Emergency Department but no one called them forensic cases, and SANEs weren’t referred to as forensic nurses at that time.”

Lynch continues, “When we talk about the evolution of forensic nursing, it wasn’t that these nurses were not practicing in forensic roles; they just didn’t know they were. I will never forget when Cindy Peternelj-Taylor, who teaches at the University of Saskatoon in Canada, wrote to me after my first article was published and thanked me. What she said has always stayed with me. She said, ‘What you have done is give us an identity. We’ve always known we were doing something very unique, very special, but you have given it an name.’ I based the development of forensic nursing categories on the categories of specialists in the American Academy of Forensic Sciences. You didn’t have to have a medical degree to be a death investigator, yet nurses were not accepted for membership at that time because they were nurses. But as a death investigator I had become a member and had established a foundation on which to project forensic nursing. It was from that platform that I began to insidiously interject forensic nursing from a wide range of perspectives — sexual assault, death investigation, psychosocial intervention and all of the existing areas. Academy members like Dr. Michael Baden, Dr. Charles Petty and Dr. Patrick Besant-Matthews supported me and have remained strong defenders of forensic nursing.”

Lynch and Battiste-Otto are among many who believe a strong forensic nursing curriculum is essential to the future growth of the field and the edification of its practitioners.

“As a result of my interest in the forensic sciences as an undergraduate nursing student working with rape victims, I began to realize that the knowledge I was gaining through forensic science was something that every nurse should know,” says Lynch, director of the Forensic Nursing and Forensic Health Science program at Beth-El College of Nursing at the University of Colorado. “As I became a death investigator, I realized the valuable contributions of forensic science to our work, not just to nurses as death investigators, but to every nurse. They weren’t teaching this information in nursing school. Some of the things most basic but critical to nursing practice, such as the difference between a cut and a laceration, weren’t being taught and could have serious legal implications.”

Lynch points to a Florida case as an example. “A nurse had repeatedly documented multiple lacerations throughout the patient’s chart. The defense attorney reviewed the chart and asked the judge to dismiss the charges against his client. He said, ‘My client was carrying a knife and a knife cannot inflict a laceration; my client wasn’t carrying a baseball bat or a club.’ Every nurse should know the difference between a cut and a laceration and yet doctors and nurses outside the forensic arena continue to miss-document the term laceration.”

Lynch relates another example. “The most frequently overlooked sign of abuse is the human bite mark, yet this is not taught in traditional nursing education. Wouldn’t you assume that if we were expected to identify crime victims, to collect evidence and report these cases to law enforcement, that the single most overlooked sign of abuse should be taught in schools of nursing? Nurses need to know the human bite mark is also commonly associated with sexual assault; or the fact that cardiac arrest is not a cause of death. The most basic concepts that every nurse should know appeared to be recognized only in forensic science.”

The gap between nursing practice and forensic science was much wider in the early days than it is now, and Lynch decided to address it.

“When I wrote my master’s degree program in forensic nursing I wanted a combination of nursing science, forensic science and criminal justice that would bridge the gap between healthcare and the law. I was in the right place at the right time and the right person who made it happen was Dr. Sam Hughes. He was the graduate dean at the University of Texas at Arlington School of Nursing; I don’t know whether it was because he was a man or because he was a military nurse, but he immediately understood my vision of forensic nursing. Unfortunately, he died my first semester and the new graduate dean didn’t understand the concept of a forensic specialist in nursing. But what Dr. Hughes did was to open the door to forensic education in nursing and from that point it has evolved into one of the most-sought after courses by nurses in the U.S. and today worldwide.”

The “F” Word

Exactly why many are skittish about using the word “forensic” is a mystery, but some forensic nurses are serious about calling a spade a spade.

“There was a dean of nursing in Georgia who told me I will could teach my course if I would eliminate the word ‘forensic,’” Lynch recalls. “I said I couldn’t do that. I had developed this field based on the definition of the word forensic as a companion role to forensic medicine; she simply didn’t understand what the word forensic means. And understanding this term has been a difficulty among nurses. You have to educate people about the meaning of the word as it pertains to the law. Forensic medicine has long been a respected component of public health; today forensic nursing holds the same status with healthcare and the law.”

Even the bastion of healthcare, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), couldn’t bring itself to use the “F” word in the early days.

“The Joint Commission, without even knowing it, laid a platform for the acceptance of forensic nursing when it stated as early as 1992 that every ED ‘shall have on staff an individual skilled in the identification of crime victims and the collection and preservation of evidence.’ They didn’t say a nurse, but they didn’t say a doctor. It has taken until this year for JCAHO to use the term forensic nurse or forensic case. And it was the word forensic that was the greatest obstacle with nursing,” Lynch states.

It’s a matter of claiming something that has always been theirs, Lynch adds.

“Nurses have always been expected to care for crime victims. They were always required to collect evidence, only they called it specimens. Nurses could just as easily be subpoenaed to court without any preparation then as now. Any nurse could. Finally they realized what forensic cases were, and yes, nurses were dealing with them on a daily basis but without specialized knowledge. I don’t think we are any different than any other new discipline in nursing ever was. Nurse practitioners had a tremendous obstacle to overcome, especially with physicians. Every nursing discipline has had to go through this developmental phase. I am not discouraged in any regard. I believe we have unlimited potential and that the future is ours. I believe one day every hospital, every trauma center will be required to have on staff a forensic nurse examiner. They will become the liaison between the hospital and police and courts of law and families. It is a position that is just beginning to evolve. What I find so exciting and interesting is that it is the nurses themselves who understand the role better than hospital administrators or other officials because it is the nurses who have had to deal with victims, with the police, with evidence, with the criticisms that came from police when nurses didn’t understand their responsibilities to the law and legal agencies. They were often viewed by police as obstructing justice.”

Battiste-Otto acknowledges the snail’s pace of the development of training and education resources for aspiring forensic nurses, and in the meantime, education occurs on the mentoring level. “We are very willing to share our expertise and knowledge but we are so small that it takes a lot of time for education to move forward. There are a few master’s degree programs out there and they can be expensive; nursing is a profession in which until recently, nurses didn’t earn a lot of money. Offering courses from reputable schools and making them affordable will help registered nurses become involved in forensic nursing. That is a lot to ask of universities, but the future of forensic nursing depends on it.”

Credentials Still on the Distant Horizon

There currently is no official certification as a “forensic nurse” in the U.S., except for SANE certification. It is a source of frustration for established and new nurses alike, but the pioneers say all in good time.

“We are coming into our own and it is just a matter of time that today’s obstacles will no longer exist,” Lynch says. “We are working as hard and as fast as we can to get the credentials nurses want and need. As more schools of nursing provide the education, the sooner we will realize this goal. Certification is secondary to the education and experience, but when we talk about lack of standardization and lack of education or credentials — it will all come in good time. Nurses have always provided these services. Whether they have a forensic education or forensic certification, nurses in every hospital in every city will still be required to care for crime victims; certification is a matter of making it official. Before there was an Emergency Nurses Association or before there was certification for psychiatric nurses, nurses were still working in those areas and it took time to establish their credentials.”

She continues, “I remember some years ago attending the ANA conference in Washington, D.C. when they featured the evolution of psychiatric nursing. It was the most amazing thing to hear some of the 90-year-old nurses that helped establish it talk about what they went through. I don’t see that we are having greater difficulties than that group of pioneering nurses. It takes patience and it takes time. The enthusiasm of nurses in forensic practice is overriding the time that it’s taking to get these credentials. They want it now, and I want them to have it now. But it doesn’t mean they can’t work as a forensic nurse until we have credentialing in areas other than sexual assault examination.

I realize these credentials are extremely important when they go to court, but guess what, nurses were going to court long before forensic nursing existed, and by having a forensic education, we can still be better expert witnesses, better fact witness, better clinicians, because we are nurses. We are taught as nurses to observe closely and document what we see and what we do. We are keen observers, excellent at documenting minute details and are fantastic caretakers of those who need us most. No one does it better than nurses. Forensic nursing is making tremendous inroads into the future of health and justice.”

To make these inroads, forensic nurses need stamina. “They also need a great deal of persistence,” Battiste-Otto adds. “Doors close in your face constantly; as an entrepreneur, doors closed in my face for three years, but I didn’t give up because I had a story to tell, a mission to complete and I wanted to make a little bit of difference in the world of forensic science. Honesty, integrity and forthrightness are of the utmost importance. If you have all of these qualities and don’t give up, you can succeed out there.”

Despite the challenges, forensic nurses remain upbeat about the future.

“I would love to see every hospital have on its staff a clinical forensic nurse specialist,” Battiste-Otto says, “one who can deal with medicolegal issues. I think we may get there but it’s a slow process. There is so much happening, we have not even hit the tip of the iceberg yet.”

“We have arrived,” Lynch declares. “Forensic nursing is an entity whose time has come, in spite of all obstacles and negativity of those who did not share this vision. Forensic nursing is here to stay.”

Perspectives on the Future of Forensic Nursing

By Georgia A. Pasqualone, MSN, MSFS, RN, CNS, DABFN

When the phone rang I was in the middle of roasting a chicken. This, by itself, was unheard of, as I don’t have time to cook anymore. My husband tells everyone that our cat eats better than he does.

The call was from a criminal defense attorney who provides me with a large portion of my consulting work. He’s the only criminal defense attorney I work for. Trust me, one is enough. There were no preliminary greetings, only, “You’ve got to go interview my client before the cops and DSS grab him and his little sister. You’ve got to go right now.”

That was the usual beginning of all my adventures with this attorney. I shut off the oven, left a note for my husband, grabbed my laptop and ran. My responsibilities with this case were as diversified as they could possibly be. It was a suspected child sexual abuse case between brother and younger sister. The potential for forensic fodder was endless. I interviewed family, neighbors, and schoolteachers. I took photographs of multiple crime scenes. I read reams of school, legal, medical and psychological documents.

I interpreted DNA findings. I assisted the attorney in reconstructing all possible scenarios in the attempt to exonerate his client of the charges of child sexual abuse. The range of role responsibilities is limitless. After all, not all defendants are guilty. That is one of the most important lessons I have learned working for the criminal defense.

Everything was going smoothly until the attorney applied for funding for me from the presiding judge on the case. The dialogue went a little like this:

I had already contributed more than 44 hours to this case. The thought that I might not get paid for all my hard work was nauseating.

The client’s family was in no position to pay for counsel; therefore, the client was eligible for state funding. State funding, though, is at the discretion of the judge. The attorney has to justify the use of experts and their price tags, and it was obvious that the judge had not been listening to the attorney, nor had he been educated about what a forensic nurse was and what they were capable of accomplishing.

Now don’t get nervous. The attorney eventually got the judge’s attention and I was granted funding. However, this is one of the dilemmas that complicate the future of forensic nursing, especially for those nurses who practice outside the four walls of a clinical setting. The general public is still oblivious to what we do and what we have the potential of doing. The populace is still under the impression that our role is limited to caring for sick people and giving shots.

Those that we have helped in a forensic setting will never forget us. I have thank you letters from grateful clients; yes, clients, not patients. The scope of practice of a forensic nurse reaches beyond the patients we have traditionally cared for in the hospital.

Judges, police officers, detectives, attorneys, school superintendents, medical examiners, coroners, physicians, and psychiatrists, to name only a few, are on a priority list for education and enlightenment regarding our emerging specialty.

Forensic nurses struggle with marketing issues which could be more easily resolved if the disciplines with which we collaborate received an information blitz regarding the skills and knowledge we can provide. Nurses need to speak out for themselves. There are no jobs in the classified section with a pink neon sign that points to forensic nursing positions. These positions exist but need to be persuaded, coaxed, and groomed into the public eye. I realize that economics play a tremendous role in curbing the expansion of forensic nursing; however, the cliché of “one step at a time” seems to fit here.

My dear friend and colleague, Janet Barber, states that the military “gets it.” More people need to “get it.” Clients who have benefited from a forensic nurse on the case “get it.” Attorneys who have had a forensic nurse in their office “get it.” Hospitals that have produced Joint Commission-approved policies and procedures written by a forensic nurse “get it.” Schools that have forensically educated nurses on staff “get it.” But the need is tremendous. The knowledge deficit is still daunting. Nursing has always been about repairing the wrongs done to patients. Forensic nursing goes much farther than that. Forensic nursing must acknowledge the magnitude of preventing these wrongs in the first place, and collaborating with other disciplines in order to mitigate and adjudicate the wrong that has been committed.

So, pull those roasts out of the oven and go market yourselves to those who need a forensic nurse by their side. If you do what you love, everything else will fall into place.  

When not in the kitchen, Georgia A. Pasqualone MSN, MSFS, RN, CNS, DABFN can be found out in the field, in the classroom, in the courtroom and on the lecture circuit, championing forensic nursing.

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