Forensic nursing is a challenging field like no other.
Sara Jennings was an ED nurse at a trauma center when she saw the need to better care for victims of violence. Sexual assault patients would come into the hospital, yet there was no one there to provide them with the specialized care they needed to process the trauma, get them additional help or collect evidence. [caption id="attachment_57626" align="alignleft" width="200"]
Sara Jennings, RN[/caption] Jennings saw a flier in the break room for an adult-adolescent Sexual Assault Nurse Examiners course and signed up. "I did the 40-hour adult-adolescent training," Jennings, DNP, RN, SANE-A, SANE-P, AFN-BC, said. "I paid for it myself because I really wanted to make a difference and to help these patients." In essence, Jennings said, the legal and medical systems must intertwine to provide better care of patients who have experienced violence. Today, Jennings is a full-time forensic nurse and education director of the International Association of Forensic Nurses, an international membership organization comprised of forensic nurses working around the world and other professionals who support and complement the work of forensic nursing. Forensic nurses in the U.S. are based in many types of settings. Often ED nurses seek training and provide care on their units. These nurses also work in child advocacy and other healthcare centers. [caption id="attachment_57627" align="alignright" width="200"]
Nicole Stahlmann, RN[/caption] They work one-on-one with patients, according to Nicole Stahlmann, MN, RN, SANE-A, AFN-BC, a forensic nursing specialist at IAFN, who also transitioned from ED nursing. These nurses provide holistic care, looking not just at patients' evidentiary needs and traumatic incidents, but also at whether patients have other medical or mental issues to address through follow-up counseling and referrals. Forensic nursing as a subspecialty often suits ED nurses because they have skills that are important to forensic nursing, including the ability to communicate with different people, think critically, problem solve and multitask, according to Jennings. "It's a combination between psychosocial and spiritual education of nursing and using our background to be trauma-informed, to provide a holistic approach to treating patients and maintaining their health and well-being or safety," Stahlmann said. Forensic nursing is unique in that it intersects with the legal system. But nurses who don't know anything about the legal system shouldn't shy away from the subspecialty, according to Stahlmann.
Daily demands of forensic nursing
In forensic nursing, no two patients or cases are the same. "We definitely base our care on the needs of the patient," Stahlmann said. Stahlmann also works as a forensic nurse for the District of Columbia Forensic Nurse Examiners. She sees patients at the hospital after they've been triaged in the ED and medically cleared. "Once they are medically cleared, we come in and do our forensic nursing portion of the exam, which is to identify the patient as being there or requesting our services, obtaining their consent to complete the exam," she said. "I would say their consent is on a continuum throughout the entire portion of the exam because that is what empowers them or gives them back their voice." Stahlmann explained they go through basic information, obtaining demographic information, past medical history, health history, medication and allergy information, etc. Then they go into the narrative, which is the hardest part of the exam. Stahlmann then examines the patient from head to toe, identifying and documenting injuries. She uses a kit to collect evidence from patients who consent.
"It is incredibly tough for the patient to come in and sit through this exam," she said. "This exam can be anywhere from two to four hours, maybe longer. But it is also tough on the provider. It's that accumulation of hearing patients' trauma. It's vicarious trauma that builds up. But I will say it is absolutely rewarding. You are there with that patient. You are one-on-one with that patient on one of the worst days of their life. But you get to see that transformation and empowerment."
The forensic nurse arranges for the patient's needed medications. In the case of the District of Columbia, a patient advocate follows the patient throughout the process, but not all hospitals in the U.S. provide those advocates, Stahlmann said. Forensic nurses might have to appear in court if the patient decides to report the incident to law enforcement, according to Stahlmann.
The need and the challenges
In the U.S., 1 in 5 women and 1 in 71 men will be raped, and 1 in 3 women and 1 in 6 men will experience some form of contact sexual violence at some point during their lives, according to the National Sexual Violence Resource Center. As common as sexual and other forms of trauma are, nurses typically do not receive trauma-informed education, according to Stahlmann. "Definitely when I was in nursing school, there was not a trauma-informed course," she said. "There was nothing related to forensic nursing. I wasn't even aware of forensic nursing until two years into my career as a nurse." A high burnout rate among forensic nurses makes it challenging to meet the demand. It is estimated that forensic nurses remain in practice about two years, according to Jennings.
Not only do forensic nurses find it difficult to hear and see the violence, but it's not usually a 9-to-5 job. Court appearances typically happen on nurses' days off, according to Jennings. Forensic nurses need to be available to answer questions from police, social services and other agencies when needed.
While the career choice is stressful, there are ways to circumvent some of that stress, according to Angelita Olowu, BSN, RN, SANE-A, SANE-P, a forensic nurse specialist with IAFN. [caption id="attachment_57628" align="alignleft" width="200"]
Angelita Olowu, RN[/caption] Olowu said she learned coping skills in her previous career as a trauma nurse at a busy facility and maintains those coping strategies as a forensic nurse. "My recommendation to forensic nurses is always, always try to practice positive self-care," Olowu said. "And try to have someone else accountable for you, if at all possible. Usually nurses are working in some sort of program or some sort of team where there is at least another nurse or a couple of nurses that are doing the same thing. Just being accountable when someone seems like they're not quite themselves or reaching out to make sure they're OK." Though it's a tough job, Olowu takes comfort in knowing she can help these patients. "I can tell you that I've never had a patient not look totally different from when they walked in the door to see me to when they walked out," she said. "They tell me they're grateful I'm there, when really I'm grateful that they're allowing me to be there for them."
What it takes
In order to practice as a forensic nurse, RNs or advanced practice nurses must take a 40-hour didactic SANE training course online or in person. There's a clinical component associated with the course where nurses become more familiar with things such as a pelvic exam and history taking, and they become competent to practice on their own. Certifications are available from the IAFN for either adults and adolescents (SANE-A) or pediatrics (SANE-P). "That's our national certification that you would take much like your CEN certification," Jennings said.
Nurses in any specialty can help
Abused and assaulted patients present in all types of healthcare settings. Nurses caring for them should have some understanding of their needs and a plan for how to care for them. These patients might not disclose the trauma, rather nurses might notice something that prompts them to ask questions.
"We've had a lot of nurses that worked in labor and delivery that have had patients that have been sexually assaulted," Olowu said. "We've had nurses in outpatient surgery where patients have disclosed in postop care. It doesn't matter where you practice, because you touch patients throughout any stages of their lives. It just has to be a right moment for that patient to be ready to talk."
Nurses from all specialties bring their perspectives to the table in forensic nursing and could make good forensic nurses. Mental health nurses, for example, have a role to play in the subspecialty. "Maybe you feel like once you do the class, do the training and see patients, that it's a little too much for you," Olowu said. "You can be a champion for whatever department you're in." Jennings suggests all nurses become familiar with free resources and information on the IAFN website. The information will help guide nurses' practice when they encounter victims of violence. Knowledge helps nurses make a plan, whether it's to transfer patients to another hospital that has a forensic or SANE nurse or arm those patients with helpful information and resources. Nurses can help by talking to their administrators and nursing directors about what that plan is, Jennings said.
Take these courses to learn more about forensic nursing:
Evidence Collection and Preservation in a Healthcare Setting (1 contact hr) It is imperative to understand that the forensic work of collecting and preserving evidence from a patient should never compromise the safety, autonomy, or legal rights of a patient. This course provides an overview about interviewing, collecting, and preserving forensic evidence, toxicology, and documentation. Forensic Nursing and School Shooters (1.5 contact hrs) Nurses working in the school, community, and emergency and psychiatric mental health settings can play a key role in the prevention of violence by understanding the dynamics and profiles behind these types of homicides. Sexual Assault and Rape (1 contact hr) The FBI indicates that 89,098 rapes were reported to law enforcement in 2015, up 6.3% from 2014. People who have been raped or sexually assaulted enter the healthcare system through many avenues. Nurses and first responders may encounter them in the field, the ED, or in obstetric or primary care settings. These patients may also be found in pain clinics; in specialty centers for GI, genitourinary, or neurological workups; or in gynecological or urologic settings as they move from specialty to specialty, seeking a medical diagnosis of their symptoms. Healthcare professionals of various disciplines who ask the right questions and assess and observe these patients can help tremendously.
