Victims of violence face many hurdles in the process of healing and seeking justice. Forensic nursing is the bridge between healthcare, law enforcement, forensic science and the legal system. Historically the role of a forensic nurse was to collect “rape kits” now recognized as a sexual assault kit. This kit included swabs of DNA collected soon after the assault and were processed in a crime lab. The field of forensic nursing as broadened to include not only sexual assault but also domestic violence, child abuse, child sexual abuse, physical assault, elder abuse and neglect, strangulation and other forms of violence. The victim’s body is evidence as well as their injuries and their story. Forensic Nursing is tasked with advocating for this evidence.
Since the spread of Sexual Assault Nurse Examiner (SANE) units, the research has consistently shown a positive impact on the quality of forensic evidence collected, law enforcement’s ability to file charges and increases the “likelihood of successful prosecution” (Crandall & Helitzer, 2003). Forensic nurses provide trauma informed care and understand that the majority of victims are assaulted by people they know and often their partners. This specialty is adept in identifying physical trauma, psychological needs and ensuring the victim receives appropriate medical care and referral follow up. Evidence collected during the exam can be used to identify the types of injury and DNA to link the victim and suspect to the crime scene. Sexual assault exams include assessment for sexual contact and for signs showing of lack of consent (Little, 2001).
Issues Unique to Rural Areas
Seventy two percent of the country’s land is considered rural and these communities are naturally isolated and have limited access to healthcare. Families living in rural communities also have higher rates of poverty and have 30% higher rates of sexual assault of females than in suburban areas. “According to the Bureau of Justice Statistics, from 2005–2010, the rate of sexual violence for females in rural areas (3.0 per 1,000) was higher than the rate of sexual violence for females in urban (2.2 per 1,000) and suburban (1.8 per 1,000) areas” (OVC). The common belief that these issues do not affect quiet rural towns is wholly untrue. Elevated Forensic Nursing (EFN) covers six counties in rural Idaho including Valley, Gem, Payette, Washington, Boise and Adams counties. EFN works closely with law enforcement in each county and local advocacies to navigate the unique needs of these rural areas.
Children in Rural Areas
A National Incidence Study of Child Abuse (NIS) conducted a country wide study of reported child abuse by CPS workers, physicians, teachers and other mandatory reporters. The study discovered the number of reported cases of maltreated children represents only the “tip of the iceberg” as so many go unreported or never catch the eye of a mandatory reporter (Sedlak, et al., 2010). Grooming and secrecy are common tactics used by abusers of children, these tactics give them continued access to the child and prevent others from seeing red flags. An 8-year-old boy may be beaten by his father regularly but he has learned to cover his bruises, make excuses and never admit there’s an issue at home. Grooming and secrecy.
Rural areas consistently show higher incidence of child abuse compared with more urban areas. Children living in rural areas are almost twice as likely to experience abuse including sexual, emotional, physical abuse and neglect. More than a quarter of the reported rural cases include more than one type of abuse (Sedlak, et al., 2010). Families in rural areas tend to experience higher poverty rates, geographic isolation, lack of social services, limited child care and lack of emergency housing. Small towns also carry a heavy social stigma for survivors of abuse and a lack of confidentiality (Sedlak, et al., 2010). Rural stressors certainly play a role in adding fuel to abuse but should never be accepted as a justification for child abuse. Rural areas can become a refuge for perpetrators who take advantage of the isolation and lack of social services and stigmas.
Forensic Nursing’s Impact on:
1) Healthcare
Victims receive more consistent and inclusive healthcare services when working with a forensic nurse than taking the traditional Emergency Room (ER) route
Victims consistently receive access to Sexually Transmitted Disease (STD) prevention treatment, pregnancy testing and prevention
Patients were discharged faster with a forensic nurse than through traditional ER visits for the same issue (Crandall & Helitzer, 2003)
Having a forensic nurse frees up physicians and medical personnel to care for medical emergencies. Patient care, treatment and discharge are taken over by the forensic nurse if deemed medically stable.
Mobile forensic nurses relieve the burden of training staff and maintaining competency. Community and hospital-based programs are notoriously difficult to start and maintain in rural areas as the training is extensive, time consuming, costly and require travel for courses. Elevated Forensic Nursing is an independent practice responsible for maintaining competency and coordinating peer consultations and reviews. Forensic nurse units from around the state consult together regularly and peer review cases for quality improvement.
Mobile forensic nurses are available 24 hours a day, 7 days a week, including holidays. As long as there are patients who need help, there will be a nurse to respond. In more critical cases, the forensic nurse can conduct the exam while the patient remains in the hospital to prevent delay in evidence collection
A forensic exam includes high quality documentation and photography. All exams are documented in detail with the victim’s history and body diagrams of physical findings. All injuries are identified, photographed, diagramed and measured.
Coordination in billing the Victim’s fund and insurance for reimbursement. The Idaho State Victim’s Fund pays for forensic exams and treatment associated with an assault. In some cases, insurance is billed first and the difference is covered by the victim’s fund. All necessary documents for billing are provided by Elevated Forensic Nursing.
Basic staff training and protocol reviews provided free of charge. Trauma informed care is the responsibility of all healthcare providers; Elevated Forensic Nursing is happy to provide training to medical staff and review the process of coordinating a forensic exam.
2) Victim Services
Local and timely service. Previously victims within these six rural counties had to travel to Boise for an exam but Elevated Forensic Nursing is now contracted with Cascade Medical Center in Cascade and Two Rivers Medical Clinic in Weiser. Mobile exams are also available at other facilities as needed.
High quality, trauma informed exam. Forensic nurses understand the effects of trauma on the mind and body and all treatment is victim centered and compassionate. The victim has control and consents to each part of the exam.
Advocates may be present for the exam and for support if the patient wishes. Elevated Forensic Nursing works closely with Rose Advocates within these six counties; these advocates provide emotional support during the process and provide referrals for aftercare and support.
Evidence collection while DNA is fresh with minimal opportunity for contamination. DNA evidence on the body may be retrievable up to five days after the assault. Forensic Nurses are trained in evidence collection and chain of custody; all kits are sealed and transported to the crime lab for processing.
Patients of a forensic nurse receive more comprehensive referrals for medical and victim services than those who take the traditional ER route (Crandall & Helitzer, 2003).
3) Law Enforcement
Benefit of a third party professional to collect the report, evidence and photograph injuries. This relieves law enforcement from having to photograph injuries. They will receive a full forensic series on each injury with patient consent as well as medical identification of each injury.
Sealed evidence and clear chain of custody. All kits are sealed by the forensic nurse before given to law enforcement. Each kit is tracked through the Idaho State Police Kit Tracking System as it makes its way through the investigation and legal process.
Basic patrol training provided free of charge. All law enforcement agencies within the six-county area are encouraged to have a basic understanding of who qualifies for a forensic exam and the process of coordinating an exam for the victim.
Suspect exams, domestic violence exams and strangulation exams are also available. Any victim of physical violence within five days of the assault qualifies for an exam. Suspect exams conducted by a forensic nurse include swabs for DNA, photographs and documentation of injuries as well.
Victim exams are billed to insurance and the victim’s fund, no charge to law enforcement or victim.
Forensic Nurse Examiner will advocate for the evidence, photographs and documentation in court
Victims are more likely to report to police and have evidence collected when working with a forensic nurse
Law enforcement is more likely to file charges after a forensic exam than without one and more charges result in arrest
Having a forensic nursing unit in the community increases the likelihood victims will report assault (Crandall & Helitzer, 2003).
4) Prosecution
Cases that have a forensic exam tend to have higher conviction rates and longer average sentences compared to those without a forensic exam (Average 5 years compared to 1 year) (Crandall & Helitzer, 2003).
The proportion of cases including a forensic exam presented to a jury increase as well as those resulting in an indictment
Criminal sexual penetration charge conviction rates also increase (Crandall & Helitzer, 2003)
Evidence collection by a forensic nurse can strengthen a prosecution’s case on behalf of the victim (Little, 2001)
Forensic Nurse Examiners are often considered credible witnesses in court dealing with cases of violence and trauma (Little, 2001)
Objectifying the impact of a forensic nursing unit on a community is easy, the data is abundant and growing. The impact on a victim, who could be your sister, mother, brother or neighbor is difficult to quantify but no less impactful. Victims are usually brought in to the exam tired, emotional, raw, traumatized, numb and all the feelings in-between. I see women, men, teens, children, toddlers and the elderly, all vulnerable in their own unique ways and all equally entitled to share their story and receive care. Forensic nurses meet patients exactly where they are in that moment and capture their story through interviews, photographs, swabs and documentation. A forensic exam is a time stamp of that moment.
Below are Victim Stories
(All names, identifying details and locations have been changed)
Ashley – 22-year-old college student living at home. Some friends were getting together for a party to celebrate one of their birthdays. Everyone wanted to drink safely so they bought their own alcohol and the friend’s parents would be home. The night went on with good food and drinking until one-by-one people wanted to sleep. Everyone agreed to stay the night so no one would drive drunk and Ashley opted for the living room couch. She has vague memories of her friend’s dad helping her as she stumbled to the couch. Another friend was asleep on the couch next to hers. She recalled still hearing his voice as she “blacked out.” The next morning, Ashley woke up with everyone else and when she went to the bathroom, she noticed her underwear was missing. She didn’t feel pain, no blood, nothing seemed wrong except for the missing underwear.
After telling her experience to a coworker the next day, the coworker suggested she get an exam. Ashley scheduled an exam and let the police know of her concerns, she also felt worried that nothing had happened and maybe she lost her own underwear while she was drinking. She had a Sexual Assault Exam and there appeared to be a small injury to her genitals showing sexual contact, Ashley was not currently sexually active. Swabs were collected for evidence and sent to the crime lab for DNA processing. Ashley received STD and pregnancy prophylaxis, follow-up support with the advocacy and referrals for testing and counseling. Ashley’s story is so common; intoxicated or unconscious people cannot legally consent to sex
Alexa – 49-year-old mother of 4 and married to her husband of 25 years. On the outside, the family appears well off, kids are active in activities with supportive parents and they love to travel. Alexa’s husband Jim drinks heavily at times and becomes violent when drunk. For 25 years he has battled alcohol and drug addiction behind closed doors where only his wife and children see. When he is drunk or high, he becomes violent and beats Alexa, he often forces her to have sex. She says Jim is a great dad, he never hits the kids and when he’s sober is a good husband. His current addiction led him into a weekend binge and therefore a weekend of violence in the home. Alexa was beat throughout the weekend with fists as well as weapons while the kids hid safely in their rooms. She said she was afraid to leave because of the kids and she had no way to support herself.
This weekend she finally called for help because she was worried he would kill her in his violent state. She was afraid of her children seeing her dead body. The police responded to the scene and like other times, Jim acted calm and compliant while Alexa was frantic and crying. At first glance, she appeared to be the aggressor. Jim told officers she was the drunk one and acting crazy but the officers were trained in assessing for the true primary aggressor. Alexa was given a forensic exam and her injuries were extensively documented, diagramed and photographed. DNA was collected as she reported he forced her to have sex without consent. Her children were placed safely with relatives during her hospital stay and the advocacy provided continued support, counseling, access to safe housing and sat with her through each interview. Jim pled guilty and it was discovered he had been previously convicted of assault.
Todd – 45m year old male, works retail and looking for a partner through dating apps. Todd met Shaun through a dating app and they had been chatting for a month before Todd agreed to a date. They met for dinner and hit it off well, Shaun invited him over to watch a movie and Todd was interested but made it clear he wasn’t interested in sex. They hung out at Shaun’s house watching a movie and they both had a couple beers. Shaun started pressing Todd to be more intimate but he didn’t feel comfortable this early in the dating relationship. Shaun persuaded him to have another beer and brought him one. Todd remembers nothing after drinking the beer. His next memory is waking up at home with no memory of how he got there. He felt nauseous, dizzy and had a headache, not his normal hangover. He noticed some anal pain but no blood and nothing seemed out of the ordinary. He texted Shaun to thank him for taking him home and to ask what happened as he has no memory of the rest of the night. Todd reported the conversation with Shaun seemed unusual and he was avoidant. He became worried maybe something had happened and he might have been drugged.
Todd went to his local hospital to ask about drug testing. The nurse assessed him and upon hearing about Todd’s night and memory loss consulted a forensic nurse. The forensic nurse explained the process for drug testing and evidence collection and Todd consented to a full exam. Law enforcement arrived at the hospital to listen in on the interview for their own report. During the exam, the forensic nurse observed an anal tear showing signs of penetration. Internal and external swabs were collected for DNA evidence; blood and urine were collected for drug testing. Todd was concerned with Shaun’s high-risk lifestyle and potential of being an HIV carrier; the forensic nurse provided STD prevention and assessed his HIV exposure risk with the CDC’s exposure algorithm. He was referred for HIV PEP, a series of antiviral medications to prevent HIV infection. During the law enforcement investigation, Shaun was asked for his HIV status and he reported being a carrier. Fortunately, Todd had started PEP within the 72-hour time frame post assault and would likely not become a carrier himself. By the time the investigation uncovered Shaun’s HIV status, it would have been too late for Todd to begin PEP to prevent infection.
On a Personal Note
The love of patient care brought me into nursing in 2004 and carried me through countless bedsides of patients during every stage of life and death. My love for patient care eventually led me to forensic nursing where I’m privileged to sit at the bedside of those who have survived violence. Instead of keeping watch over breathing machines and IV tubing, I’m keeping watch over evidence and broken people. Instead of teaching cardiac diets, I’m teaching about the trauma response. Instead of pushing life saving medications, I’m providing STD and pregnancy prevention to ensure the lifelong effects of the assault are limited. Singing Disney songs during pediatric exams is still the same though!
References
Crandall, C & Helitzer, D (2003). Impact Evaluation of a Sexual Assault Nurse Examiner (SANE) Program. https://www.ojp.gov/pdffiles1/nij/grants/203276.pdf
Little, K (2001). Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims. Office for Victims of Crime (OVC) U.S.
Department of Justice (DOJ). https://vawnet.org/sites/default/files/assets/files/2016-09/OVC_SANE0401-186366.pdf
Office for Victims of Crime (OVC) Creating Programs in Unique Community Settings https://www.ovcttac.gov/saneguide/building-a-sustainable-sane-program/creating-programs-in-unique-community-settings/
Sedlak, A.J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., Greene, A., and Li, S.
(2010). Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families.
About the Author
Teresa Donnahoo owns Elevated Forensic Nursing and is a practicing forensic nurse living in Valley County, Idaho. She got her start in forensics in CA practicing in LA and Orange counties with Forensic Nurse Specialists. Teresa lives with her husband and 3 children, 2 fur babies and 2 turtles. She enjoys any activity on or in the lake and creating art projects in her spare time.
Contact:
Elevatedforensicnursing.com
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