by Jeanne Parrish DNP, LNP, FNP-C, EMT-P, Forensics Coordinator/Nurse Practitioner, University of Virginia Medical Center Forensics Team
What is a forensic nurse? The International Association of Forensic Nurses (IAFN) has this description “a forensic nurse is a Registered or Advanced Practice Nurse who has received specific education and training. Forensic nurses provide specialized care for patients who are experiencing acute and long-term health consequences associated with victimization or violence, and/or have unmet evidentiary needs relative to having been victimized or accused of victimization. In addition, forensic nurses provide consultation and testimony for civil and criminal proceedings relative to nursing practice, care given, and opinions rendered regarding findings. Forensic nursing care is not separate and distinct from other forms of medical care, but rather integrated into the overall care needs of individual patients.” I describe it to my patients as a kindergarten playground with two sandboxes. Medical in one and legal in the other, and we have one foot in both, bridging the two.
As a healthcare provider, my primary objective is the health and well-being of my patient. Not just the immediate physical concerns, but the long term effects – physically, psychologically, and spiritually. As an example, 90% of patients whom experience sexual assault will experience Post-Traumatic Stress Disorder in the weeks after, more than ANY other violent crime (Rape, Abuse, and Incest National Network). Many victims will turn to unhealthy coping mechanisms such as drugs and alcohol in additional to the mental health effects and devolve into a spiral of poor coping strategies. One of our primary objectives is to interrupt that path at the beginning and help them become survivors instead of victims. That starts by simply believing the patient, and providing trauma informed care. We partner with multiple area resources such as SARA, SHE, Foothills Child Advocacy Center, ReadyKids, and Region 10 to provide ongoing support and care after the forensic exam. In many ways, this is the most important thing we do.
My second objective is to gather evidence of the crime from their bodies, which is now a crime scene. This includes things like DNA swabs, foreign material such as hair or fibers, and fingernail scrapings in addition to detailed documentation and photography of their injuries as well as signs and symptoms. This evidence can be used in the prosecution of the crime, if the victim chooses to report to law enforcement. Child abuse, elder abuse, and penetrating trauma are mandated reporting events. Sexual assault, domestic violence, and strangulation are not. Patients have the option of not involving law enforcement in these cases. This is critical because of our first objective – the health and well-being of the patient. Law enforcement involvement can be a barrier to accessing care after an event, so having the option of getting this critical care without involving law enforcement is huge from the perspective of ensuring the patient’s health and well-being.
We started out in the early 1990s as a Sexual Assault Nurse Examiner (SANE) Team, staffed by nurses who had completed SANE training and agreed to be on call to respond to cases as needed. I joined the Team in 2010 and completed the training to be a SANE-A, which is specific to sexual assault of adults and adolescents. In 2012, I completed SANE-P training, which is specifically for pediatric sexual abuse. I continued with my education, completing my MSN and becoming a Nurse Practitioner (NP), and then my doctorate, which was focused on Forensics. Even though my primary employment was as an NP outside of UVA, I maintained my position on the SANE Team and continued to take a significant amount of call hours.
In 2016, the decision was made to expand the SANE Team into a comprehensive Forensics Team and in order to do that a full-time coordinator who could also see patients as a provider was needed. As I was an NP with 6 years of experience with the Team at that time as well as a doctorate degree focused on Forensics, I applied for the position and began my current role in January of 2017.
In April of 2017, we expanded our protocols and transitioned from a SANE Team to a comprehensive Forensic Team. We currently see patients whom have experienced child abuse (physical and sexual), elder abuse, domestic violence, strangulation, and sexual assault. Our services are available 24/7 in the Emergency Department (ED) for emergent situations, as well as anywhere within the inpatient care areas. We will also respond to any main campus outpatient clinic if there is a patient there whom needs services and is unable or unwilling to go to the ED. We have two outpatient clinics specifically for our pediatric populations, the SAFE Clinic at Battle and the Foothills Child Advocacy Center Medical Clinic.
Since expanding our services, we have seen a steady increase in our patient volumes. In 2016, we had a total of 72 cases. In 2017 – 195 cases, 2018 – 309 cases, and 2019 – 386 cases. So far in 2020 we are matching our 2019 volumes despite very low numbers for several months after COVID hit in March.
Our pediatric patients are unique in that it is uncommon that an event gets reported immediately. If it is, they absolutely should present to the ED immediately. However, children tend to disclose later — sometimes even years later — if at all, particularly for sexual abuse. We know that it is important these children get a forensic medical exam regardless of how much time has passed since the event occurred. However, it does not have to occur in the ED as it is not emergent and can at times be harmful. In these types of cases, the forensic interview of the child is critical, and needs to be as unbiased as possible. Asking the child questions about what happened, or discussing what happened in front of the child will bias the interview, and these activities are an important part of a medical exam. It is therefore better in these cases to have the medical exam after the forensic interview.
Recognizing going to the ED for services was a barrier to many families in seeking this important care, we established the SAFE Clinic at Battle and began seeing non-emergent child abuse cases there in September of 2018. We see sexual abuse patients, patients with minor injuries from suspected physical abuse, as well as follow-up visits after inpatient non-accidental trauma work-ups.
In March of 2020 we established the Foothills Child Advocacy Center Medical Clinic. Foothills is the site for many forensic interviews, and we recognized the need to provide services on site to reduce the amount of driving and coordination of care that needed to occur during a highly emotional time for these families. Children can have a medical exam on site at Foothills immediately after their forensic interview as long as they don’t require any laboratory or radiological testing.
It is important to note that we see pediatric patients in all of our case categories, except elder abuse. Thus far in 2020, 55% of our patients have been under the age of 18. Further, children in a home where domestic violence is occurring are just as affected as the direct recipient of the violence. So even when the patient is an adult, if she is a mother we are still providing care that will directly affect the children.
We are not in a silo and we don’t function alone. We try to work in the community as much as possible. Each situation is unique. Even child abuse cases are different, depending on the age of the child. I consult with CPS a lot. Our team serves Charlottesville, Albemarle, Nelson, Buckingham, Fluvanna, Louisa, Orange, Greene, and Madison.
Since 2017, I’ve been a part of the multidisciplinary team (MDT) meetings held monthly in every jurisdiction. These monthly meetings are hosted by the Commonwealth Attorney’s Office of the jurisdiction and there are representatives from CPS, law enforcement, forensic specialists such as myself, social workers, therapy services, and court services and we discuss every child abuse case. Bringing this group of people together has been incredible because everyone has a different perspective, and it allows us to collaborate across disciplines as our standard work. Our goal is to provide the optimal services we can for each family. These meetings occur until the case is completely resolved. Sometimes that is a month, sometimes it is over a year.
Here is what I tell my nurses when we are training: you have to focus on the small wins. So rarely do these cases go to court and get criminal justice intervention. Only 1 in 16 sexual assaults make it to court. That’s a big reason why patients don’t want to report. We are starting to see a cultural shift – like the #MeToo movement – but we’re not completely there yet. Our focus is on the patient – support, education, and empowerment.
We focus on the patient. We know that these traumas are devastating. The most important thing we can do is set them on the path to be a survivor, not a victim. We have to believe them. It sounds so simple but it’s so important. Patients say things like, “I knew better” and it is our job to let them know that they are not responsible for anyone else’s choices or behaviors.
In a domestic violence situation, I never tell a person they must leave. It is often safer to go back home, make a plan, and get resources in place. Almost 50% of domestic homicides happen when a woman leaves the home. We have to be so very careful.
For pediatric patients, we need to concentrate on what is best for the patient. Sometimes that means removal from the home. Removal is never easy and it has significant effects on the child as well as the family. Sometimes what is best means keeping the family intact and putting resources and support in place to educate the parents and prevent further injury to the child. Each case is unique and complex and participating in the multidisciplinary process truly ensures the best possible response and outcome for these families.
Our goal is to make a connection with the patient. Our focus is on education. They need to make the decision for themselves. Sometimes it’s just explaining the process and giving them options and telling them there is no right or wrong choice. We tell them that we are here when they’re ready. Sometimes it works and sometimes it doesn’t. Sometimes they don’t report and that’s okay, as long as they are willing to reach out to get support to process their trauma, build resiliency and ensure the long-term health and well-being not just of themselves, but of their families, too.
We can’t change the fact that the trauma has happened. There will always be violence and trauma in the world. So, we give patients the best tools we can to combat that violence and trauma – to become survivors.
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