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Forensic nursing: An emerging competency for contemporary practice
Teaching and Learning in Nursing (2010) 5, 98–103
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Forensic nursing: An emerging competency for contemporary practice1 Charman L. Miller MSN, ANP, BC⁎, Camille Leadingham MSN, ANP, BC, CNE, James R. McKean MA, Charlotte McManus MSN, RN Ohio University-Chillicothe, PO Box 629, Chillicothe, OH 45601, USA KEYWORDS: Forensic nursing; Law enforcement technology; Interdisciplinary course
Abstract Forensic nursing is an emerging specialty field of practice for nurses. Nurses have been challenged to share responsibility with the legal system to augment the resources available to patients with liability-related injuries, crime victims, and perpetrators or suspects in police custody. These challenges have prompted collaboration between faculty from nursing and law enforcement technology criminal justice to develop an introductory forensic nursing course utilizing an interdisciplinary teaching approach. Health care and the law often become enmeshed during the critical moments when patient care supersedes the concern for social justice. This interdisciplinary course was designed to increase awareness and practical application of principles of forensic science in the professional nurse. This article describes an interdisciplinary collaboration focusing on student and faculty perceptions of utilizing an interdisciplinary approach for teaching introductory forensic nursing principles. © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction Forensic nursing is an emerging specialty field in nursing that deals with the “population of people whose lives have been affected by societal violence” (Goll-McGhee, 1999, p. 8). The contemporary rate of violent crimes including rape, assault, and murder in the United States is alarming. The Disaster Center (n.d.) statistics reflect that over 1.4 million violent crimes were reported in our country in 2007. Although the statistics are alarming, the issue more relevant to professional nursing is the fact that each of those crimes involves at least one human victim in need of care. In contrast to the more traditional view of the term forensic as pertaining
1
This study was presented at the Association for University Regional Campuses of Ohio (AURCO) Annual Conference, Dayton, Ohio, May 2008, and Ohio Association of Two Year Colleges (OATYC) Annual Conference, Akron, Ohio, October 2007. ⁎ Corresponding author. E-mail address: [email protected]
exclusively to death investigation, the contemporary reality is that forensic nursing focuses on the living forensic patient. The living forensic patient includes those patients who are survivors of civil- or criminal-liability-related injuries. This may include survivors of sexual assault, interpersonal abuse, motor vehicle accidents, pedestrian accidents, work- or product-related injuries, medical negligence, prisoners, and alleged perpetrators or suspects in need of nursing care. With increasing attention to the fact that violence is a preventable public health problem, contemporary nurses must possess the knowledge and skills required to competently assess violent crime victims, implement appropriate interventions, and make crucial referrals (Freedburg, 2008; Sekula, 2005). The traditional relationship between law enforcement and nursing has often been one of conflict rather than collaboration in medicolegal cases. Law enforcement has often perceived nurses as obstructing justice as they function in their care and advocacy roles; likewise, nursing has perceived law enforcement as invading the privacy of patients or interfering with medical care in the process of
1557-3087/$ – see front matter © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2010.01.001
Forensic nursing investigation. Forensic nursing leaders and advocates recognized this gap between the criminal justice and health care systems and recognized the unique potential of nurses to close this gap. The result has been an increased awareness of the need for standards of care in forensic nursing practice, advanced training for nurses who frequently come into contact with forensic patients, and an interdisciplinary approach to providing quality care to forensic patients with medicolegal needs. This trend has led nurse educators to begin discussion about the incorporation of these concepts into nursing curricula (Freedburg, 2008). This article describes an interdisciplinary collaboration between associate degree nursing (ADN) faculty and law enforcement technology (LET) faculty focusing on student and faculty perceptions of utilizing an interdisciplinary approach for teaching introductory forensic nursing principles.
2. Review of the literature 2.1. Forensic nursing education Forensic nursing has been defined as “the application of forensic aspects of health care combined with the biopsychosocial education of the RN in the scientific investigation and treatment of trauma, and/or death of victims and perpetrators of violence, criminal activity, and traumatic accidents within the clinical community” (Lynch, 2006, p3). The primary role of the forensic nurse remains nursing, with the ancillary forensic specialty functioning as a bridge to the criminal justice system and forensic science practitioners. The evolution of forensic nursing in America can be traced to the recognition of forensic nursing as a scientific discipline in 1991 by the American Academy of Forensic Sciences and the formation of the International Association of Forensic Nurses (IAFN) in 1992. Historically, the evolution of the forensic nurse role was stimulated by interdisciplinary role conflict between police officers and nurses involving the collection of critical evidence during criminal investigations. Through lack of awareness of methods for preserving and/or collecting evidence from living victims, nurses often inadvertently contaminated or destroyed potential medicolegal evidence in the process of providing nursing care (Stevens, 2004, Freedburg, 2008). The American Nurses Association's Congress of Nursing Practice formally adopted forensic nursing standards for practice in 1995, creating the structural framework necessary to guide health care practitioners and criminal justice practitioners in the effective utilization of this emerging specialty. Nurses remain the most common first point of contact for the patient and are thus uniquely positioned to assess traumarelated injuries involving child abuse, elder abuse, sexual assault, domestic violence, or other incidents of interest to law enforcement (Kramer, 2002). Accordingly, the Joint Commission on Accreditation of Healthcare Organizations (n.d.) recognizes the importance of proper assessment of
99 injuries by health care practitioners and recommends a basic introduction to forensic science for all health care providers. Through the efforts of nurse leaders and forensic nursing advocates, educational opportunities for professional nurses have expanded to include care of living forensic patients. Formally, the University of Texas at Arlington is credited with establishing the first formal educational program in forensic nursing (Lynch, 1995). Currently, there are a growing number of certificate programs for forensic nursing and graduate programs with a focus on forensic nursing. Also illustrating the growing attention to the need for forensic nursing education is the newly published Forensic Nursing: Scope and Standards of Practice (American Nurses Association & IAFN/ANA, 2009). This document is the result of an international volunteer initiative to develop standardized scope of practice and practice standards for forensic nurses. Despite the ongoing recognition of the need for this type of training, it has been identified that there is a general lack of basic preparation of new nurses entering the workforce to adequately care for forensic patients (Woodtli & Breslin, 1996; Woodtli & Breslin, 2002). Healthy People 2010 (U.S. Department of Health and Human Services, 2000), the government's blueprint for improving health care and quality of life, identified the need for reducing violence and injuries related to violence, rape, and sexual assault (Printing Office, n.d.). Both Healthy People 2010 (U.S. Department of Health and Human Services, 2000) and the World Report on Violence and Health (World Health Organization, 2002) suggest increasing health promotion and disease prevention education into nursing and medical school curricula as a strategy to reduce the incidence and impact of violence in society. Today, with the increase in personal violence and trauma cases experienced by health care practitioners, terrorist threats, and potential for weapons of mass destruction, interdisciplinary collaboration in institutions of higher education remains a viable opportunity to extend critical forensic patient care knowledge to entry-level nurses.
2.2. Interdisciplinary teaching in nursing The literature is replete with examples of interdisciplinary or cross-disciplinary collaboration to the mutual benefit of faculty and students (Erkel, Nivens & Kennedy, 1995; Watson, 1996; McDaniel & Robertson, 1997; Ross, Hoff, McComas, Carswell, Bunn and Coutu-Wakulcyzk, 1998). Billings and Halstead (2005) stated that successful interdisciplinary course development and implementation depend on “faculty's commitment to the goal of interdisciplinary practice, professional respect and role clarity” (p. 327). In specific regard to forensic nursing principles, Ross et al. (1998) stated that “nurses and other health care professionals have only recently acknowledged their pivotal role in helping stem the tide of violence” (p. 17). This interdisciplinary collaborative pursuit to provide contemporary ADN students with the practical and applied knowledge necessary to
100 provide safe and effective care to patients with medicolegal needs was developed based on a review of the literature pertaining to interdisciplinary pedagogy. Nikitna (2006) examined interdisciplinary strategies from an integrative framework based on the purpose of the inquiry. Nikitna's system of classification considers the primary disciplinary epistemology as the starting point for developing “…the mechanism of connection, the questions asked, the nature of the inquiry that takes place, and the standards of validation applied” (p. 252). From this starting point, Nikitna suggested three primary interdisciplinary teaching strategies—contextualizing, conceptualizing, and problem centering. Problem centering emerged as the primary teaching strategy for guiding the development of this interdisciplinary course based on the applied disciplines of nursing and law enforcement. According to Nikitna (2006), “problemcentring is aimed at generating tangible outcomes and change. The pragmatic real-life orientation of this pedagogy…most readily captures the spirit of the applied sciences” (p. 263). The authors' goal in developing this interdisciplinary teaching model was to positively enhance the application of forensic nursing principles by entry-level nurses to promote positive change as regards the competence of care for patients with medicolegal needs. The description of course learning activities and student and course evaluations that follow are in consideration of the cautions of Colarossi and Forgey (2006) for additional evaluative processes when an interdisciplinary teaching approach is utilized to determine whether “…students transfer new knowledge and attitudes to behavioral skills in practice” (p. 320).
3. Interdisciplinary collaboration 3.1. Course development In the context of the current health care environment, awareness of the increasing number of ADN graduates accepting positions in emergency room, intensive care, and trauma settings where contact with forensic patients is frequent; recognition of the need for an enhanced focus on assessing, intervening, and appropriately referring forensic patients in all health care settings; and recognition of the value of interdisciplinary collaboration, law enforcement, and nursing faculty at Ohio University-Chillicothe collaborated to design and deliver a course in introductory forensic nursing concepts for students enrolled in the ADN program. The faculty conceptualized, developed, and delivered the course to examine the fundamental interrelationships between nursing and forensic science. Course topics were selected based on a review of ADN student program outcomes, review of the literature pertaining to forensic nursing, and current and future nursing practice trends. Table 1 shows the course content, beginning with an introduction to law enforcement and forensic nursing
C.L. Miller et al. practice on Week 1. A review of the IAFN (2002) Web site is visited, with class discussion of standards for forensic nursing practice and the role that nurses play in facilitating an effective investigation when violence touches the lives of clients. Week 2 integrates concepts and theories of forensic nursing, with evidence collection and preservation. Week 3 discusses human rights and homeland security. Weeks 5, 6, and 7 transition the student into elder abuse, sexual assault, child abuse, and domestic violence content, with integration of vital assessment, evidence collection methods, and implementation of appropriate nursing interventions for these types of clients. Week 8 discusses forensics within the hospital and safety issues faced by nurses caring for all victims of violence. Week 9 discusses depositions and courtroom testimony, with Week 10 ending the quarter with a mock trial.
3.2. Learning activities Billings and Halstead (2005) defined learning activities as student-centered activities that serve as a vehicle to facilitate the student's acquisition of the desired knowledge, competencies, behaviors, and values specified by the course. The faculty utilized several different learning activities beginning day 1, with students viewing a short media crime scene and interacting with peers and faculty to apply law enforcement and forensic nursing principles to systematically assess the findings and apply the steps of the nursing process to generate assumptions as to what and how the violent act had occurred. The crime scene was faculty developed based on actual-life crime scene data. Crime scene simulation was utilized on Week 2. Students received a 90-minute lecture on crime scene analysis and basic evidence collection. Upon completion of the lecture content, students traveled to the LET building on campus, where three simulated crime scenes awaited them. They were placed in groups of five and had 40 minutes to survey the scene and victim; dust for fingerprints; gather clothing, bullets, or weapons as evidence; and document their findings. Faculty served as team leaders by facilitating student's needs, answering questions, and clarifying content. A 20-minute debriefing took place to reveal the group's findings. Several guest lecturers were utilized to enhance course content. For example, the director of the local child abuse coalition, a pediatrician, spoke about her personal experiences and shared insight into local agencies that facilitate help for these types of victims. A past graduate of the ADN program, who has become a sexual assault nurse examiner, spoke on her role and demonstrated the sexual assault kit and its impact on case outcomes. Students participated in a brief simulation of hymen assessment in the child and adult with a focus on identifying soft tissue damage, role-played nursing interview strategies with alleged victims of sexual assault, and completed sample body map documentation of soft tissue trauma on a mannequin.
Forensic nursing Table 1
101
Weekly course schedule and instructor assignments Course syllabus
Week 1
Instructor
Content
Leadingham
Introduction; course requirements and syllabus Introduction to forensics in health care—the specialty of forensic nursing Chapters 1 and 2 Pages 1–12, 13–17 Introduction to criminal investigation and forensic science Blackboard student handouts In-class exercise: case study Concepts and theory of forensic nursing Chapter 3 Pages 19–28 Evidence collection and preservation Chapters 10 and 11 Pages 91–108 Blackboard student handouts In-class exercise: case study Human rights Chapter 4 Pages 33–42 Homeland security and torture Group activities Blackboard student handouts Elder abuse and sexual assault Chapters 25 and 26 Pages 271–304 Midterm examination Guest speaker Child abuse Domestic violence Chapters 23 and 24 Pages 249–258, 260–269 Evidence collection methods Child abuse and domestic violence Chapter 53 Pages 570–577 Guest lecturer Forensics in the hospital/Occupational health and safety issues Chapters 52 and 54 Pages 559–569, 578–592 Depositions and courtroom testimony Chapter 42 Pages 452–456 Mock trial assignments Mock trial
McKean
Week 2
Leadingham
McKean
Week 3
McManus
McKean
Week 4
Miller
Week 5
Miller
Week 6
Miller
Week 7
McKean
Week 8
McManus
Week 9
All faculty
Week 10
All faculty
The faculty felt that, based on their own clinical experience and the literature review, students needed a greater awareness related to legal and ethical responsibilities in the care of victims of violence. The mock trial was derived from actual case material involving a domestic violence situation that escalated to partner violence with treatment at a local emergency room with resulting charges to the spouse. Beck (1999) stated that mock trials provide teachers with an excellent strategy for integrating a variety of skills, such as oral expression and listening, questioning and persuasion, and role-playing. Trial preparation began Week 9 as students were introduced to the fundamental principles of courtroom conduct and deliberations. The case was introduced, and students volunteered for roles in
the trial, such as attorneys, defendant, witnesses, family members, emergency room physician, and nurse. The faculty served as the judges, and the rest of the class not directly involved in a role became jurors. Students had a week to formulate their plan and apply principles learned from the course to their role. On Week 10, the students arrived to a simulated courtroom, with the faculty judges presiding. The 3-hour class session unveiled that students had gained an increased awareness of legal terms and courtroom procedure process. Postsimulation discussion indicated that students also perceived themselves as gaining a greater understanding of the role of the nurse and the complexity of the nurses' role as advocate and witness.
102 Table 2
C.L. Miller et al. Standard course evaluation: questions and means
Questions
M (n = 24)
Overall rating of the course Clarity of instructor's oral delivery Instructor's enthusiasm for the course Thoroughness of instructor's preparation Instructor's openness to student ideas Instructor's ability to motivate interest Clarity of course objectives Clarity of grading criteria Correlation of examinations and course content Intellectual challenge of the course
4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9
3.3. Evaluation of learning activities Evaluation of teaching and learning is a continuous process for both faculty and students (Billings & Halstead, 2005). This course utilized several learning activities that engaged students actively and challenged them to think critically to apply principles of content to simulated cases. Formative feedback was obtained through minute papers, muddiest point, and verbal feedback. The findings revealed that students enjoyed having the opportunity to immediately apply principles learned in class to simulated scenarios and cases. Summative evaluation of the course was assessed utilizing two case study group examinations and a mock trail. For group examinations, students were randomly assigned to groups of four and collaborated on a short-answer client-case situation that encompassed data from the course. Each group case study was composed of a situation and photos of the victim or crime scene. Students had to utilize the nursing process and apply core concepts from the course to answer the essay-style questions. In addition, students demonstrated their competency by conducting the mock trial involving courtroom testimony and presentation of evidence, including the principles of evidence collection that were utilized. Ohio
Table 3
University requires a standardized course evaluation tool to be utilized. The tool uses a 5-point Likert scale for students to rate the course. Table 2 contains a sample of student evaluation data collected from this tool. In addition, students are provided written-comment surveys pertaining to the strengths and weaknesses of the course and any suggestions for further course offerings. Analysis of the written comments from this courses revealed that students enjoyed the interdisciplinary approach and found the simulations and guest speakers to be a major strength of the course. Students also felt that they were much better prepared to assess, identify, intervene, and refer victims of crime in health care settings as a result of the course. Students also felt that gaining an understanding of the process of collaboration between the health care team and law enforcement was beneficial to future practice. There were no written comments pertaining to course weaknesses, but suggestions for future course offerings included incorporating additional simulations. Table 3 contains sample student comments to the coursespecific evaluation questions. The faculty participating in this course reported experiencing a sense of collaboration and the belief that the interdisciplinary educational approach enriched the learning in the courses beyond that which could have been provided with an exclusively nursing faculty. Faculty concurred that the interdisciplinary collaboration of the faculty modeled the interdisciplinary approach needed to provide care to forensic patients.
4. Plans This collaboration was an overwhelmingly positive experience for faculty and students. The faculty have reviewed student comments from the course evaluations and have begun planning for expansion and improvement of the course. Specifically, utilization of expanded interdisci-
Standard course evaluation: themes and sample student comments
Themes
Sample student comments (n = 24)
Interdisciplinary collaboration
• “I learned how to effectively communicate with members of law enforcement to make sure my patients get the care and the justice they deserve.” • “Working with law officers and other healthcare team members to provide safety and comfort for the patient.” • “I learned how important it is to work as a team to make sure that patients don't just get good nursing care but also to look out for them from a legal sense.” • “I feel a lot better about documenting assessment findings on victims or suspected victims. I know my responsibilities as a professional nurse and what types of cases I need to make sure get reported to police.” • “I realize how important my documentation is to a patient's potential legal case. I will be a lot more careful to document with this in mind.” • “I liked getting the chance to use a body map for documentation. This really makes it easier to remember what the patient's injuries looked like if you had to review it after a while has passed.” • “I had no idea how specific I need to be with collecting evidence from victims. This was eye-opening!” • “I learned the signs to be alert for, how to trust my own suspiciousness factor, and how to properly collect evidence and subjective data (interviewing).” • “I learned what to do when I have a forensic patient—the first thing to do, steps to take to make sure evidence is preserved even if the patient has serious physiological needs that take priority at the initial point of contact.”
Documentation
Data collection/ Assessment
Forensic nursing plinary simulations including violence screening with interviewing and documentation techniques is being developed, utilizing faculty and students from additional disciplines such as Spanish and deaf studies. Field observation experiences may be planned for students in forensic nursing settings, including correctional facilities, family court, Job and Family Services, and domestic violence shelters. The new Forensic Nursing: Scope and Standards of Practice (IAFN/ANA, 2009) will also be used as a guideline for future course content revision.
5. Conclusion Nursing faculty must respond to the tremendous negative impact that violence and victimization have on public health. The physical effects of violence can be fatal or disabling, and the emotional effects can be lifelong, including depression, substance abuse, and somatic complaints for which victims require repeated medical care and assistance (Coker, Smith, Bethea, King & Mckeown, 2000). Modeling an interdisciplinary approach to care of forensic patients can foster understanding and respect between nursing and law enforcement professionals. Emergency response planning, including the use of Disaster Medical Assistance Team and Disaster Mortuary Operational Response Team, will be enhanced by the inclusion of forensic nurse specialists during times of national crisis. The cooperation and collaboration between the nursing and criminal justice disciplines during the investigation of local crimes such as sexual assault, elder abuse, and domestic violence will only strengthen as the disciplines merge advances in forensic science. This educational collaboration provided further support for some of the many positive effects that interdisciplinary teaching can provide. Additional research is needed to further explore and evaluate interdisciplinary teaching in undergraduate nursing. Incorporation of university-level courses for professional nurses that introduce and clarify basic to advanced forensic nursing principles has the potential to fortify the collaborative relationship forged between law enforcement and nursing in the mutual pursuit of truth, justice, and equity.
References American Nurses Association & International Association of Forensic Nurses. (2009). Forensic nursing scope and standards of practice. Silver Spring, MD: Nursebooks.org. Beck, C. (1999). Francine, Kerplunk, and the golden nugget—conducting mock trials and debates in the classroom. The Societal Studies, 90(2), 78−84.
103 Billings, D., & Halstead, J. (2005). Teaching in nursing, 2nd ed. Philadelphia: W.B. Saunders. Coker, A., Smith, P., Bethea, L., King, M., & Mckeown, R. (2000). Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine, 9, 451−457. Colarossi, L., & Forgey, M. A. (2006). Evaluation study of an interdisciplinary social work and law curriculum for domestic violence. Journal of Social Work Education, 42(2), 307−323. Disaster Center. Retrieved November, 2008, from http://www.disastercenter. com/crime/uscrime.htm. Erkel, E. A., Nivens, A. S., & Kennedy, D. E. (1995). Intensive immersion of nursing students in rural interdisciplinary care. Journal of Nursing Education, 34(1), 37−41. Freedburg, P. (2008). Integrating forensic nursing into the undergraduate nursing curriculum: A solution for a disconnect. Journal of Nursing Education, 47(5), 201−208. Goll-McGhee, B. (1999). The role of the clinical forensic nurse in critical care. Critical Care Nursing Quarterly, 22(1), 8−18. International Association of Forensic Nurses. (2002). What is forensic nursing? Retrieved September 17, 2009, from http://www.iafn.org/ displaycommon.cfm?an=1&subarticlenbr=137. Joint Commission on Accreditation of Healthcare Organizations. (n.d.). Retrieved August 15, 2007, from http://www.jacho.org. Kramer, A., (2002). Domestic violence: How to ask and how to listen. Nursing Clinics of North America, 37, 180–210, ix. Lynch, V. (1995). Forensic nursing: What's new? Psychosocial Nursing, 33(9), 1−7. Lynch, V. (2006). Forensic Nursing. St. Louis: Elsevier. McDaniel, A., & Robertson, K. (1997). Teaching collaboration skills to baccalaureate nursing students: An interdisciplinary teaching project. Journal of Nursing Education, 36(6), 271−273. Nikitna, S. (2006). Three strategies for interdisciplinary teaching: Contextualizing, conceptualizing, and problem-centring. Journal of Curriculum Studies, 38(3), 251−271. Ross, M. M., Hoff, L. A., McComas, J., Carswell, A., Bunn, H., & Coutu-Wakulcyzk, G. (1998). Strengthening the interdisciplinary education of nurses in violence prevention, detection, and intervention. Nurse Educator, 23(3), 17−18. Sekula, L. K. (2005). The advance practice nurse in the emergency department. Topics in Emergency Medicine, 27(1), 5−14. Stevens, S. (2004). Cracking the case: Your role in forensic nursing. Nursing, 34(11), 54−56. U.S. Department of Health and Human Services. (2000). Access to quality health services. Health promotion and disease prevention objectives. Washington, D.C.: U.S. Government. Printing Office. Retrieved September 9, 2009 from http://www. healthypeople.gov/Document/. Watson, J. (1996). From discipline specific to “infer” to “multi” to “transdisciplinary” health care education and practice. Nursing & Health Care: Perspectives on Community, 17(2), 90−91. Woodtli, M. A., & Breslin, E. T. (1996). Violence-related content in the nursing curriculum: A national study. Journal of Nursing Education, 35, 173−182. Woodtli, M. A., & Breslin, E. T. (2002). Violence-related content in the nursing curriculum: A follow-up national survey. Journal of Nursing Education, 41, 340−348. World Health Organization. (2002). World report on violence and health: Abstract. Geneva: Author Retrieved September 1, 2009, from http:// www.who.int/violnece_injury_prevention/violence/worls_report/en/ abstract_en.pdf.
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Forensic nursing: An emerging competency for contemporary practice1 Charman L. Miller MSN, ANP, BC⁎, Camille Leadingham MSN, ANP, BC, CNE, James R. McKean MA, Charlotte McManus MSN, RN Ohio University-Chillicothe, PO Box 629, Chillicothe, OH 45601, USA KEYWORDS: Forensic nursing; Law enforcement technology; Interdisciplinary course
Abstract Forensic nursing is an emerging specialty field of practice for nurses. Nurses have been challenged to share responsibility with the legal system to augment the resources available to patients with liability-related injuries, crime victims, and perpetrators or suspects in police custody. These challenges have prompted collaboration between faculty from nursing and law enforcement technology criminal justice to develop an introductory forensic nursing course utilizing an interdisciplinary teaching approach. Health care and the law often become enmeshed during the critical moments when patient care supersedes the concern for social justice. This interdisciplinary course was designed to increase awareness and practical application of principles of forensic science in the professional nurse. This article describes an interdisciplinary collaboration focusing on student and faculty perceptions of utilizing an interdisciplinary approach for teaching introductory forensic nursing principles. © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
1. Introduction Forensic nursing is an emerging specialty field in nursing that deals with the “population of people whose lives have been affected by societal violence” (Goll-McGhee, 1999, p. 8). The contemporary rate of violent crimes including rape, assault, and murder in the United States is alarming. The Disaster Center (n.d.) statistics reflect that over 1.4 million violent crimes were reported in our country in 2007. Although the statistics are alarming, the issue more relevant to professional nursing is the fact that each of those crimes involves at least one human victim in need of care. In contrast to the more traditional view of the term forensic as pertaining
1
This study was presented at the Association for University Regional Campuses of Ohio (AURCO) Annual Conference, Dayton, Ohio, May 2008, and Ohio Association of Two Year Colleges (OATYC) Annual Conference, Akron, Ohio, October 2007. ⁎ Corresponding author. E-mail address: [email protected]
exclusively to death investigation, the contemporary reality is that forensic nursing focuses on the living forensic patient. The living forensic patient includes those patients who are survivors of civil- or criminal-liability-related injuries. This may include survivors of sexual assault, interpersonal abuse, motor vehicle accidents, pedestrian accidents, work- or product-related injuries, medical negligence, prisoners, and alleged perpetrators or suspects in need of nursing care. With increasing attention to the fact that violence is a preventable public health problem, contemporary nurses must possess the knowledge and skills required to competently assess violent crime victims, implement appropriate interventions, and make crucial referrals (Freedburg, 2008; Sekula, 2005). The traditional relationship between law enforcement and nursing has often been one of conflict rather than collaboration in medicolegal cases. Law enforcement has often perceived nurses as obstructing justice as they function in their care and advocacy roles; likewise, nursing has perceived law enforcement as invading the privacy of patients or interfering with medical care in the process of
1557-3087/$ – see front matter © 2010 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.teln.2010.01.001
Forensic nursing investigation. Forensic nursing leaders and advocates recognized this gap between the criminal justice and health care systems and recognized the unique potential of nurses to close this gap. The result has been an increased awareness of the need for standards of care in forensic nursing practice, advanced training for nurses who frequently come into contact with forensic patients, and an interdisciplinary approach to providing quality care to forensic patients with medicolegal needs. This trend has led nurse educators to begin discussion about the incorporation of these concepts into nursing curricula (Freedburg, 2008). This article describes an interdisciplinary collaboration between associate degree nursing (ADN) faculty and law enforcement technology (LET) faculty focusing on student and faculty perceptions of utilizing an interdisciplinary approach for teaching introductory forensic nursing principles.
2. Review of the literature 2.1. Forensic nursing education Forensic nursing has been defined as “the application of forensic aspects of health care combined with the biopsychosocial education of the RN in the scientific investigation and treatment of trauma, and/or death of victims and perpetrators of violence, criminal activity, and traumatic accidents within the clinical community” (Lynch, 2006, p3). The primary role of the forensic nurse remains nursing, with the ancillary forensic specialty functioning as a bridge to the criminal justice system and forensic science practitioners. The evolution of forensic nursing in America can be traced to the recognition of forensic nursing as a scientific discipline in 1991 by the American Academy of Forensic Sciences and the formation of the International Association of Forensic Nurses (IAFN) in 1992. Historically, the evolution of the forensic nurse role was stimulated by interdisciplinary role conflict between police officers and nurses involving the collection of critical evidence during criminal investigations. Through lack of awareness of methods for preserving and/or collecting evidence from living victims, nurses often inadvertently contaminated or destroyed potential medicolegal evidence in the process of providing nursing care (Stevens, 2004, Freedburg, 2008). The American Nurses Association's Congress of Nursing Practice formally adopted forensic nursing standards for practice in 1995, creating the structural framework necessary to guide health care practitioners and criminal justice practitioners in the effective utilization of this emerging specialty. Nurses remain the most common first point of contact for the patient and are thus uniquely positioned to assess traumarelated injuries involving child abuse, elder abuse, sexual assault, domestic violence, or other incidents of interest to law enforcement (Kramer, 2002). Accordingly, the Joint Commission on Accreditation of Healthcare Organizations (n.d.) recognizes the importance of proper assessment of
99 injuries by health care practitioners and recommends a basic introduction to forensic science for all health care providers. Through the efforts of nurse leaders and forensic nursing advocates, educational opportunities for professional nurses have expanded to include care of living forensic patients. Formally, the University of Texas at Arlington is credited with establishing the first formal educational program in forensic nursing (Lynch, 1995). Currently, there are a growing number of certificate programs for forensic nursing and graduate programs with a focus on forensic nursing. Also illustrating the growing attention to the need for forensic nursing education is the newly published Forensic Nursing: Scope and Standards of Practice (American Nurses Association & IAFN/ANA, 2009). This document is the result of an international volunteer initiative to develop standardized scope of practice and practice standards for forensic nurses. Despite the ongoing recognition of the need for this type of training, it has been identified that there is a general lack of basic preparation of new nurses entering the workforce to adequately care for forensic patients (Woodtli & Breslin, 1996; Woodtli & Breslin, 2002). Healthy People 2010 (U.S. Department of Health and Human Services, 2000), the government's blueprint for improving health care and quality of life, identified the need for reducing violence and injuries related to violence, rape, and sexual assault (Printing Office, n.d.). Both Healthy People 2010 (U.S. Department of Health and Human Services, 2000) and the World Report on Violence and Health (World Health Organization, 2002) suggest increasing health promotion and disease prevention education into nursing and medical school curricula as a strategy to reduce the incidence and impact of violence in society. Today, with the increase in personal violence and trauma cases experienced by health care practitioners, terrorist threats, and potential for weapons of mass destruction, interdisciplinary collaboration in institutions of higher education remains a viable opportunity to extend critical forensic patient care knowledge to entry-level nurses.
2.2. Interdisciplinary teaching in nursing The literature is replete with examples of interdisciplinary or cross-disciplinary collaboration to the mutual benefit of faculty and students (Erkel, Nivens & Kennedy, 1995; Watson, 1996; McDaniel & Robertson, 1997; Ross, Hoff, McComas, Carswell, Bunn and Coutu-Wakulcyzk, 1998). Billings and Halstead (2005) stated that successful interdisciplinary course development and implementation depend on “faculty's commitment to the goal of interdisciplinary practice, professional respect and role clarity” (p. 327). In specific regard to forensic nursing principles, Ross et al. (1998) stated that “nurses and other health care professionals have only recently acknowledged their pivotal role in helping stem the tide of violence” (p. 17). This interdisciplinary collaborative pursuit to provide contemporary ADN students with the practical and applied knowledge necessary to
100 provide safe and effective care to patients with medicolegal needs was developed based on a review of the literature pertaining to interdisciplinary pedagogy. Nikitna (2006) examined interdisciplinary strategies from an integrative framework based on the purpose of the inquiry. Nikitna's system of classification considers the primary disciplinary epistemology as the starting point for developing “…the mechanism of connection, the questions asked, the nature of the inquiry that takes place, and the standards of validation applied” (p. 252). From this starting point, Nikitna suggested three primary interdisciplinary teaching strategies—contextualizing, conceptualizing, and problem centering. Problem centering emerged as the primary teaching strategy for guiding the development of this interdisciplinary course based on the applied disciplines of nursing and law enforcement. According to Nikitna (2006), “problemcentring is aimed at generating tangible outcomes and change. The pragmatic real-life orientation of this pedagogy…most readily captures the spirit of the applied sciences” (p. 263). The authors' goal in developing this interdisciplinary teaching model was to positively enhance the application of forensic nursing principles by entry-level nurses to promote positive change as regards the competence of care for patients with medicolegal needs. The description of course learning activities and student and course evaluations that follow are in consideration of the cautions of Colarossi and Forgey (2006) for additional evaluative processes when an interdisciplinary teaching approach is utilized to determine whether “…students transfer new knowledge and attitudes to behavioral skills in practice” (p. 320).
3. Interdisciplinary collaboration 3.1. Course development In the context of the current health care environment, awareness of the increasing number of ADN graduates accepting positions in emergency room, intensive care, and trauma settings where contact with forensic patients is frequent; recognition of the need for an enhanced focus on assessing, intervening, and appropriately referring forensic patients in all health care settings; and recognition of the value of interdisciplinary collaboration, law enforcement, and nursing faculty at Ohio University-Chillicothe collaborated to design and deliver a course in introductory forensic nursing concepts for students enrolled in the ADN program. The faculty conceptualized, developed, and delivered the course to examine the fundamental interrelationships between nursing and forensic science. Course topics were selected based on a review of ADN student program outcomes, review of the literature pertaining to forensic nursing, and current and future nursing practice trends. Table 1 shows the course content, beginning with an introduction to law enforcement and forensic nursing
C.L. Miller et al. practice on Week 1. A review of the IAFN (2002) Web site is visited, with class discussion of standards for forensic nursing practice and the role that nurses play in facilitating an effective investigation when violence touches the lives of clients. Week 2 integrates concepts and theories of forensic nursing, with evidence collection and preservation. Week 3 discusses human rights and homeland security. Weeks 5, 6, and 7 transition the student into elder abuse, sexual assault, child abuse, and domestic violence content, with integration of vital assessment, evidence collection methods, and implementation of appropriate nursing interventions for these types of clients. Week 8 discusses forensics within the hospital and safety issues faced by nurses caring for all victims of violence. Week 9 discusses depositions and courtroom testimony, with Week 10 ending the quarter with a mock trial.
3.2. Learning activities Billings and Halstead (2005) defined learning activities as student-centered activities that serve as a vehicle to facilitate the student's acquisition of the desired knowledge, competencies, behaviors, and values specified by the course. The faculty utilized several different learning activities beginning day 1, with students viewing a short media crime scene and interacting with peers and faculty to apply law enforcement and forensic nursing principles to systematically assess the findings and apply the steps of the nursing process to generate assumptions as to what and how the violent act had occurred. The crime scene was faculty developed based on actual-life crime scene data. Crime scene simulation was utilized on Week 2. Students received a 90-minute lecture on crime scene analysis and basic evidence collection. Upon completion of the lecture content, students traveled to the LET building on campus, where three simulated crime scenes awaited them. They were placed in groups of five and had 40 minutes to survey the scene and victim; dust for fingerprints; gather clothing, bullets, or weapons as evidence; and document their findings. Faculty served as team leaders by facilitating student's needs, answering questions, and clarifying content. A 20-minute debriefing took place to reveal the group's findings. Several guest lecturers were utilized to enhance course content. For example, the director of the local child abuse coalition, a pediatrician, spoke about her personal experiences and shared insight into local agencies that facilitate help for these types of victims. A past graduate of the ADN program, who has become a sexual assault nurse examiner, spoke on her role and demonstrated the sexual assault kit and its impact on case outcomes. Students participated in a brief simulation of hymen assessment in the child and adult with a focus on identifying soft tissue damage, role-played nursing interview strategies with alleged victims of sexual assault, and completed sample body map documentation of soft tissue trauma on a mannequin.
Forensic nursing Table 1
101
Weekly course schedule and instructor assignments Course syllabus
Week 1
Instructor
Content
Leadingham
Introduction; course requirements and syllabus Introduction to forensics in health care—the specialty of forensic nursing Chapters 1 and 2 Pages 1–12, 13–17 Introduction to criminal investigation and forensic science Blackboard student handouts In-class exercise: case study Concepts and theory of forensic nursing Chapter 3 Pages 19–28 Evidence collection and preservation Chapters 10 and 11 Pages 91–108 Blackboard student handouts In-class exercise: case study Human rights Chapter 4 Pages 33–42 Homeland security and torture Group activities Blackboard student handouts Elder abuse and sexual assault Chapters 25 and 26 Pages 271–304 Midterm examination Guest speaker Child abuse Domestic violence Chapters 23 and 24 Pages 249–258, 260–269 Evidence collection methods Child abuse and domestic violence Chapter 53 Pages 570–577 Guest lecturer Forensics in the hospital/Occupational health and safety issues Chapters 52 and 54 Pages 559–569, 578–592 Depositions and courtroom testimony Chapter 42 Pages 452–456 Mock trial assignments Mock trial
McKean
Week 2
Leadingham
McKean
Week 3
McManus
McKean
Week 4
Miller
Week 5
Miller
Week 6
Miller
Week 7
McKean
Week 8
McManus
Week 9
All faculty
Week 10
All faculty
The faculty felt that, based on their own clinical experience and the literature review, students needed a greater awareness related to legal and ethical responsibilities in the care of victims of violence. The mock trial was derived from actual case material involving a domestic violence situation that escalated to partner violence with treatment at a local emergency room with resulting charges to the spouse. Beck (1999) stated that mock trials provide teachers with an excellent strategy for integrating a variety of skills, such as oral expression and listening, questioning and persuasion, and role-playing. Trial preparation began Week 9 as students were introduced to the fundamental principles of courtroom conduct and deliberations. The case was introduced, and students volunteered for roles in
the trial, such as attorneys, defendant, witnesses, family members, emergency room physician, and nurse. The faculty served as the judges, and the rest of the class not directly involved in a role became jurors. Students had a week to formulate their plan and apply principles learned from the course to their role. On Week 10, the students arrived to a simulated courtroom, with the faculty judges presiding. The 3-hour class session unveiled that students had gained an increased awareness of legal terms and courtroom procedure process. Postsimulation discussion indicated that students also perceived themselves as gaining a greater understanding of the role of the nurse and the complexity of the nurses' role as advocate and witness.
102 Table 2
C.L. Miller et al. Standard course evaluation: questions and means
Questions
M (n = 24)
Overall rating of the course Clarity of instructor's oral delivery Instructor's enthusiasm for the course Thoroughness of instructor's preparation Instructor's openness to student ideas Instructor's ability to motivate interest Clarity of course objectives Clarity of grading criteria Correlation of examinations and course content Intellectual challenge of the course
4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9 4.9
3.3. Evaluation of learning activities Evaluation of teaching and learning is a continuous process for both faculty and students (Billings & Halstead, 2005). This course utilized several learning activities that engaged students actively and challenged them to think critically to apply principles of content to simulated cases. Formative feedback was obtained through minute papers, muddiest point, and verbal feedback. The findings revealed that students enjoyed having the opportunity to immediately apply principles learned in class to simulated scenarios and cases. Summative evaluation of the course was assessed utilizing two case study group examinations and a mock trail. For group examinations, students were randomly assigned to groups of four and collaborated on a short-answer client-case situation that encompassed data from the course. Each group case study was composed of a situation and photos of the victim or crime scene. Students had to utilize the nursing process and apply core concepts from the course to answer the essay-style questions. In addition, students demonstrated their competency by conducting the mock trial involving courtroom testimony and presentation of evidence, including the principles of evidence collection that were utilized. Ohio
Table 3
University requires a standardized course evaluation tool to be utilized. The tool uses a 5-point Likert scale for students to rate the course. Table 2 contains a sample of student evaluation data collected from this tool. In addition, students are provided written-comment surveys pertaining to the strengths and weaknesses of the course and any suggestions for further course offerings. Analysis of the written comments from this courses revealed that students enjoyed the interdisciplinary approach and found the simulations and guest speakers to be a major strength of the course. Students also felt that they were much better prepared to assess, identify, intervene, and refer victims of crime in health care settings as a result of the course. Students also felt that gaining an understanding of the process of collaboration between the health care team and law enforcement was beneficial to future practice. There were no written comments pertaining to course weaknesses, but suggestions for future course offerings included incorporating additional simulations. Table 3 contains sample student comments to the coursespecific evaluation questions. The faculty participating in this course reported experiencing a sense of collaboration and the belief that the interdisciplinary educational approach enriched the learning in the courses beyond that which could have been provided with an exclusively nursing faculty. Faculty concurred that the interdisciplinary collaboration of the faculty modeled the interdisciplinary approach needed to provide care to forensic patients.
4. Plans This collaboration was an overwhelmingly positive experience for faculty and students. The faculty have reviewed student comments from the course evaluations and have begun planning for expansion and improvement of the course. Specifically, utilization of expanded interdisci-
Standard course evaluation: themes and sample student comments
Themes
Sample student comments (n = 24)
Interdisciplinary collaboration
• “I learned how to effectively communicate with members of law enforcement to make sure my patients get the care and the justice they deserve.” • “Working with law officers and other healthcare team members to provide safety and comfort for the patient.” • “I learned how important it is to work as a team to make sure that patients don't just get good nursing care but also to look out for them from a legal sense.” • “I feel a lot better about documenting assessment findings on victims or suspected victims. I know my responsibilities as a professional nurse and what types of cases I need to make sure get reported to police.” • “I realize how important my documentation is to a patient's potential legal case. I will be a lot more careful to document with this in mind.” • “I liked getting the chance to use a body map for documentation. This really makes it easier to remember what the patient's injuries looked like if you had to review it after a while has passed.” • “I had no idea how specific I need to be with collecting evidence from victims. This was eye-opening!” • “I learned the signs to be alert for, how to trust my own suspiciousness factor, and how to properly collect evidence and subjective data (interviewing).” • “I learned what to do when I have a forensic patient—the first thing to do, steps to take to make sure evidence is preserved even if the patient has serious physiological needs that take priority at the initial point of contact.”
Documentation
Data collection/ Assessment
Forensic nursing plinary simulations including violence screening with interviewing and documentation techniques is being developed, utilizing faculty and students from additional disciplines such as Spanish and deaf studies. Field observation experiences may be planned for students in forensic nursing settings, including correctional facilities, family court, Job and Family Services, and domestic violence shelters. The new Forensic Nursing: Scope and Standards of Practice (IAFN/ANA, 2009) will also be used as a guideline for future course content revision.
5. Conclusion Nursing faculty must respond to the tremendous negative impact that violence and victimization have on public health. The physical effects of violence can be fatal or disabling, and the emotional effects can be lifelong, including depression, substance abuse, and somatic complaints for which victims require repeated medical care and assistance (Coker, Smith, Bethea, King & Mckeown, 2000). Modeling an interdisciplinary approach to care of forensic patients can foster understanding and respect between nursing and law enforcement professionals. Emergency response planning, including the use of Disaster Medical Assistance Team and Disaster Mortuary Operational Response Team, will be enhanced by the inclusion of forensic nurse specialists during times of national crisis. The cooperation and collaboration between the nursing and criminal justice disciplines during the investigation of local crimes such as sexual assault, elder abuse, and domestic violence will only strengthen as the disciplines merge advances in forensic science. This educational collaboration provided further support for some of the many positive effects that interdisciplinary teaching can provide. Additional research is needed to further explore and evaluate interdisciplinary teaching in undergraduate nursing. Incorporation of university-level courses for professional nurses that introduce and clarify basic to advanced forensic nursing principles has the potential to fortify the collaborative relationship forged between law enforcement and nursing in the mutual pursuit of truth, justice, and equity.
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