An 8-year-old boy is brought to the school nurse for sleeping in class. His teacher is concerned because every Monday, he is belligerent, distracted, and sleepy. The school nurse learns that he spends weekends with his father. His mother is concerned that the father is sexually abusing her son.
The visiting nurse is concerned about Margaret, an 82-year-old woman who lives with her granddaughter. On her most recent visit, the electricity was not working, and Margaret said she hadn't eaten in a few days. Margaret asked the visiting nurse not to "make a fuss" because she didn't want to upset her granddaughter.
A 19-year-old college student is brought to the campus clinic. The student says her friends made her come. She tells the nurse that two nights ago she woke up in the lobby of her building. Her clothes were on backwards and she wasn't wearing underwear. The last thing she remembers is drinking and dancing at a party in another residence hall.
All of the patients above have markers that have criminal or civil forensic medical implications and potential court involvement. Violence and crime unite two of the most powerful systems in the world: criminal justice and healthcare. These two systems work together to ensure that justice, health, and public safety are restored and maintained. Forensic nursing, a fast-growing specialty, sits at the intersection of violence and health. Forensic nursing is the application of nursing science to public or legal proceedings. The practice of forensic nursing facilitates connections among the healthcare, social services, and criminal justice systems to assist victims, perpetrators, and their families to receive assistance, services, and resources. While all nurses are familiar with the healthcare system, fewer nurses are familiar and comfortable with legal proceedings. Unfortunately, education and training in most nursing schools does not prepare nurses entering the general workforce to provide care to patients who are victims of violence, nor perpetrators of violence who require healthcare services.
CAUTION: As healthcare clinicians, we must all be aware of our own behavior when working with victims so that we do not cause secondary victimization through victim blaming. We must be able to set aside our own biases when working with patients.
Violence is a major factor in healthcare today. Regardless of where a nurse works within the healthcare system, he or she will care for many victims and perpetrators of violence throughout his or her career. Exploring how to care for these patients, and the theoretical underpinnings of violence, are among the goals for this book. The psychological trauma experienced by victims of violence places them at risk for long-term mental health issues, including post-traumatic stress disorder (PTSD) and other comorbidities (Bonanno, 2004). Nurses in the generalist settings are most often the first to interact with a victim. For this reason, all nurses should have a basic understanding of forensic issues that affect their practice and ultimately their patients.
The purpose of this book is to provide nurses with essential information that can be incorporated into practice. The goal is to provide nurses with a practical, evidence-based guide to understanding and applying forensic nursing science in their practices. This book will introduce nurses to theoretical perspectives on violence, concepts essential to understanding forensic science and applying it in practice, and violence-prevention strategies. The book will highlight sociocultural diversity and relevant legal, ethical, societal, and policy issues. The information in the chapters will also include challenges in the practice area and potential solutions.
In 2013, an estimated 6.1 million United States adolescents and adults experienced a violent victimization (Truman & Langton, 2014). Violent crime, which includes rape or sexual assault, robbery, and aggravated and simple assault, often results in injury, pain, and physical and emotional trauma. Burglary is more often reported to the police; rape is least reported to the police (Hart & Rennison, 2003; Rennison, 2002). In crimes that are reported to the police, the victim is also more likely to receive healthcare (Tjaden & Thoennes, 2000). An estimated $105 billion per year is spent on medical care, mental health services, victim services, property loss or damage, and reductions in work productivity due to crime (Wright & Vicneire, 2010).
Crimes are offenses or omissions that are punishable by law. Crimes typically involve victims and offenders. Victims may be harmed, injured, or killed by crime and violence, an accident, or action. Some crimes are considered victimless: actions that are against the law but involve consenting adults. Offenders (perpetrators) are persons who commit a criminal act.
Crimes can be prosecuted in civil and/or criminal courts. Civil courts handle noncriminal actions, such as disputes between two persons that they cannot resolve, like property disputes. On the other hand, criminal courts have the authority to punish offenders when found guilty of the crime. The founders of the United States specifically conceived of a criminal justice system to ensure that every person is innocent until proven guilty. The criminal justice system provides safeguards that are designed to protect the rights of the accused. In order to be found guilty in a criminal court, the burden of proof is "beyond a reasonable doubt." In the civil court, the burden of proof is "more likely than not." As an example, the 1994-95 criminal trial prosecuting O. J. Simpson for the murders of Nicole Brown Simpson and Ronald Lyle Goldman did not prove guilt beyond a reasonable doubt, and so Mr. Simpson was acquitted. In the civil case against him, however, he was found guilty because the burden of proof was that a reasonable person would agree that it was more likely than not that he committed the crime.
It's important to consider the effects of the criminal justice system on victims. For a criminal complaint, the victim does not decide whether a case will go to court or not. The state makes that decision, and in most cases it is the district attorney or a grand jury that serves as the state in making that decision—it is the state vs. the offender. The victim usually testifies in the criminal case. A civil case is brought before the court by the victim (grievant), usually with the assistance of a lawyer.
Victims have established rights in criminal proceedings, including the right to attend the criminal justice proceedings and the right to be heard. Victims have the right to be notified when offenders are released or escape from incarceration. Provisions are made through the Office of Victims of Crime for victim compensation, which is a government program that provides reimbursement of expenses related to the crime to victims of violent crime. Compensation even extends to surviving or affected family members. Law enforcement or the district attorney usually notifies victims that they are eligible to apply for funds. Compensation can be paid even when no one is arrested or convicted of the crime.
The term secondary victimization is characterized by victim-blaming attitudes, behaviors, and practices, which result in additional trauma to the victim (Campbell & Raja, 1999). The victim may not feel supported by family, friends, and professionals/clinicians, which leads to additional emotional harm. Victims may feel secondary revictimization in a criminal justice system that makes them recount their stories multiple times to various individuals involved in the case. A common example of secondary victimization occurs when the victim of sexual assault is blamed for the clothes she was wearing, or the alcohol she drank, or for her life choices. And when she is made to repeat her story many times, defense lawyers will focus on any discrepancies among the various reports that are made when the victim repeats her story.
Using victim advocates can be a helpful provision when assisting a patient. Advocates are professionals who are trained to provide support and resources to victims of crime. Advocates assist the victims while in the healthcare system and throughout their legal case. Nurses should be aware of this resource within their community and know how and when to refer victims.
As the largest sector of healthcare employees, nurses are in hospitals, clinics, correctional facilities, schools, and other healthcare settings. Forensic nursing entails skills in assessing and treating victims of violence, evidence collection and preservation, documentation, and understanding the legal system (Burgess, Berger, & Boersma, 2004). The medicolegal aspects of providing care to victims necessitate having background knowledge of violence and crime, which prepares the nurse to provide more comprehensive care. Because so few healthcare education programs, including nursing, provide forensic education and training, few healthcare clinicians are prepared to meet the responsibilities involved with caring for victims and perpetrators (Henderson, Harada, & Amar, 2012). While criminal investigations are within the purview of law enforcement, it is incumbent upon providers to understand forensic issues in their evaluation and plan of care for patients. The International Association of Forensic Nursing and its publication, the Journal of Forensic Nursing, are resources for nurses wishing to learn more about forensic nursing.
The chapters in this book are designed to provide a basic understanding of forensic nursing and the many roles forensic nurses perform. The early chapters focus on forensic science and assessment of wounds and injuries. Theoretical perspectives on violence, victimization, and perpetration are provided to increase the nurse's understanding of victims and offenders. Neurobiological, psychological, social, physical, and behavioral responses to trauma are presented so that nurses can recognize the immediate and long-term effects of violence on health. The middle section of the book provides information on various crimes. Each chapter contains background information, relevant laws and statutes, assessment, and treatment. Case studies are provided to illuminate the content. The final section contains information on community strategies for violence prevention and intervention. Strategies to institute trauma-informed care in healthcare settings are provided. These chapters are not meant to explain all aspects of forensic care. Rather, they provide a starting point for the non-forensic nurse to begin to transform practice.