Forensic Nursing
Moving Between the Medical and Legal Worlds
By Doug Childers

Forensic nurses help patients heal while also gathering evidence for criminal investigations.

“The collection of DNA evidence has dramatically improved with trained forensic nurses.”

Bonnie Price, who conducted the three-hour examination, recalled the elderly woman saying repeatedly, “If only I hadn’t left that window open.”

The rapist had broken into the house through the open window, and he was waiting for her when she came home.

“ He brutally assaulted her physically and sexually,” said Price, RN, BSN, SANE-A. Price is clinical coordinator of forensic nurse examiners at St. Mary's Hospital in Richmond.

During the attack, the elderly woman asked her attacker, “Do you have a grandmother? Is she alive?”

“Police think that may be what kept her alive since the scene suggested the man was planning on killing her when he was done,” Price said.

The woman was able to give police a physical description of her attacker, but she couldn’t identify him. A few years passed without an arrest. Then investigators got a DNA cold hit.

“A lot of nurses are practicing forensic nursing and don’t even realize it, but the additional forensic education is an essential component.”

Police had arrested the attacker for committing another crime. When his DNA was collected and added to the state DNA database, it matched the DNA sample that Price had collected from the woman’s clothing during the original examination.

Police charged him with the elderly woman’s assault. A jury found him guilty, thanks in part to the victim’s testimony.

During her testimony, “you could have heard a pin drop,” Price said. “She was brave and strong, and she told it like it was. The DNA sealed it, but it was her presence in the court that convinced the jury, I think.”

In the years after the attack, the woman’s life had changed significantly. She had lived independently her entire adult life, but after the attack, she moved into an assisted living facility.

“She could never go back to the home she’d lived in for 40 or 50 years,” Price said.

That’s not unusual with elderly victims, Price pointed out. “They can’t go back to the life they had before the assault. A younger victim might be able to overcome it with counseling. The elderly don’t get over it.”

Price talked with the woman during the trial. “She liked the assisted living home where she was living,” Price said. “Things were getting better, but it was sad – you could see her in court going right back to the way she was the day I examined her. She kept saying, ‘I’m your grandmother.’”

As Price noted, “A lot of women in her place might have said, ‘I don’t want to deal with this.’ But she told me, ‘I had to do this for peace of mind and so that he couldn’t do this to somebody else.’”

Forensic nurses like Price straddle two worlds, one medical and the other legal. In addition to collecting evidence from victims of adult sexual assault, domestic violence, elder abuse, child abuse and child sexual assault , they provide expert court testimony about their findings.

But the examination is more than an opportunity to collect DNA samples, said Cindy Teller, RN, CSN, SANE-A. “It’s the holistic care the patient receives: the exam,  STD  testing and prophylactic treatment, pregnancy testing and hormone therapy for pregnancy prevention,” along with “other services they need to start their recovery process.”

Teller is co-coordinator for the forensic nurse examiner program in the emergency room at Sentara Norfolk General Hospital as well as the owner of Forensic Nurse Consultants of Hampton Roads. On Nov. 5, she received the Forensic Nurse Examiner of the Year award from the Virginia chapter of the International Association of Forensic Nurses (IAFN).

“A forensic nurse’s day could vary greatly,” Price said. “You could be called in to see a sexually abused adult or child, a stabbing or gunshot wound victim, an elderly person who has been abused or a victim of domestic abuse. You never know what that call is going to be. You can’t predict when it will happen, either.”

While forensic nursing is diverse, Price said, “In Virginia most of the forensic nurses are either sexual assault nurse examiners or clinical forensic nurses.” Unlike forensic nurse death investigators, clinical forensic nurses typically work with the living population.

Forensic nursing is a relatively new area of healthcare. The American Nurses Association officially recognized the field in 1995. Today, the IAFN has 2,200 members internationally. They include sexual assault nurse examiners, forensic nurse investigators, nurse coroners, legal nurse consultants, forensic psychiatric nurses, forensic correctional nurses, nurse attorneys and forensic nurse educators.

The Virginia chapter, which was the association’s second chapter to be established, has 112 members. “We have a very active chapter of forensic nurses in Virginia,” said Price, who is the chapter’s president.

Suzanne Brown, MSN, RN, SANE-A, CFN, c linical nurse manager of the SANE Program at Inova Fairfax Hospital / Inova Fairfax Hospital For Children , pointed out that forensic nursing has helped improve the quality of criminal investigations. “The collection of DNA evidence has dramatically improved with trained forensic nurses.” And the care of patients reporting a sexual assault has improved as well.

To become a forensic nurse in Virginia, you must already be a registered nurse in good standing and undergo training that could take one to three years to complete, depending on your chosen field of expertise. To be certified, forensic nurses must pass the national S exual Assault Nurse Examiner (SANE) examination.

“A lot of nurses are practicing forensic nursing and don’t even realize it,” said Brenda Johnston, MSN, RN, CEN, SANE-A. “But the additional forensic education is an essential component.” Johnston is coordinator of the forensic nurses examiner program at Winchester Medical Center.

Several locations in Virginia offer SANE courses, including St. Mary's Hospital in Richmond and Inova Fairfax Hospital in Falls Church . Several universities now offer a master’s degree in forensic nursing, as well.

Because of popular television crime shows like “CSI: Crime Scene Investigation,” many nurses have expressed an interest in becoming forensic nurses.

“On TV, it looks exciting,” Price said.

But the so-called CSI effect gives patients as well as juries an unrealistic expectation for what forensic investigations can do – and how quickly they can be conducted.

“I have found myself explaining the difference between the ‘CSI’ TV show and reality many times,” said Ann Adkins, RN, FNE, SANE-A, forensic nursing coordinator for the Lewis Gale Medical Center in Salem.  “Unfortunately, it may take months to a year to have evidence processed at the state lab.  We have to explain to some of our patients that we don't have the evidence lab in the back room and that in one hour we won't ‘know who did it.’”

Despite the interest sparked by shows like “CSI,” forensic nursing programs face shortages, just as many other fields of nursing do. The reasons are simple. The hours put in by forensic nurses can be long, the burnout rate is high, and the time it takes to train a forensic nurse means it isn’t easy to fill an open position from the relatively small pool of forensic nurses.

“You could finish training to become an adult sexual assault nurse examiner in a year, but child sexual abuse would take another year or two,” Price said. “So for me to get a nurse could take three years.”

And because the demand isn’t high enough to merit three daily shifts, 24 hours a day, most forensic nurses in Virginia don’t work in their field full-time.

“Most nurses take a forensic position in addition to their other job, and the forensic job gives them more meaning for their work,” Price said.

Typically, nurses are on call as forensic nurses on their days off from their primary jobs.

At Norfolk General Hospital , for example, its 10 forensic nurses are required to take no less than 12 hours of call per week and a 24-hour weekend shift every six weeks as forensic nurse examiners. They are also full-time ER nurses.

Price said that most of the eight nurses on her staff at St. Mary’s Hospital “take five to six shifts a month for me, to keep them competent. With five to six shifts, you may have no cases at all. Or you may have them constantly. It could take eight hours to do an examination. You can’t leave at the end of the day because you’re in the chain of custody. So you have to talk to the supervisor at your primary job.”

“It takes a tremendous amount of time and dedication to be a SANE nurse / forensic nurse examiner,” said Susan Carson, RN, FNE, coordinator of the Virginia Commonwealth University Medical Center’s forensic nurse examiners program. She is president-elect of the Virginia chapter of the IAFN.

Johnston said the shortage of forensic nurses can be especially difficult in rural areas because “The caseload is typically smaller, and this makes it difficult for nurses to gain the necessary experience to function in such an independent practice.”

As Adkins, points out, though, “Unfortunately in today's society, there are many acts of violence, and the field of forensic nursing will continue to grow.”