Presentation outline:-

- introduction

- Overview of forensic nursing.

- Definition of forensic nursing.

- Historical view of forensic nursing

- Forensic psychiatry and the Palestinians

- Principles of forensic nursing.

- Presentation of mental health need in forensic client.

- Specific forensic nursing skills.

- Client assessment.

- Care planning and intervention

Introduction:

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When many people hear the term Forensic Nursing, they are not exactly sure of what that means. With the advent of shows like "CSI", "The Forensic Files" or "Bones", many envision the forensic nurse as a type of medical detective out at a murder scene. Put simply, a Forensic nurse is a nurse with specialized training in forensic evidence collection, criminal procedures, legal testimony expertise, and more. The Forensic nurse becomes that liaison between the medical profession and that of the criminal justice system. When you combine the medical training of a nurse, with the investigative prowess of police detectives and the legal training of a lawyer, you have created a formidable enemy for criminals. Most Forensic Nurses work out of a hospital, at the first point of contact. The Emergency Room. Most people who come to the emergency room don't know that they may be in need of a forensic nurse when the present at the hospital. Trying to accurately assess a patient can be difficult enough, but toss in the chaos of a typical emergency room and things really go downhill in a hurry. Take for example the case of the distraught mother who brings in her son who is complaining that his arm hurts. The mother says he ran into a door trying to catch the dog. Better check vitals and get an x-ray of the arm to see if its broken right? Did you make the child change into a gown? did you get a complete head to toe assessment? Because without it, you would have missed the evidence of previous contusions on his legs from two weeks ago when he was beat with a wrench for not cleaning his room right.Or what about the woman who comes in stating she was in a car accident. Her boyfriend who was driving says she hit her head and cut her face as the glass shattered. Did you notice that most of her injuries were on the left side of her face? Logically if she was the passenger most of the injuries should be on the right side, since that would be the most likely point of impact.Forensic nursing can also expand outside the world of criminal investigation. After the devastation of hurricane Katrina in the gulf states, identification of some of the remains found could only be determined through the use of forensic evidence collection. This type of work is usually referred to as Medicolegal Death Investigation.If I become a forensic nurse does that mean that I have to work with dead bodies? Of course not, but that is one of your options if you should choose to learn more about that career path. There are many career branches that open up to forensic nurses including; expert medical witness, Sexual Assault nursing, Nurse death investigator, or Medicolegal death investigation, community education. The list goes on and on

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Medicolegal death investigation is a growing field for nurses, but more often than not a forensic nurse will spend a majority of their time treating victims of a sexual assault or performing examinations for a child abuse case. As part of the training to becoming a Forensic Nurse education on legal testimony and the proper collection of evidence and how to preserve that valid chain of evidence is critical.Definition of forensic nursing:Forensic nursing is the term used when nursing is applied to those people who have come into contact with the criminal justice system due to their offending behaviors. Forensic nursing relates to the care, treatment and management of those persons who come into contact with the criminal justice system. This includes: high security, medium security, low security hospitals and community setting. It can also include police station, courts and prisons

Historical overview:The definition of forensic nursing is continually evolving. In 1997 it was defined as "the application of forensic science combined with the bio-psychological education of the registered nurse, in the scientific investigation, evidence collection and preservation, analysis, prevention and treatment of trauma and/or death related medical-legal issues." (IAFN/ANA, 1997) The word "forensic" comes from the Latin word ‘forensis’ meaning public debate. The word forensic is used now to describe the debates that occur in courts of law and is even more broadly defined as any matter that is "pertaining to the law." (Evans, Wells, 1999)

In 1998 that definition was expanded as follows. "Forensic Nursing is the application of nursing science to public or legal proceedings; the application of the forensic aspects of health care combined with the bio-psychosocial education of the registered nurse in the scientific investigation and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity and traumatic accidents. " (IAFN 1998)"Forensic Nursing is the health care response to (criminal and interpersonal) violence. Identification of crime victims, prevention of further injury or death due to cyclical violence, and early detection of potentially abusive situations are critical steps to stem the effects of human violence. Forensic Nursing provides a continuity of care from the emergency department and/or crime scene to courts of law… and a wider role in the investigation of crime and the legal process that contributes to a safer, healthier society." (IAFN, 1998)

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Forensic psychiatry and the Palestinians:According to El-Sarraj, after the six Day war and during the Israel occupation, level of antisocial behavior and aggression, including homicide, increased within Palestinian population. In addition drug abuse, especially cocaine, spread among younger Palestinians. Similar increases in criminality and drug abuse have occurred more recently within Israel Arab communities, though aspect of social change are not identical for Palestinians in the territories and Arab living within Israel. The concept of family honor remains prominent for Muslims, with episodes of young women being Murdered by their fathers or brothers for having brought "shame" on the family continuing to occur.The psychiatric hospital in Bethlehem and Gaza are generally unable to take offender patients who may require a significant degree of security on account of their being dangerous to society. Indeed, the provision of high and medium secure facilities for dangerous mentally disordered offender is also a current issue in Israel. In practice Israel prisons have provided psychiatric care for most dangerous offender, whether or not mentally disordered and whether Palestinian or Jewish. The rate of incarceration in Israel prison was recorded as being higher than in any country in Western Europe except Northern Ireland, though than in the united states.

What are the Specialty Roles in Forensic Nursing?Educating and informing potential employers regarding the profession of forensic nursing and the valuable skills provided by qualified forensic nurses. Meeting and establishing professional relationships with other forensic professionals, including crime scene technicians, medical examiners and attorneys is called "networking". Through networking you will establish a professional identity within the forensic community which will ultimately help. Always join as many professional forensic organizations as you can. The International Association of Forensic Nurses (IAFN) will keep you informed of professional developments in the field of forensic sciences. As their responsibilities evolve, forensic nurses are assuming increasingly diverse roles, in risk management, employee litigation, forensic nurse investigator, forensic clinical nurse specialist, forensic nurse educator, bioterrorism, domestic and international investigations of human rights abuse, psychiatric forensic nursing, forensic geriatric nursing, correctional nursing, emergency room forensic nursing,

pediatric forensic nursing, sexual assault and domestic violence. Newly proposed is the child abuse nurse examiner. The most common roles are sexual assault nurse examiner (SANE), advanced practice forensic nurse or

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forensic clinical nurse specialist, nurse death investigator and nurse coroner.Sub Specialties of Forensic NursingThere are many different roles and specialties that a forensic nurse can try to specialize in. the following list is meant to give some helpful ideas of careers for forensic nursing, and should not be viewed as a complete list of nursing career choices.

- Medical Examiner's office - Medical Legal Consultant - Emergency Room Nursing - Medicolegal death investigator - Evidence collection trainer - Expert medical witness - Law enforcement teams

Principles of forensic nursingIn working with forensic client, five guiding principles are required: partnership, engagement, flexibility, pragmatism and team working.

PartnershipThe need for collaboration and negotiation are paramountThe nurse should be working towards restoring

EngagementThe need for honesty, genuineness and acknowledging the limitation of forensic mental health are crucial.

FlexibilityForensic nursing requires a great deal of the nurse. Decisions about care and risk need to be constantly evaluated and re-evaluated, sometimes on second by second basis. PragmatismThe focused of nursing is based on the principles of Pragmatism as opposed to the application of theories or models.

Team workingThis includes working with other professionals and encouraging the whole team to work in partnership with the client. Team working can often involve including the family in assessing and meeting the client’s needs.

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What do Forensic Nurses actually do?"Forensic Nurses work with patients who are in some way involved in the criminal justice system. That is, patients who have allegedly committed or who have been convicted of a criminal offence, or alleged victims of crime.

"The forensic nurse provides direct services to individual clients, consultation services to nursing, medical and law-related agencies, as well as providing expert court testimony in areas dealing with trauma and/or questioned death investigative processes, adequacy of services delivery and specialized diagnoses of specific conditions as related to nursing." (IAFN 1998).

The services provided by forensic nurses can include examination of victims of abuse, sexual assault, violence, trauma or death, with documentation of injuries and findings, both in the written record and photographically. These services can include recognition, collection and preservation of physical evidence, either from the victim, the victim’s clothing or from the scene of the crime, accident or injury. These services can include examination of suspects for injuries, as well as collection of trace evidence and/or exemplars to be used for comparison to those found on the victim or at the scene. These services can include the collection of legal blood and urine specimens for alcohol and drug testing. These services can include providing physical and emotional comfort to victims and their family members, as well as help with decisions about organ and tissue donation. These services can include examining medical records for any clues as to cause and manner of death, or to possible liability in civil or criminal proceedings. Services provided by forensic nurses can include assessments of infants, children, teenagers, adults and the elderly; of the mentally well and the mentally ill; of the victim or the offender; of the innocent as well as the convicted and the incarcerated; of the living as well as the dead.

Presentations of mental health need in forensic clients:Forensic clients are defined by the nature of their offending or their propensity for potential offending and not by the nature of their mental health needs. There is violence. Individuals with psychotic disorders are more likely (than the general population) to behave violently towards other (bernnan et al 2000) and to have criminal convictions for violence (Wallace et al 1998). Consequently, a whole spectrum of mental health needs may be present. Invariably, there are tow factors that the nurse is required to consider:

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- The mental health needs of the client - The actual or potential offending behavior.

This leads to focus on forensic nursing as having one of three potentialities (Rogers & Curran 2004)Assessment, care, intervention and management for actual or potential offending only (e.g. sexual offending)Assessment, care, intervention and management for mental health needs only (e.g. delusional beliefs)

Assessment, care, intervention and management for both (e.g. violence to other which is driven by delusional beliefs)Ordinary, forensic nursing is focused on the third of these three potentialities, where it is considered that either the offending behavior harms the persons mental health or the person mental health leads to actual or potential offending.

Specific forensic nursing skills required:Forensic nurse requires a wide range of knowledge and skills. A client may be depressed, suicidal and self-injurious after killing their children while in psychotic state. Another client may have post-traumatic stress disorder (PTSD) after crashing a stolen car they were driving in which their best friend died. Yet another client may be suffering from paranoia and command hallucinations causing behaviors that are difficult to manage in an acute mental health unit.

*1* Formulating riskMental health needs will be the main reason for contact with forensic nurses, there will also be the potential for, or the occurrence of actual offending behavior. The ability to skillfully formulate risk and the relationship between risk and mental health need develops over time through practice, discussion with client, seeking feedback about working formulation, and discussions with clinical team member and sometimes with family member. Experience in formal methods and procedures of risk assessment are necessary. *2* Awareness and management of selfForensic nursing should also have an ability to remain objective, logical and evidence based. Occasionally a client may challenge our own beliefs and values through the nature of their offence.Asking question about the behavior is more useful :

- What were the client’s experience at that time?- What function did the behavior serve?

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- What were the client’s circumstances at the time?

*3* CommunicationEffective communication is also essential as forensic services rely on the quality of information

*4* CollaborationBy far the most important skill collaboration. Collaboration is a term that is often used in the wider mental health literature.Collaboration is paramount within forensic settings and requires the therapist to: (work with, as opposed to work against people)

What are Some Additional Settings for Forensic Practice?Tissue and Organ Donation: In large trauma facilities, the skills of an experienced, knowledgeable forensic nurse are a significant contribution to the crisis intervention team working with families of potential donors. The nurse needs to know the specifics regarding the "legal framework of organ donation, familiarity with brain death criteria, and confident skills in required consent request... The nurse must meet the legal requirements and at the same time provide emotional support to the grieving family." (Lynch, 1995)Pediatrics: Forensic nurses may specialize in the recognition, evaluation, treatment and support of young victims of abuse through various facilities and organizations. Child abuse and neglect cases can be handled by forensic nurses depending on the protocols for that facility. Each facility will have protocols which specify who may examine and counsel pediatric victims. In some cases, SAFE nurses may not have authority to work with these patients. Correctional: Correctional nurses have a great deal of autonomy, provide acute and chronic assessments, dispense medications, manage acute illness and injuries, perform health screenings, and educate inmates on various health related topics. Correctional facilities also reflect the society at large, therefore the incarcerated population is aging and has a wide range of health issues that need to be addressed while serving their sentence. Some facilities are privately owned and hence hire their own healthcare staff or

contract with healthcare companies to supply staffing needs. There are institutions of all sizes and for many different populations and age groups.Psychiatric: There are but a few states in the nation that have the Psychiatric Forensic Nursing Classification. Employment is usually through the state civil service system, associated with the Department of Public Welfare. Nurses working in this role are responsible for psychiatric evaluation and treatment of criminal offenders by order of the court

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system. The offenders are typically admitted to a state facility for a brief period of evaluation and then returned to the county jails for sentencing. This specialty is closely tied to correctional nursing, violence issues with children at all age levels. School nurses are accessible and trusted healthcare professionals who can work with students on skills such as conflict resolution, stress management, suicide/injury prevention, and relationship management.School Settings: In the educational environment, school nurses are in a position to observe, assess, educate and intervene when necessary.

Assessment:Assessment should cover psychiatric, psychological and social functioning, risk to the individual and others, including previous violence and criminal record, any needs arising from co-morbidity, and personal circumstances including family or other carers, housing financial and occupational status.

Assessment goalsA comprehensive assessment will result in:

- A detailed and precise description of the problems the client is experiencing.

- A clear description of the client’s current symptoms- A comprehensive risk assessment- A description of the client’s social, occupational and domestic

circumstances- The support available to the client- Family/carer perspectives- An over management care plan- A treatment care plan- Methods for treatment to be evaluated

Timing of assessment:Frequent assessment is potentially the ‘backbone’ of the forensic nursing.Frequent assessment reduce the likelihood that a client’s mental health needs or risk have increase without the nurse being aware. Usually it is uncommon for the clinical team member to want to assess the client through interview and psychometric measurement within the first week or tow of contact.Pre-admission assessment is cornerstone if many forensic services when admission is likely.

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Sources of assessment information:Assessment information come from a variety of people (client, carer/family, referrer, criminal justice system) and in several ways (letters, verbal reports, case note, court reports).The primary source of information in the assessment setting is patient himself or herself.Secondary source are the assessor, family and carers, case record, court reports, questionnaires and rating scales.

Assessing risk:Assessing risk is not unilateral procedure, but should involve all the professions and involve a range of assessment that are captured on record. Risk assessment can be categorized as risk to self and risk to others.Known factors associated with a risk of self-injurious behavior include:

- Past self –harm attempts ( nature, motivation, dangerousness)- Presence and severity of current depression- Presence of current suicidal ideation (method, ability to

complete method, motivation)- Past and current drug or alcohol use- Past and current psychotic symptoms and their nature.

Risk to others includes assessment of the following:- Known history of violence- Severity of previous violence- Who the victim of violence were- Thoughts of violence- Previous and current psychotic symptoms and their nature

(e.g. paranoia, command hallucinations)- Past and current drug or alcohol use.

Observation:Observation is a key intervention. Observation has been defined as (standing nursing and midwifery advisor committee 1999,p2)Regarding the patient attentively while minimizing the extent to which they feel under surveillance.Has classified observation into four levels:

- General observation- Intermittent observation- Within eyesight- Within arms length

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Observation forms three functions:- First, it’s a process of ongoing assessment of the client.- Second, is used as a management procedure. (when a patient

is at risk of suicide)- Third, observation is used as a potential means of engaging

with and developing a relationship with clients.

Inter-observer agreement:The first is inter-observer agreement. This relates to whether all those involved in observation identify all relevant instances of the behavior or symptom and record these in the same way.

The second factor relates to whether the same observer will reliably produce similar accounts of the same behavior conducted at different times or in different settings.

ReactivityA final, and very important, factor to consider is the effect of the observer on patient and their behavior. In some cases the behavior or symptoms that are being assessed may vary according to the presence of the observer. This is known as reactivity. For example, some patients may appear more agitated, anxious and aggressive if they are aware that their behavior is being regularly monitored.

Care plans that are designed to manage are in effect plans where the nurse has determined situations where the mental health staff take control from the client.A comprehensive care plan to manage problem areas should include:

- The specific problem behavior that the plan is designed to manage

- Triggers for the problem behavior- Strategies to address such triggers in an attempt to avert their

occurrence- Nursing strategies to be employed before the management

plan is implemented- The specifics of the management plan and roles of each nurse- Strategies to be used with the client in order to assist them to

regain control of the problem behavior as soon as is practical- The care that should be provided after the event including

discussions with the client in order that all concerned can

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learn from the event and evaluate the usefulness of the care management plan- Reporting and recording processes

Care plans designed to ‘intervene’A comprehensive care plan to intervene with mental health need should include:

- A clear statement of the problem including relevant results from measurement procedures

- The treatment goals (preferably specified in the client’s word and not the nurse’s)

- The interventions that are to be used- Who is responsible for conducting the interventions- Methods for monitoring progress and the frequency of such

monitoring - The family’s or carer’s involvement in such intervention

Examples of specific clinical areas:A large degree of variation exists between peoples mental health and offending behavior. People commit offences for a variety of reasons, including financial gain, when influenced by peer or group pressure, when under the influence of drugs and or alcohol or as a result of behavioral responses to hearing voices or delusional beliefs.

Problem solving strategiesA person’s offending behavior may relate to poor problem solving skills related to certain triggers.Problem solving including:

- Identifying when problems arise- Generating alternative behaviors/strategies- Identifying steps to reach an alternative goal- Practicing implementing new skills through role-play

Interventions for delusional beliefsProvide clients with a normalizing as opposed to alienating rationale for their experiences.

The focus of intervention is to develop a safe and therapeutic relationship whereby the client can view their problems as worthy of examination and exploration.

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Interventions for command hallucinations:There is a known high prevalence of people with command hallucinations in forensic environments, found 38% of patients had command hallucinations.An examination of the research literature shows that:

- There is evidence for relationship between violent content command hallucinations and violence.

- There is relationship between self-harm command hallucinations and self-harm behavior in inpatient settings.

Highly supportive and structured cognitive behavioral strategies are employed to assist the client to examine their perceptions about command hallucinations

- Educating people about mental health symptoms can help them consider alternative explanations.

- Coping strategy enhancement can be used

Reverence:-Mental health nursing 2009.-Gaza community mental health program 2007.

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