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The challenges forensic nurses face when their patient is comatose: Addressing the needs of our most vulnerable patient population

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Abstract

Since 1996, the American Nurses Association has recognized forensic nursing as a formal specialty. Despite this recognition, Sexual Assault Nurse Examiners and Emergency Department nurses struggle with incorporating evidence collection into the care they give the unconscious or comatose patient they suspect has been sexually assaulted. Through case example, this article provides an abbreviated review of the circumstances under which these patients present for care, current challenges, and barriers in upholding the standard of forensic nursing care, as well as proposed interventions for the practicing forensic nurse.

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... T he discipline of forensic nursing is inherently multidisciplinary, bringing nursing theory and practice into a legal context (Campbell, Greeson, & Patterson, 2011;Lynch, 2006;Pierce-Weeks & Campbell, 2008). Although the primary focus of forensic nursing is patient health care (International Association of Forensic Nurses [IAFN], 2009;Lynch, 2006;Pierce-Weeks & Campbell, 2008), there has been sustained interest in the academic literature and in policy circles regarding how Sexual Assault Nurse Examiner (SANE) programs may bolster sexual assault prosecution rates in their communities (Campbell, Patterson, & Bybee, 2012). ...
... T he discipline of forensic nursing is inherently multidisciplinary, bringing nursing theory and practice into a legal context (Campbell, Greeson, & Patterson, 2011;Lynch, 2006;Pierce-Weeks & Campbell, 2008). Although the primary focus of forensic nursing is patient health care (International Association of Forensic Nurses [IAFN], 2009;Lynch, 2006;Pierce-Weeks & Campbell, 2008), there has been sustained interest in the academic literature and in policy circles regarding how Sexual Assault Nurse Examiner (SANE) programs may bolster sexual assault prosecution rates in their communities (Campbell, Patterson, & Bybee, 2012). SANE programs consist of specially trained nurses who provide comprehensive psychological, medical, and forensic services for victims/survivors of sexual assault, and several case studies have highlighted how these programs are an important resource to the legal community (Campbell, Patterson, & Lichty, 2005). ...
Article
In large-scale, multi-site contexts, developing and disseminating practitioner-oriented evaluation toolkits are an increasingly common strategy for building evaluation capacity. Toolkits explain the evaluation process, present evaluation design choices, and offer step-by-step guidance to practitioners. To date, there has been limited research on whether such resources truly foster the successful design, implementation, and use of evaluation findings. In this paper, we describe a multi-site project in which we developed a practitioner evaluation toolkit and then studied the extent to which the toolkit and accompanying technical assistance was effective in promoting successful completion of local-level evaluations and fostering instrumental use of the findings (i.e., whether programs directly used their findings to improve practice, see Patton, 2008). Forensic nurse practitioners from six geographically dispersed service programs completed methodologically rigorous evaluations; furthermore, all six programs used the findings to create programmatic and community-level changes to improve local practice. Implications for evaluation capacity building are discussed. Copyright © 2015 Elsevier Ltd. All rights reserved.
... The case for promoting the collection of evidence is primarily done with caveats, or conditions that require patient anonymity, or a provision for holding evidence until consent for release is obtained either by the patient, or a surrogate decision-maker such as a family member, guardian or judge. Pierce-Weeks and Campbell [5] argue that evidence collection has become a standard of care in the Emergency Department and to not take evidence is to fall short of that gold standard of care. They maintain that non-emergent care is routinely given along with emergent care; therefore a thorough medical/forensic examination does not violate any standards of care. ...
... Maine's legislation incorporates an implied consent clause, and a provision granting immunity from liability for the clinician [31]. Other jurisdictions may require a search warrant to collect evidence from the unconscious patient [5]. ...
Article
Full-text available
Forensic nurses are faced with making an ethical decision when an unconscious patient presents with signs of sexual assault. If the patient is unable to consent, the nurses need to decide whether or not to perform a forensic exam. Hospitals have policies in place regarding consent for emergency care, but not all of them consider the collection of forensic evidence. The window of opportunity for forensic collection may disappear before contacts are made or proper consent is established. Ethical, legal, and policy considerations that complicate this scenario are discussed.
... First, challenges around day-to-day team coordination can become more pronounced when updating local or state protocols (Cole & Logan, 2008;Greeson & Campbell, 2013). Second, clinicians have difficulty with informed consent, including explaining the risks and benefits of the procedures, determining when the patient is capable of providing consent, caring for an unconscious patient, and consenting for release of SAMFE records (Pierce-Weeks & Campbell, 2008). Third, confidentiality remains difficult for many communities, with providers challenged by operating within the context of limitations of confidentiality (Cole, 2018). ...
Article
This article reviews two types of community-based approaches to addressing sexual assault that survivors may encounter—sexual assault nurse examiners and victim advocates from nonprofit community agencies—and highlights ways that the Violence Against Women Act (VAWA) and its reauthorizations have influenced this work. We also review information on the intersections of the work of these providers with police and prosecutors and include how these relate to survivors’ experiences. We conclude with thoughts that look forward to future research on these issues emphasizing authentic engagement of practitioners and survivors in the research process.
Article
There has been sustained interest in the academic literature and in policy circles regarding how Sexual Assault Nurse Examiner (SANE) programs may bolster sexual assault prosecution rates in their communities, in addition to the health care they provide to their patients. To build evaluation capacity among forensic nurses so that they can evaluate their own programs, a practitioner-oriented, step-by-step evaluation toolkit (the SANE Practitioner Evaluation Toolkit) that can be used by SANE-A and SANE-P programs, and their community partners, to examine sexual assault prosecution rates in their local jurisdictions was created and validated. This article describes the process of creating and empirically validating the toolkit and presents the toolkit itself and accompanying resources that are available to practitioners. This article also provides recommendations regarding program readiness to engage in evaluation activities, without compromising program sustainability and patient care.
Article
Full-text available
Forensic nursing is multidisciplinary in nature, which can create tensions for practitioners between their responsibilities to patient care and collaborations with law enforcement and prosecutors. Because there are compelling reasons grounded in both nursing theory and legal precedent to maintain separation, there is a pressing need to understand how sexual assault nurse examiner (SANE) programs successfully negotiate these potentially conflicting roles. The purpose of this study was to examine how SANEs define their work with their patients, how they collaborate with law enforcement, and how they negotiate roles differentiation. As part of a mixed methods evaluation of a community-based SANE program, qualitative interviews were conducted with forensic nurses regarding their interactions with patients and members of the legal community. Results indicated that a strong patient care practice had positive indirect effects on victims' participation in the criminal justice system. Implications for forensic nursing practice are discussed.
Article
Sexual assault cases are challenging for both the patient and provider, particularly given the emotional and logistic overlays in the majority of these cases. In this article we offer sexual assault programs information and areas for consideration when developing a policy addressing sexual assault examinations on patients who are either incapacitated or otherwise unable to consent to examination. This information is based on our experience in creating and implementing such a policy for our program. We also offer the written policy and associated consent form that we designed (see Figures 1 and 2). The protocol manual for sexual assault medical forensic examinations authored by the Department of Justice actually recommends that each and every sexual assault nurse examiner (SANE) program have “internal policies based on applicable jurisdictional statutes governing consent for treatment of vulnerable adult patients. In cases of adolescents, the jurisdictional statutes governing consent and access to the exam should be followed.“
Article
Full-text available
Women who seek medical care following sexual assault are usually evaluated and treated in an emergency department (ED). Therefore, EDs can be an important source of sexual assault surveillance data. The authors compared the incidence of sexual assault presenting for emergency care in a single county during July to November of 1974 and 1991. Participants included all female sexual assault victims aged 14 and older who presented for ED evaluation. Treating physicians prospectively collected data using standardized forms. The z statistic was used to compare sexual assault incidence. There was a 60% increase in the incidence of sexual assault victims presenting for emergency care in 1991 compared to 1974, primarily due to an increase in the incidence of women presenting to the ED after rapes by known assailants. In contrast, the annual incidence of reported stranger assaults was similar in the two study years.
Chapter
Investigations into reports of drug-facilitated crimes (DFCs) have increased substantially in recent times. These crimes are investigated when an individual reports having been robbed or assaulted while incapacitated due to the effects of a drug, usually a strong central nervous system (CNS) depressant. The CNS depressant prevents the individual from consenting to the action of the perpetrator or fighting off their attacker. The drug, in essence, acts as a weapon for the offender. This article provides information on the manner in which DFCs occur, the drugs that are used to commit these crimes, and means of improving the detection of the drugs through toxicological analyses. Keywords: drug-facilitated crime; DFC; drug-facilitated sexual assault; DFSA
Article
Objectives: To compare the characteristics of sexual assault in pubertal girls (<18 years old) and adults in a community-based population of women presenting to an urban sexual assault clinic. Methods: This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic during a three-year study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from the two patient groups (adolescents vs. women ≥18 years of age) were analyzed using chi-square test and t-test. Results: A total of 766 cases were identified: 43% of the victims were 13 to 17 years old (mean 15.0 years old), and 57% were older than 17 years old (mean 30.8 years old). Adolescents were more likely to be assaulted by an acquaintance or relative (84% vs. 50%, p < 0.001) and to delay medical evaluation (17 hours vs. 12 hours, p < 0.001) than were older women. Adolescent sexual assault was less likely to involve weapons or physical coercion (29% versus 57%, p < 0.001) and was associated with fewer nongenital injuries (33% vs. 55%, p < 0.001). Adolescents had a greater frequency of anogenital injuries (83% vs. 64%, p < 0.001), however, compared with older women. Common sites of injury in adolescents were posterior, including the fossa navicularis, hymen, fourchette, and labia minora. The injuries showed consistent topologic features, varying with the site and nature of tissue. Adult victims of sexual assault had a less consistent pattern of anogenital injuries with fewer hymenal injuries, greater injury to the perianal area, and widespread erythema. Conclusions: Of women presenting to an urban sexual assault clinic, 43% were adolescents. The epidemiology of sexual trauma and the pattern of anogenital trauma in this age group are unique and may pose special challenges to emergency health care providers.
Article
Coma is defined as a sleeplike state in which the patient is unresponsive to self and the environment. Coma should be distinguished from the persistent vegetative state and locked-in syndrome. It is important to obtain a carefully taken history from eyewitnesses and to perform a rapid neurologic examination focusing on pupillary responses, eye movements, and motor responses. Pupils reactive to light usually indicate metabolic or medical coma; cerebellar infarction or hemorrhage is a notable exception. A pupil unreactive to light often points to a structural brain lesion and the need for urgent neurosurgical consultation. The prognosis for coma depends on the cause.
Article
Pooling data from four samples in which 1,882 men were assessed for acts of interpersonal violence, we report on 120 men whose self-reported acts met legal definitions of rape or attempted rape, but who were never prosecuted by criminal justice authorities. A majority of these undetected rapists were repeat rapists, and a majority also committed other acts of interpersonal violence. The repeat rapists averaged 5.8 rapes each. The 120 rapists were responsible for 1,225 separate acts of interpersonal violence, including rape, battery, and child physical and sexual abuse. These findings mirror those from studies of incarcerated sex offenders (Abel, Becker, Mittelman, Cunningham-Rathner, Rouleau, & Murphy, 1987; Weinrott and Saylor, 1991), indicating high rates of both repeat rape and multiple types of offending. Implications for the investigation and prosecution of this so-called "hidden" rape are discussed.
Article
The aim of the study was to describe victim, assailant, assault characteristics for sexual assault victims according to the time between the last sexual assault and the examination, and to provide descriptive data on medico-legal findings. The study was based on 418 examined victims of sexual assault during the year 1998. Victims were referred from investigating police authorities. All examinations were performed with the use of colposcopy by physicians with special training in forensic medicine. Two groups of victims were defined:a first group of victims examined in emergency within 72 h after the last sexual assault;a second group of victims examined after 72 h. About 86% of the cases were female victims. The mean age of the cases of the first group was 22.4 years. Conversely, 76% of the victims examined after 72 h were under the age of 15 years. Vulnerability was present in 31% of the cases examined in emergency, including disabled and pregnant victims. Sexual assault happened once in 87% of the cases of the first group and in 64% of the cases of the second group. The victim's home was the most frequent place of sexual assault (35% of the cases of the first group and 56% of the cases of the second group). The assailant was a stranger in 51% of the cases of the first group. In the second group of the victims, the assailant was a family member in 58% of the cases (the father in 30% of the cases). There was a single assailant in the majority of the cases for the two groups. Threats were used by the assailant in 66% of the victims examined in emergency and in 33% of the cases of the second group. The type of sexual assault was penetration in the majority of the cases for the two groups. Vaginal, oral and anal penetration was respectively involved in 55, 23 and 13% of the cases of the first group. General body trauma was found in 39.1% of the cases examined in emergency and in 6.3% of the cases of the second group. Genital trauma occurred in 35.7% of the cases of the first group and in 19.5% of the cases of the second group. Hymenal, vulvo-vaginal and anal lesions were respectively found in 11, 20 and 7% of the cases examined in emergency. Toxicological analysis was performed in 14.3% of the cases examined in emergency. In 47% of the tested cases, drug was detected. Cytology was performed in 61.5% of the cases examined in emergency. Detection of spermatozoa was found in 30.3% of these cases. Our study has shown that sexual assault victims had different characteristics according to the time between the sexual assault and the examination. Public health campaigns against sexual abuse and rape as well as medical management of the sexually assaulted victims should adapt to the needs and the characteristics of these two different populations of victims.
Article
To compare the characteristics of sexual assault in pubertal girls (<18 years old) and adults in a community-based population of women presenting to an urban sexual assault clinic. This case-series analysis evaluated consecutive female patients presenting to a sexual assault clinic during a three-year study period. The clinic is associated with a university-affiliated emergency medicine residency program and is staffed by forensic nurses trained to perform medicolegal examinations using colposcopy with nuclear staining. Patient demographics, assault characteristics, and injury patterns were recorded using a standardized classification system. Data from the two patient groups (adolescents vs. women > or =18 years of age) were analyzed using chi-square test and t-test. A total of 766 cases were identified: 43% of the victims were 13 to 17 years old (mean 15.0 years old), and 57% were older than 17 years old (mean 30.8 years old). Adolescents were more likely to be assaulted by an acquaintance or relative (84% vs. 50%, p < 0.001) and to delay medical evaluation (17 hours vs. 12 hours, p < 0.001) than were older women. Adolescent sexual assault was less likely to involve weapons or physical coercion (29% versus 57%, p < 0.001) and was associated with fewer nongenital injuries (33% vs. 55%, p < 0.001). Adolescents had a greater frequency of anogenital injuries (83% vs. 64%, p < 0.001), however, compared with older women. Common sites of injury in adolescents were posterior, including the fossa navicularis, hymen, fourchette, and labia minora. The injuries showed consistent topologic features, varying with the site and nature of tissue. Adult victims of sexual assault had a less consistent pattern of anogenital injuries with fewer hymenal injuries, greater injury to the perianal area, and widespread erythema. Of women presenting to an urban sexual assault clinic, 43% were adolescents. The epidemiology of sexual trauma and the pattern of anogenital trauma in this age group are unique and may pose special challenges to emergency health care providers.
The preparation and trial of medical malpractice cases State of Maine Revised Statute Annotated 24. 2986.5 Performing forensic examinations for alleged victims of gross sexual assault
  • R E Shandell
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Shandell, R. E., Smith, P., & Schulman, F. A. (2006). The preparation and trial of medical malpractice cases. New York: Law Journal Press. State of Maine Revised Statute Annotated 24. 2986.5 Performing forensic examinations for alleged victims of gross sexual assault (2005).
Estimate of the incidence of drug-facilitated sexual assault in the United States
  • A Negrusz
  • M Juhascik
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  • U S Department
  • Justice
Negrusz, A., Juhascik, M., Gaensslen, R. E., & U.S. Department of Justice. (2005). Estimate of the incidence of drug-facilitated sexual assault in the United States. Washington, DC: US Department of Justice. Patients' Rights. (2005). West's encyclopedia of American law. 2nd Ed. In J. Lehman and S. Phelps (Eds.). Thomson Gale, eNotes.com. Accessed August 2, 2008, from: http://law.enotes.com/wests-law-encyclopedia/ patients-rights. Schloendorff v. Society of New York Hospital, 211 NY 125, 105 NE 92 (1914).
The epidemiology of female rape victims who seek immediate medical care: Temporal trends in the incidence of sexual assault and acquaintance rape
  • Magid