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Evolution of Forensic Nursing
Theory—Introduction of the Constructed
Theory of Forensic Nursing Care:
A Middle-Range Theory
Julie L. Valentine, PhD, RN, CNE, SANE-A
1
, L. Kathleen Sekula, PhD, PMHCNS, FAAN
2
,
and Virginia Lynch, RN, FAAFS, FAAN
ABSTRACT
The constructed theory of forensic nursing care is a middle-range nursing theory developed from the integrated
practice model for forensic nursing science,aconceptualframework.Theoryevolutionwasachievedfollowinga
critique of the conceptual framework and through inductive and deductive reasoning. A review of nursing theory
growth and significance of middle-range theories is presented as background information in understanding the
importance of this emerging forensic nursing middle-range theory. The philosophical and theoretical founda-
tions of forensic nursing are bolstered with the addition of three nursing theories, two healthcare models and
one social theory. Links are made between theory components and the current state of forensic nursing. Assump-
tions and concepts are clearly defined. The middle-rangetheoryprovidesthreetestablepropositionstoframe
forensic nursing practice, education, and research. Research conducted on the propositions will expand the fo-
rensic nursing scientific base leading to enhanced evidence-based practice. A pictorial model illustrates the
propositions as relational statements. The constructed theory of forensic nursing care affirms the focus of forensic
nursing care is on the nurse–patient relationship and improved health outcomes. Additional results of forensic
nursing care are improved forensic science and criminal justice system outcomes.
KEY WORDS:
Education and research; forensic nurse; forensic nursing; nursing theory evolution;
middle-range nursing theory; theory-based practice
The theoretical basis for forensic nursing was first
established through a conceptual model, the inte-
grated practice model for forensic nursing science,
developed by Virginia Lynch as her master’sthesisproject
(Lynch, 1990). At the time of theconceptual model develop-
ment, forensic nursing was a comparatively unrecognized
professional specialty. The integrated practice model for
forensic nursing science was pivotal in the establishment of
forensic nursing as both a nursing and forensic specialty.
Indeed, forensic nursing was acknowledged as a forensic
specialty by the American Academy of Forensic Sciences in
1991, following Lynch’s presentation on forensic nursing
based on the conceptual model. In 1992, forensic nursing
pioneers established the International Association of Forensic
Nurses (IAFN). Three years later, the American Nurses
Association granted specialty status to forensic nursing.
The integrated practice model for forensic nursing science
Author Affiliations:
1
Brigham Young University College of
Nursing,
2
Duquesne University School of Nursing.
The authors declare no conflicts of interest.
Correspondence: Julie L. Valentine, PhD, RN, CNE, SANE-A, 532
Kimball Tower, Provo, UT 84604. E-mail: Julie-valentine@byu.edu.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Web site
(www.journalforensicnursing.com).
Received November 3, 2019; Accepted February 17, 2020
Copyright © 2020 The Author(s). Published by Wolters Kluwer
Health, Inc. on behalf of the International Association of Forensic
Nursing. All rights reserved. This is an open-access article
distributed under the terms of the Creative Commons Attribution-
Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND),
where it is permissible to download and share the work provided it
is properly cited. The work cannot be changed in any way or used
commercially without permission from the journal.
DOI: 10.1097/JFN.0000000000000287
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Journal of Forensic Nursing www.journalforensicnursing.com 1
was further described and refined in publications of Forensic
Nursing, which featured the conceptual model as the theo-
retical background for the profession (Lynch & Duval,
2006, 2011).
Forensicnursinghasadvancedsignificantlyoverthepast
30 years since the introduction of the integrated practice
model for forensic nursing science with improved under-
standing of the scope of practice, roles and responsibilities,
educational guidelines, and professional priorities (American
Nurses Association & IAFN, 2017; IAFN, n.d.; Price &
Maguire, 2015). In addition, research studies have clarified
the role of forensic nurses and their impact within an inter-
disciplinary, global sphere (Campbell et al., 2011, 2012,
2005; Corum & Carroll, 2014; Drake et al., 2018; Schmitt
et al., 2017; Valentine et al., 2016). To match the growth
of the practice and science of forensic nursing, the theoretical
basis for the profession should progress beyond a conceptual
model. In 2014, a critique of the integrated practice model
for forensic nursing science was published with a response
from Virginia Lynch supporting the premise that it was
time for the conceptual model to advance to a more defined
theory, specifically a middle-range theory, to support the
growth of forensic nursing science (Lynch, 2014; Valentine,
2014). Theory evolution from a conceptual framework to
amiddle-rangenursingtheorywill strengthen the scientific
base of forensic nursing by supporting interdisciplinary
research to further define and improve forensic nursing
practice, education, and research. The purpose of this arti-
cle is to introduce and describe the constructed theory of
forensic nursing care: a middle-range theory developed
from the conceptual model, the integrated practice model
for forensic nursing science.
▪
Background
Theory provides a creative and rigorous structuring of ideas
that project a tentative, purposeful, and systematic view of
phenomena (Chinn & Kramer, 2015). Although theory
frames our thoughts, beliefs, and actions, nurses often ask
what the value of theory is in their daily practice. In at-
tempting to answer that question, Glanz et al. (2018) pro-
posed that theories are important in a discipline as they
shape the field, define the scope of practice, and determine
future nursing practice by influencing education and social-
ization. Quite simply, theory helps make sense out of why
nurses do what they do.
Theories provide us with two types of understanding:
explanatory, which describes concepts and interactions
among concepts, and predictive, which anticipates outcomes.
As a practice profession, nursing requires both explanatory
and predictive understanding to move theory into practice
through application of the nursing process. Explanatory un-
derstanding primarily guides the nursing process steps of
assessment, diagnosis, and planning, whereas predictive
understanding influences the nursing process steps of plan-
ning, interventions, and evaluation. Yet, explanatory and
predictive understanding are interactive building blocks of
knowledge guiding each step of the nursing process.
Nursing Theory and Middle-Range Theory
Development
Nursing theory has progressed substantially over the past
50 plus years. Dickoff and James (1968), not nurses them-
selves, were the first to challenge nurses to think about
theory development and application to substantiate the
practice of nursing. Following publications by Dickoff and
James(1968), nurses began to study philosophy andexplore
the application of theory to support and direct research and
practice to advance nursing science. Nursing history from
the 1960s and 1970s involved the debate among nurse aca-
demicianson theproper approachof applyingphilosophyto
developtheoryand expandnursingscienceto guidepractice.
Kikuchi (1992) accurately summarized that, without an un-
derstandingof philosophyin nursing,therecan be noscience
of nursing. Guyer and Wood (1992) emphasized the need
for theory to guide practice in their well-known statement,
“Theorywithout practice is empty; practice without theory
is blind”(p. 109). Through the years, nursing theory became
defined as “asetofinterrelatedconcepts,definitions,and
propositions that present asystematic view of events or situ-
ations by specifying relations among variables, in order
to explain and predict events or situations”(Glanz et al.,
2008, p. 26).
Early in the development of nursing theories, nurses
focused on abstract theories such as conceptual models
andgrandtheorieswhiledebatingthestructureandmethods
for developing focused, practice-oriented theories such as
middle-range theories (Higgins & Moore, 2000). Chinn
and Kramer (2011) elucidated the importance of middle-
range theories in nursing, “Substantive middle-range theory
can inform practice and lead to new practice approaches as
well as investigate factors that influence the outcomes that
are desired in nursing practice”(p. 48). Middle-range theo-
ries are viewed as essential to building nursing knowledge
astheycontainbothexplanatoryand predictiveunderstand-
ing allowing for empirical testing and clear application to
practice, education, and research (Lenz, 1998a, 1998b;
Liehr & Smith, 1999, 2017; Peterson & Bredow, 2009;
Smith & Liehr, 2014). Recently, with the emergence and
proliferation of the doctor of nursing practice degrees, the
need for middle-range theories as frameworks for evidence-
based practice projects has grown (Liehr & Smith, 2017).
Middle-range theories not only serve to structure evidence-
based projects and research studies by providing testable
propositions but guide the interpretation and application
of the findings. In essence, middle-range theories provide
a theoretical lens to illuminate practice, education, and
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research, thereby stimulating research and structuring knowl-
edge to guide nursing practice and build nursing science.
Methodology of Theory Evolution to a
Middle-Range Forensic Nursing Theory
The integrated practice model for forensic nursing science
(see Figure 1) introduced in 1990 defined the role of forensic
nursing as both a nursing and forensic specialty and estab-
lished the collaborativenature of forensicnursing withcrim-
inal justice and forensic science partners (Lynch, 1990). As a
conceptual model, the integrated practice model was based
on relevant sociological, philosophical, and nursing theories
and sought to link nursing theories with other disciplines to
provide direction in caring for patients affected by violence
(Valentine,2014; Waldman & Neill, 2016). The conceptual
modelpresentedabstractconceptsandassumptionsgleaned
from other theories to define forensic nursing as a unique,
interdisciplinary profession.
Thefirststep innursingtheoryevolutionfroma concep-
tual model to a middle-range theory involved a critique of
the existing conceptual model. A critique published in 2014
of the integrated practice model for forensic nursing science
indicated that, although the conceptual model defined the
role of forensic nursing within an interdisciplinary context,
the core components of the theory (assumptions, concepts,
and propositions) needed clarification and consistency
(Valentine, 2014). Specifically, the critique addressed the
need for the theory propositions to evolve into relational
statements to clearly support practice, education, and research.
The theoretical components of the underlying philosophical
theories, assumptions, concepts, and propositions ought
to build upon one another to clarify and strengthen the
theory. When the theoretical components are clearly linked
and support the propositional statements, then growth
in nursing science occurs through theory-driven research
(see Figure 2).
The evolution from a conceptual framework, the inte-
grated practice model,toamiddle-rangenursingtheoryre-
quired inductive and deductive reasoning as middle-range
theories are developed from both processes (Chinn &
Kramer, 2011; Liehr & Smith, 1999, 2017; Peterson &
Bredow, 2009; Smith & Liehr, 2014). Inductive reasoning
occurs from practice and research leading to observations
and conclusions, whereas deductive reasoning indicates
application of existing theories and abstract concepts to
emerging ideas or theories. Inductive reasoning for the
middle-range theory development required a synthesis of
seminal and current literature related to forensic nursing
and theory development, as well as the theorists’experi-
ences providing forensic nursing care and conducting fo-
rensic nursing research. Deductive reasoning for this theory
development required exploring additional philosophical
theories and assumptions and their application to the cur-
rent state of forensic nursing.
▪
The Constructed Theory of Forensic
Nursing Care: A Middle-Range Theory
The constructed theory of forensic nursing care: a middle-
range theory is not meant to replace the integrated practice
model for forensic nursing science,butratherbuildupon
the constructs within the established conceptual model. The
constructed theory of forensic nursing care theory compo-
nents are reviewed in the following order: name or title,
underlying theoretical and philosophical foundations, as-
sumptions, concepts, and propositions (see Table 1).
Theory Name or Title
The nameof a middle-range theory should reflect the central
ideas represented in the theory and designated theory ab-
straction level. The title of the conceptual model, integrated
practice model for forensic nursing science,containsthe
word “integrated,”which was the optimal adjective to de-
scribe the model that created the foundation for the profes-
sion by integrating philosophies, theories, and concepts
from nursing and otherdisciplines to define forensic nursing
as a unique profession. In many ways, this early conceptual
model was similar to creating a dot-to-dot picture and
connecting the dots to create a picture of forensic nursing.
The new middle-range theory is represented by the word
“constructed,”as this implies building upon, establishing,
and bringing together various elements into a cohesive
whole. “Constructed”also connects the theory to con-
structionism, which suggests that scientific growth is
FIGURE 1. Pictorial model of the integrated practice model for
forensic nursing science.
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Journal of Forensic Nursing www.journalforensicnursing.com 3
influenced by historical and cultural influences (Reed &
Shearer, 2011). As expected, the global culture surround-
ing and influencing forensic nursing in 1990 has changed
over the past 30 years. The conceptual model outlined the
picture of forensic nursing, whereas the middle-range the-
ory is poised to augment the growth and construction of fo-
rensic nursing into the future.
The remaining middle-range theory title provides clari-
fication on the theory focus and level of abstraction. The
phrase in the title, “forensic nursing care,”is essential as it
represents the core disciplinary perspective of nursing—
nursing care. Nurses provide care to patients, whether the
patient is an individual, family, group, community, or popu-
lation. The primary focus of the middle-range theory is to
improve outcomes of patients impacted by violence and
trauma, from individuals to populations, through forensic
nursing care. The final portion of the theory title clearly
states the abstraction level as a middle-range theory.
Theoretical and Philosophical Foundations
The integrated practice model for forensic nursing science
referenced six nursing theories, three sociological theories,
and one ancient philosopher, Plato. The constructed theory
middle-range theory remains grounded in the philosophical
foundations of the integrated practice model but reinforces
the theoretical base with the addition of three nursing theo-
ries, a socialtheory and twohealthcare models(see Table 2).
Lynch (1990, 2006, 2011) delineated the foundational
support of the referenced nursing theories to frame the role
development of forensic nursing. Detailed background in-
formation on the theoretical basis of the integrated practice
model is not the focus of this article but is available in other
documents (Lynch, 1990, 2006, 2011; Valentine, 2014)
FIGURE 2. Theoretical components leading to growth in science base.
TABLE 1. Definitions of Theory Components
Theory component Definition
Theory name or title Theory name that accurately
represents the main tenets, focus,
and abstraction level of the theory.
Theoretical and
philosophical
foundations
Principles that provide foundational
background and support for the
assumptions, concepts and
propositions in the theory.
Assumptions Statements accepted as guiding
truths within a theory. Assumptions
emanate from the theoretical
foundations and form a basis for the
resulting concepts and propositions.
Concepts Definitions of the subject matter or
phenomena presented in a theory.
Theories have increased clarity,
applicability, and strength when
concepts are clearly defined.
Propositions Statements describing the
relationships between two or more
concepts. Propositions stimulate
research as the statements are
meant to be tested.
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Theadditionaltheoriessupportingthe constructedtheoryof
forensic nursing care build upon Lynch’s approach to inte-
grate nursing theories with theories from other disciplines
to support forensic nursing care. Furthermore, the addi-
tional theories incorporate the growth that has occurred in
forensic nursing and provide a platform for future growth.
Nursing Theories
Two nursing theoriesincorporated within the middle-range
theory, caring science (Watson, 1979, 1985, 2008) and the
quality-caring model (Duffy, 2009, 2018), are focused on
the aspect of caring as this is the defining aspect of any nurs-
ing discipline, yet not clearly featured in the integrated prac-
tice model. When Lynch developed her conceptual model,
the goal was to establish a new nursing profession linking
nursing science with forensic science and criminal justice.
The integratedpractice model met this goalthrough forensic
nursing role conceptualization and interdisciplinary ac-
ceptance. At this time, the theory focus needs to adapt to
emphasize the importance of patient care while also de-
fining what “caring”means within forensic nursing. The
IAFN website clearly states, “forensic nurses are nurses first”
(IAFN, n.d.), implying that the focus of forensic nursing care
is on patient care.
The third additional nursing theory, emancipatory nurs-
ing praxis (Walter, 2017), highlights the significance of social
justice in forensic nursing. Indeed, the first pillar of the
IAFN Strategic Plan for 2018–2022 is the social justice pil-
lar confirming social justice as a core value within the pro-
fession (IAFN, 2018b). In 2018, the Journal of Forensic
Nursing published a special issue on social justice. Guest
editors Colbert and Donley (2018) asserted, “The very na-
ture of the work of forensic nurses is grounded in social
justice”(p. 51). A newly created IAFN Social Justice
Committee established a definition of social justice within
forensic nursing: “Social justice is the concept of ensuring
that the inherent rights of all people are respected, regard-
less of characteristics or vulnerabilities”(IAFN, 2019).
Caring science. Watson (1979) largely began the shift
within nursing theory to define the essence and science
of caring. Over the past 40 years, Watson has refined car-
ing in nursing to illuminate the concept of caring as both
a unique nurse–patient connection and a way of being.
Watson notesthe importance of definingcaring science,
caring responses, caring relationships, and carative factors
within the language of nursing. In Watson’s theory, caring
science is viewed as the essence of nursing and established
through human-to-human connections. Caring responses
are interactions that honor the patient in their current state
while acknowledging their becoming or future state. Caring
relationships are founded on authenticity, love, kindness,
and respect. The original 10 carative factors have evolved
to caritas processes to clearly connect caring with healing
through human connectedness (Watson, 2008).
Watsonnotes the significance of the caring moment as a
transpersonal experience when “two persons (nurse and
other) together with their unique life histories and phenom-
enal field (of perception) become a focal point in space and
time, from which the moment has a field of its own that is
greater than the occasion itself”(Watson, 1985, p. 59).
The concept of the caring moment is highly applicable
to many interactions between forensic nurses and others
(patients). Forensic nurses often connect with patients in
moments of trauma and distress necessitating the need for
nurses to create caring moments to facilitate healing.
Quality-caring model. The quality-caring model acknowl-
edges Watson’stheoreticalcaringconceptsandbuildsupon
the importance of establishing distinct caring relationships:
caring for the patient and family, others, self, and community.
TABLE 2. Underlying Nursing, Philosophical, and Social Theories and Models
Nursing theories Philosophical and social theories
Theories and models from the integrated practice model for forensic
nursing science
Patterns of knowing theory (Carper, 1978) Plato on truth (Plato, 427–347 B.C.)
Novice to expert theory (Benner, 1984) Social interaction theory (Mead, 1934)
Theory of culture care diversity (Giger & Davidhizer, 1991) Deviant behavior (Farrell & Swigert, 1982)
Fundamental patterns of knowing (Chinn & Kramer, 1995) Role theory (Conway & Hardy, 1988)
Transcultural nursing theory (Leininger, 1995)
Humanistic nursing theory (Paterson & Zderad, 1998)
Additional theories and models for the constructed theory of forensic
nursing care: a middle-range theory
Caring science (Watson, 1979, 1985, 2008) Social justice theory (Rawls, 1971, 1999)
The quality-caring model (Duffy, 2009, 2018) Biopsychosocial model of health (Engel, 1977)
Emancipatory nursing praxis: a theory of social justice in nursing(Walter, 2017) Trauma-informed care model (SAMHSA, 2014)
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Journal of Forensic Nursing www.journalforensicnursing.com 5
Caring relationships are defined as “human interactions
grounded in clinical caring processes”(Duffy & Hoskins,
2003, p. 82). Duffy (2009, 2018) identifies eight caring be-
haviors to maximize the identified relationships: mutual
problem-solving, attentive reassurance, human respect,
encouraging manner, appreciation of unique meaning,
healing environments, basic human needs, and affiliation
needs.
Although the first identified relationship in the quality-
caring model is caring for the patient and family, the theory
also encompasses the importance of caring relationships
between nurses and “others.”As forensic nurses function
within an interdisciplinary sphere, “others”relates to inter-
disciplinary colleagues with whom nurses develop caring,
supportive relationships to enhance patient care and benefit
communities. In addition, Duffy’sbroadviewofcaringre-
lationships not onlyinvolvesnurse–patient relationships
but acknowledges the importance of self-care for nurses.
As forensic nurses care for patients in traumatic situations
and environments, nurses may suffer from vicarious trauma
and compassion fatigue requiring attention to self-care.
The quality-caring model links the development of
caring relationships to improved patient health outcomes
(Duffy & Hoskins, 2003). As the scientific knowledge base
of nursing has grown, exploration of the positive health im-
pacts of nurse–patient caring relationships has escalated.
The quality-caring model has been cited as a theoretical
framework applicable to forensic nursing (Meunier-Sham
et al., 2019; Office of Justice Programs, Office for Victims
of Crime, 2016). Incorporation of nursing theories focused
on caring within the theoretical foundations of the con-
structed theory of forensic nursing care confirms that the
essence of nursing—all nursing—is caring.
Emancipatory nursing praxis: A theory of social jus-
tice in nursing. Walter (2017) developed a middle-range
theory on social justice in nursing through an international,
constructivist grounded theory study. Her goalin theory de-
velopment was to improve the conceptual clarity of social
justice in nursing to guide practice, education, and research.
Four dynamic concepts were constructed from the data:
becoming, awakening, engaging, and transforming. Move-
ment between the concepts was found to be influenced by
relational context (individual, group, organizational, com-
munity, national, and international) and reflexivity context
(descriptive, self-aware, critical, and emancipatory).
The process outlined in Walter’s theory is suggestive of
patterns of knowing theory, referenced in the integrated
practice model, in which emancipatory knowing is defined
as “the ability to recognize social and political problems of
injustice or inequity…to identify or participate in social
and political change to improve people’slives”(Chinn &
Kramer, 2011, p. 64). The addition of emancipatory nursing
praxis theory expands forensic nurses’understanding of
social justice while connecting constructs to prior theoretical
underpinnings.
Philosophical and Social Theories and Models
Three additional philosophical and social theories and/or
models complete the underlying theoretical framework of
the constructed theory of forensic nursing:social justice the-
ory (Rawls, 1971), biopyschosocial model of health (Engel,
1977), and trauma-informed care model. Collectively, these
theories/models substantiate the connection between foren-
sic nursing and interdisciplinary partners while emphasizing
health as a primary forensic nursing principle. The philo-
sophical and social theories referenced in the integrated
practice model focused on role development and deviant
behavior. In addition, truth was listed as theoretical foun-
dation, assumption, and concept(seeSupplementalDigital
Content 1: An Examination of Truth, http://links.lww.com/
JFN/A48).
Social justice theory. Rawls (1971, 1999) prepared the
groundwork for the concept of social justice within multiple
disciplinesand societies. Rawls declared that all people have
basichumanrights,liberties,and opportunitiesregardlessof
gender, age, race, social class, or other potentially discrimi-
natory categories.When theseconcepts are applied to health
care, they imply that all people in similar situations should
have equity in health care and resources. In turn, when these
conceptsareappliedto criminaljusticeproceedings,theyim-
plythatall peopleinsimilarsituationsshouldreceivefairand
equitable treatment and outcomes. Incorporation of this
theory within the constructed theory of forensic nursing
care’sfoundational principles expands our understanding
of social justice within forensic nursing and with our inter-
disciplinary partners.
Biopsychosocial model of health. The biopsychosocial
model of health acknowledges that the state of one’s health
reflects biological, psychological, and social influences. Engel
(1977) introduced this model to expand the understanding
of health and illness as a dynamic,complex interaction be-
tween multiple factors specific to each unique individual.
The term “patient-centered”developed from the princi-
ples within the biopsychosocial model (Biderman et al.,
2005; Smith et al., 2013). The biospsychosocial model
has been adopted internationally to evaluate health status
and guide practice, education, and research (World Health
Organization, 2002).
The IAFN core value statement strongly references a
patient-centered approach: “Our work will be guided and
informed by our commitment to ensuring access to evidence-
based, trauma-informed, patient-centered forensic nurs-
ing services”(IAFN, 2018a). Clearly, an adoption of the
principles within the biopsychosocial model frames the
current state of forensic nursing. In addition, as forensic
nursing is an international profession, the incorporation
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of the globally accepted biopsychosocial model connects
forensic nursing practice throughout the world. Inclusion
of the biopsychosocial model also reaffirms that the ground-
ing of forensic nursing is in health care and improved patient
care outcomes.
Trauma-informed care model. Recognition of the im-
pact of trauma on mental and physical health has grown
dramatically over the past 40–50 years. The emergence of
trauma-informed care principles in the 1970s was influenced
by social movements connected to the Vietnam War and the
expanding feminist movement. Burgess and Holmstrom
(1974) identified rape trauma syndrome, bringing attention
to trauma from interpersonal violence. Felitti et al. (1998)
connected traumatic childhood experiences with poor adult
health outcomes in the Adverse Childhood Experiences
Study. In the United States, the Substance Abuse and Men-
tal Health Services Administration (SAMHSA) has been at
the forefront of creating trauma-informed approaches for
healthcare delivery and services (SAMHSA, 2014).
To unify interdisciplinary approaches to trauma ser-
vices, leading experts developed the following definition of
trauma: “Individual trauma results from an event,series
of events, or set of circumstances that is experienced by an
individual as physically or emotionally harmful or life
threatening and that has lasting effects on the individual’s
functioning and mental, physical, social, emotional and
spiritual well-being”(SAMHSA, 2014). This definition led
to the identification of the three “Es”inherent in trauma:
event, experience, and effects. Following a unified definition
of trauma, development of a trauma-informed approach
focused on the four “Rs”:realizationoftheeffectsoftrauma,
recognize signs of trauma, respond using trauma-informed
principles, and resist retraumatization of clients and service
providers. To implement a trauma-informed approach, six
key principles are outlined for application across a variety of sit-
uations and settings: safety; trustworthiness and transparency;
peer support; collaboration and mutuality; empowerment,
voice and choice; and cultural, historical, and gender issues
(SAMHSA, 2014).
As noted earlier, the IAFN Core Value Statement con-
firms a commitment to “ensuring access to evidence-based,
trauma-informed,patient-centeredforensicnursingservices”
(IAFN, 2018a). Caring for patients who have experienced
recent and/or past trauma is inherent in the work of forensic
nurses. The ability for forensic nurses to understand and
apply trauma-informed care principles is essential to im-
prove healthcare outcomes of patients and avoid secondary
traumatization of forensic nurses and interdisciplinary
partners. Moreover, by understanding the long-lasting
effects of trauma and violence, forensic nurses work with
interdisciplinary partners to prevent violence in societies.
Following the establishment of the theoretical founda-
tions of the constructed theory of forensic nursing care,the
remaining theory components are presented and defined
as follows: assumptions, concepts, and propositions (see
Table 3).
Assumptions
The assumptions within the constructed theory of forensic
nursing care are derived from the theoretical foundations
and led to the concepts and proposition. The first assump-
tion broadly describes forensicnursing care as“specialized”
and identifies global patient populations. The second as-
sumption establishes forensicnursing asa collaborative pro-
fession in an interdisciplinary sphere and implies forensic
nurses, as part of interdisciplinary teams, are vested in
preventing violence and trauma as well as caring for those
who have experienced trauma. Middle-range theories with
few assumptions have higher explanatory poweras only ba-
sic conditions need to be met before making a hypothesis
from thepropositions (Meleis, 2012).
Concepts
As listed, the concepts are terms describing phenomena ad-
dressed within the constructed theory of forensic nursing
TABLE 3. Theory Components of the Constructed Theory of Forensic Nursing Care
Assumptions Concepts Propositions
1. Forensic nurses provide specialized nursing care to
diverse groups of individuals (victims, secondary
victims, witnesses, suspects, and perpetrators of
violence), families, groups and populations
affected globally by trauma and violence.
2. Forensic nurses practice as part of
interdisciplinary teams including other
healthcare professionals, victim advocates,
forensic scientists, law enforcement officers,
criminal justice professionals, researchers,
legislators and policy makers, and community
members to care for those affected by trauma
and violence and prevent violence in societies.
Forensic nurses
Forensic nursing care
Patients
Health
Forensic evidence
Forensic science
Criminal justice system
Forensic nursing care informs, impacts, and
improves:
–patient health outcomes
–forensic evidence outcomes
–criminal justice system outcomes
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Journal of Forensic Nursing www.journalforensicnursing.com 7
care. Clear definitions ofthe conceptsare necessary to create
a unifying theoretical language.
•Forensic nurses—Registered nurses with undergradu-
ate or graduate degrees, licensed by a government or
regulatory body to function as registered nurses with
specialized education in forensic nursing care and prin-
ciples (American Nurses Association & IAFN, 2017).
Although forensic nurses have additional education
and training related to forensic sciences and criminal
justice, they “are nurses first and foremost”inferring
the focus of forensic nurses remains on patients and
health care (IAFN, n.d.).
•Forensic nursing care—Forensic nursing care is foun-
ded upon theories and models referenced in this theory
to provide specialized and equitable physical, mental,
and emotional health care to patients impacted by vio-
lence, natural disasters, or mass destruction (American
Nurses Association & IAFN, 2017). Forensic nursing
care is patient-centered and trauma-informed reflecti-
ng best practices to develop evidence-based practice.
Best practices are determined through employing nurs-
ing criticalthinking skills and the nursing processto in-
dividualize patient care. Forensic nursing care includes
the assessment, evaluation, documentation, and treat-
ment of trauma response and injuries. Furthermore,
forensic nursing care withincommunitiesalsosupports
violence prevention through education and legislative/
policy reforms.
•Patients—Forensic nurses regard individuals, families,
groups and populations affected by violence and trau-
matic events as their patients;from victims and witnesses
of violence and disasters to perpetrators of violence.
In addition, patients may be living or deceased. Often,
patient populations include vulnerable and marginal-
ized individuals and communities (American Nurses
Association & IAFN, 2017).
•Health—Forensic nurses view health as a state of
wellness, as defined by patients, in a biopsychosocial
perspective. As a global nursing discipline, forensic
nurses support the World Health Organization’s
(2015) definition of health: “Health is a state of com-
plete physical, mental and social well-being and not
merely the absence of disease or infirmity.”Forensic
nurses understand the profound effects of trauma and
violence on patients’health and well-being.
•Forensic evidence—Forensic evidence refers to evidence
collected at crime scenes oronvictims,analyzedin
forensic laboratories, and possibly presented in court.
Types of forensic evidence include DNA, trace samples,
toxicology, pathology, digital, impression and pattern,
controlled substance, anthropology, and dental records
(Goux, 2016). Forensic nurses generally collect, docu-
ment, and package the following types of evidence:
DNA, trace, and toxicology samples; although forensic
nurse death investigators mayinterfacewithadditional
types of forensic evidence. Patient exam documenta-
tion, including photo documentation, is also evidence.
Forensic nurses have expertise in determining what fo-
rensic evidence to collect and how to maintain the integ-
rity of the evidence.
•Forensic science—Forensic science refers to multiple
branches of science in the quest to provide criminal jus-
tice information by employing the scientific method.
Forensic nurses have specialized knowledge of forensic
science principles to guide evidence collection, docu-
mentation, and containment.
•Criminal justice system—The criminal justice system
includes law enforcement, prosecuting attorneys, defense
attorneys, judges, juries, correctional officers, and correc-
tional facilities established by governments. Forensic
nurses have specialized knowledge of criminal justice
system procedures related to consulting with criminal
justice professionals, testifying in court, and maintain-
ing evidence integrity and documentation, and chain
of custody. Forensic nurses strive to be objective and
impartial in legal proceedings, testifying for both pros-
ecution and defense, to help establish equitability, truth,
and justice as criminal justice system outcomes.
Propositions
The power of theories to advance science is in the proposi-
tions as they provide testable hypotheses. Propositions are
the pinnacle of a theory. The propositions within the con-
structed theory for forensic nursing care are relational prop-
ositions, linking the concept of forensic nursing care to three
essential outcomes:
1. Forensic nursing care informs, impacts, and improves
biopsychosocial health outcomes for patients: individ-
uals, groups, families, communities, and populations.
2. Forensic nursing care informs, impacts, and improves
forensic evidence outcomes through thorough injury
assessment, evaluation, and documentation; proficient
evidence collection and documentation; and proper
containment of evidence.
3.Forensicnursingcare informs,impacts,andimproves
criminal justice system outcomes within local, regional,
state, national, and/or global communities.
Through the establishment of these relational proposi-
tions,research can be conducted to determine if in fact foren-
sic nursing care does inform, impact, and improve health,
forensic evidence, and criminal justice system outcomes.
The verification of these outcomes is highly significant for
the growth of the forensic nursing profession to validate the
need for forensic nurses throughout society and internationally.
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8www.journalforensicnursing.com Volume 00 •Number 0 •Month 2020
Establishment of these relationships bolsters the social jus-
tice pillar (forensic nurses ensure inherent rights of all per-
sons) of the IAFN Strategic Plan 2018–2022 pillars, as well
as two additional pillars: access pillar (forensic nurses avail-
able in every community) and public awareness pillar (foren-
sic nurses are valued, respected, and seen as integral to health
care; IAFN, 2018a). In addition, a long-term outcome of
the IAFN Research Agenda is to demonstrate that forensic
nursing care improves patient healthcare outcomes (IAFN,
2018b)—the most significant proposition within the theory.
The stated propositions are poised to advance the growth
of forensic nursing science by inspiring and supporting
nursing and interdisciplinary research.
Pictorial Model
The pictorial model of a theory should clearly represent
the concepts and propositions contained in the theory (see
Figure 3). The model developed for the constructed theory
of forensic nursing care contains the defined concepts and
visually represents the propositions. The pictorial model
highlights the importance of the first propositional state-
ment that forensic nursing care informs, impacts, and
improves patient health outcomes. The emphasis on this
propositionaffirms that the focus of the constructed theory
of forensic nursing care is on the relationships between
forensic nurses and the full range of patient populations.
The other two propositions are equal in importance to
each other, flanking the central proposition. Although the
primary direction between the concepts is forensic nursing
care improving outcomes, multidirectionalrelationships ex-
ist between the concepts. Patient health, forensic evidence,
and criminal justice outcomes should continually inform,
impact, and improve forensic nursing care. In addition, the
outcomes in the three categories are interrelated in a dy-
namic, collaborative manner.
▪
Conclusion
The constructed theory for forensic nursing care: a middle-
range theory serves to unify the focus of forensic nursing to
guide practice, structure education, and stimulate research.
Although the roles and settings of forensic nurses are diverse
throughout the world, the aims of forensic nursing care to
provide patient-centered, trauma-informed, evidence-based,
and equitable nursing care to those impacted by trauma
and/or violence are universal. In addition, forensic nursing
care should positively impact forensic evidence and criminal
justice system outcomes due to the specialized expertise of
forensic nurses. The overarching goal of the middle-range
theory is to validate the critical importance of forensic
nursing care to improve societies.
Theory-based practice is meant to “serve the betterment
of humankind”(Cody, 1999, p. 13). Forensic nursing
developed from nurses inspired to do just that—better
humankind. Continued growth in forensic nursing based
on theoretical principles will amplify the global impact of
forensic nurses to care for humankind.
FIGURE 3. The pictorial model of the constructed theory of forensic nursing care.
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Journal of Forensic Nursing www.journalforensicnursing.com 9
▪
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