The Academy Aperçus is a monthly feature that celebrates 75 years of forensic science by spotlighting the history and anticipating the future of each section of the Academy. Beginning in March 2022 and progressing through each section in the order of acknowledgement by the Academy, sections will memorialize salient events, highlight members, and provide insight into why the Academy remains the premier forensic science organization in the world. This month features the Academy's newest section — the Forensic Nursing Science Section.

Creation of a Nursing Role in the Forensic Sciences

Source: Virginia A. Lynch, MSN, RN

As the AAFS 2018 Distinguished Fellow, Retired, I am honored to provide this information on the Forensic Nursing Science Sectionwith input from my colleagues, Joyce P. Williams, DNP, RN, Section Chair, and Jessica Volz, DNP, as they describe their exploration into the American Academy of Forensic Sciences.

The Forensic Nursing Science Section

Forensic Nursing is one component of the multidisciplinary, multi-sectored, forensic investigative sciences that works to minimize the devastating impact of social and cultural violence. As forensic nursing practice evolves problematic social situations corresponding to the escalation of reported violence reinforce the need to redefine the role dynamics, processes, and guidelines. The enduring purpose of this new science is to promote forensic healthcare and help determinetruth where the scales of justice may be poised on the forensic nurse along with other trial testimonials. After three decades of refining the implementation and advancement of this concept and theory; 21st century forensic and nursing science now requires enhancement and expansion. This specialty emphasizes exceptional nursing care and prevention modalities with a forensic focus on health and justice. These principles guide the forensic nurse clinician toward positive outcomes of holistic, forensic nursing care, which includes body, mind, spirit, and the law.

History of the Forensic Nursing Science Section

From the time I attended my first American Academy of Forensic Sciences meeting in 1985, I knew I wanted to be a part of this moving force in the world of the forensic sciences. I found an identity for what I hoped to achieve and an inspiration for what I have accomplished since that time. The outcome has been the evolution of Forensic Nursing Science…a model for the futuristic advancement of a forensic specialist in nursing science that would help provide greater outreach for health and justice globally. I became the first forensic nurse to be admitted to the membership of the American Academy of Forensic Sciences. However, it wasn't because I was a nurse. Although I held a Bachelor of Science Degree in Nursing Science, it was not an approved discipline at that time. I was admitted as a Medical Death Investigator. Little did I know that I would still be here 38 years later…

As an undergraduate nursing student I was assigned a project pertaining to the social and judicial impact of human violence against patients with crime-related trauma. This project took me into the wider world of interpersonal crime and the scientific investigation of death. It became my entry into the forensic sciences and the physiological, psychological, and spiritual trauma associated with victims of human violence and the associated medical and legal outcomes of death. During my time as a surgical and emergency clinician I recognized the need for nurses to be enlightened in the precise preservation and relevance of forensic evidence.

Forensic nursing did not exist as a recognized discipline in 1984. I wanted to understand why some patients died and others survived the same or similar procedures. Death investigation subsequently provided me with many answers and became a focus of my health and justice career at that time. After studying the legal impact of forensic science in healthcare I studied medical death investigation under Dr. Charles Petty, Chief Medical Examiner and Dr. Patrick Besant Matthews, Deputy Chief Medical Examiner in Dallas, Texas, which included Dr. Irving Stone, Chief Criminalist and Director of the Southwestern Institute of Forensic Sciences. Later, I had the opportunity to study advanced death investigation under Dr. Charles Hirsch, Chief Medical Examiner, New York City.

This experience broadened my perspectives regarding the potential contributions of nurses in innovative forensic roles which led me to advocate for the role of the forensic nurse death investigator. This role had first been implemented by Dr. John Butts, Chief ME of Alberta, Canada in 1975. After these important opportunities to acquire knowledge in this field I discovered there were no joint university courses available in this specialty. I was appointed a medical death Investigator under the Direction of Dr. Nizam Peerwani, Chief Medical Examiner of the Tarrant-Parker County Medical Examiner District in Ft. Worth, Texas. I was the first medical investigator in Parker County, an adjoining jurisdiction transforming a Justice of the Peace jurisdiction to a Medical Examiner System thus becoming the first forensic nurse investigator in this jurisdiction of a population of 65,000 in 900 square miles. Several years later I was appointed a Coroner in the state of Georgia.

AAFS

The American Academy of Forensic Sciences refocused my professional interest, centering the forensic and nursing sciences at the core of my career and inspiring me to learn more about its application to nursing practice. My first experience in a crime laboratory confirmed the need to incorporate specialized studies in the forensic sciences. I learned that numerous interpersonal crimes are never adjudicated, often due to the failure to report, failure to recover, loss of evidence inadvertently discarded, improperly preserved, or unsecured after collection by healthcare personnel. Forensic nurses can assist the forensic pathologist with their knowledge of natural disease processes, anatomy, physiology, and pharmacology, among other medical related issues. I discovered that forensic medicine lay the entire foundation for all clinical medicine.

Without the determination of cause of death we would not know how to save lives, extend life, or prosecute homicide appropriately. Yet, forensic medicine is the second smallest medical specialty worldwide. Forensic medicine requires a designated fellowship to study forensic medicine under the direction of Board Certified Forensic Pathologists. Due to the shortage of forensic pathologists, severe issues are created in the time-limited requirements for court cases, infectious diseases, burial requirements, and/or investigations, and family law related to inheritances. Forensic nurses who are interested in death investigation may also function as an elected coroner in areas of the U.S. where there are no forensic pathologists. The forensic nurse coroner coordinates their cases with a forensic pathologist who performs the autopsy. Both may testify in court about the specific role they filled.

The forensic nurse death scene investigator may also testify regarding their role at the scene, interviews with first responders, and the conversations with the decedent's physician and family when making notification of death. Working in the field of death investigation is an appropriate and important role for nurses as an associate to the forensic pathologist to help recover medical evidence and intercede with grieving and bereaved families in a sensitive manner. The sexual assault nurse examiner (SANE) may also be requested to provide the post mortem sexual assault examination, recover physical and biological evidence prior to the autopsy as an expert clinician who is a specialist in this role and testifies in court.

The Power of Forensic Nursing

Forensic nursing is a progressive discipline that recognizes human violence and trauma through a contemporary domain of scientific knowledge, health care, human rights, social justice, public health, and evidence-based practice. Broadly defined, forensic nursing science is nursing applied to the law, following the long-established exemplar of forensic medical science through a collaborative relationship.

Forensic nurses are licensed registered healthcare providers qualified in the examination, evaluation, and treatment of patients presenting with forensic biomarkers of crime-related trauma and the clinical investigation of questioned deaths where no medical treatment is required. Forensic nurses do not practice medicine and refer any medical treatment to the Forensic Nursing Services Medical Director on duty.
The International Association of Forensic Nursing generalist forensic nurse examiner or sexual assault nurse examiner provides fact or expert witness testimony on their case as the physician is considered a consultant. If the case is transferred to the medical examiner after death the nurse may testify to the previous clinical treatment and the medical examiner testifies to the autopsy.
Global violence, problematic social and cultural situations reinforce the need to define the dynamics, processes, and guidelines for forensic nursing practice as it evolves and endures change.
Nurses have historically cared for victims of violence — both the living and the dead. In the 17th century, nursing had not yet become a science and midwives filled this role. Two centuries later, Florence Nightingale established the first aspects forensic nursing when caring for the Crimean War wounded and dead. Injury and death of civilians during times of war are categorized as crimes of war based on the Geneva Convention.

Forensic Nursing Education

In 1984, I proposed a Master of Science in Nursing in the Clinical Specialization of Forensic Nursing to the University of Texas, Arlington. It was approved by the Graduate Dean of Nursing, the curriculum committee, and the Board of Regents becoming the first Graduate program in this discipline worldwide and the first listed in the National League of Nursing (NLN).
Currently, there are 92 U.S. colleges and/or universities offering forensic nursing at various levels, from certificate to doctoral programs with a number of international degree programs available.
In 1991, the American Academy Forensic Sciences (AAFS) recognized forensic nursing as a scientific discipline within the General Sciences Section. A BSN is considered an entry level degree for nurses by the ANA and the AAFS. The classification of a specialist requires a minimum level of a master's degree or above.
This pronouncement launched a movement now recognized worldwide. The following year, the International Association of Forensic Nurses (IAFN) was founded with 72 nurses, currently expanding to 6,500 members including 50 international countries.
By1995, the American Nurses Association (ANA) Congress of Nursing Practice bestowed the official status of a nursing specialty upon the science of forensic nursing.
India has become the first country to mandate a full semester course in forensic nursing science for all BSN nursing students in every nursing college across India with plans to develop a master's degree in this field for advanced nursing studies.
In 2018, the Academy of Forensic Nursing (AFN) was established offering one more option for nurses to seek a forensic organization, educational benefits, and membership.
In 2022, Forensic Nursing Science was recognized as the American Academy of Forensic Sciences' 12th Scientific Section and has set precedence for other academies of forensic sciences to incorporate forensic nursing in a variety of disciplines.
The Balkan Academy of Forensic Sciences has emulated the AAFS in creating a Forensic Nursing Science Section that will reach across the 11 Balkan countries establishing a new trend in the international academies of the forensic sciences to include forensic nursing.

Forensic Education in Nursing

Prior to 1986, no formal education or professional role that required a forensic education existed for nurses engaged in forensic enterprises. Although nurses performed various forensic tasks only in-house training was available - no entry level degree, competency examinations, or certifications existed or were required. University programs were required to arrange external forensic clinical areas that are essential to be recognized as an expert in this field. Qualifications for the forensic nurse expert necessitate specialty education, academic degrees, professional experiences, publications, and membership in professional organizations.

Forensic nursing requires a unique course of studies and clinical practice to provide forensic nursing expertise. I recognized the need for nurses to be educated about the precise preservation and relevance of forensic evidence and was motivated to establish a discipline to pursue practice changes in a new nursing specialty aimed at improving health and legal outcomes for victims of violence and the falsely accused.

With approval from the University of Texas, Arlington (UTA), Samuel Hughes, PhD, RN, Graduate Dean of Nursing understood the necessity to create a professional role in a discipline that requires precise understanding of the scientific method, current research, and pertinent law, including the vital aspects of theoretical and evidence-based practice, a formal academic education was born. With the encouragement and approval of Luther Christman, PhD, RN, to qualify as a forensic nurse, on-the-job training would no longer be considered sufficient.

During my position as a medical death investigator I pursued my master's degree with a focus on the science of what I titled Forensic Nursing, a program I was instrumental in designing. Initially, I had proposed it as an independent study. However; the dean was intrigued and chose to offer it as a full graduate curriculum. This initial program left a blueprint for forensic nursing programs to be designed and recreated in contemporary methods, curriculums, clinical internships, and advanced sciences. Forensic nursing education has become a prerequisite for forensic competency, ethics, and leadership. Yet, it has been historically absent in traditional nursing education. Until traditional nursing programs begin to fulfill this need, forensic nursing education has to be sought through external resources and institutions of higher learning where specialized programs are offered with independently arranged clinical experiences to advance knowledge, proficiency, and recognition. They are more available at present and are also accessible online. Furthermore, AAFS membership is a conduit for a wider range of education, mentorship, collegial advice, and opportunities.

Founding a New Science

Since the advent of forensic nursing as a scientific discipline was first academically recognized by UTA , a global action has advanced this evolving force in healthcare to the forefront of the health and justice systems. As the foci of human violence impacts life and death, the science of forensic nursing has been recognized: in trauma centers, emergency departments, crisis shelters, conflict and war zones, scenes of mass disasters and deaths, police agencies, medical examiner systems, and courts of law. This is an exciting moment in the history of forensic nursing science and promises to provide a solid knowledge base for theoretical analysis and role development. By identifying the basic and advanced competencies required at each level of academic preparation, forensic nursing theories will help prepare forensic nurses for the challenges ahead: advocating for health-based forensic interventions for the reduction and prevention of violence, the protection of individual human rights, and global health diplomacy.

As the health and justice systems become familiar with the benefits of forensic nursing, they will come to appreciate the efficacy of collaborative relationships between these professional disciplines to resolve issues associated with the medicolegal case management of forensic patients. One of the most complex cases admitted to the hospital emergency department (ED) is that of the patient who reports sexual assault. Despite the number of these patients treated, many EDs do not have a sexual assault nurse examiner on staff to oversee proper attention to the legal implications and meticulous recovery of the fragile and highly perishable biological evidence upon admission.

Investigation: A Nursing Role

The concept of investigation is a foundational principle that is clearly identified in the academic application of forensic nursing practice. Investigation is the basis for all evidence-based nursing practice signifying a systematic process of assessment and application of the scientific method pertaining to health and justice outcomes. Forensic nursing introduces investigation as an instrument to allow resolution of health and legal issues that offer the best possible care alternatives to meet the objectives of both. Accordingly, this concept has been further confirmed as stated in that the function of the scientific method in nursing practice leads to resolution of problems and offers the best possible care alternative.

One solution has been the addition of the sexual assault nurse examiner, a highly skilled forensic clinician who can be certified in the analysis and examination of adult and/or pediatric, male or female, living or deceased sexual assault patient. The presence of the SANE on each shift eliminates unnecessary delay in response to initiate the examination; this system has proven to enhance the quality of medical forensic evidence and to increase successful prosecution. The forensic nurse, both FNE and SANE, maintain a professional partnership with the forensic physician known as, a clinical forensic physician, a chief medical officer, or a police surgeon in many countries, the emergency physician or medical director of forensic nursing services in the U. S. A. and /or the chief medical examiner (forensic pathologist) in cases of questioned deaths. The forensic nurse serves as an associate to these professionals and maintains an independent role to perform forensic functions and tasks with the exception of when medical treatment is required. At that time the medical director of forensic nursing services or designated physician is called.

Founded in the traditional principles of the nursing process, the investigative approach of forensic nursing promotes flexibility and independent thinking to avoid omissions and premature conclusions related to court testimony where innocence and guilt are in question. The theoretical foundations have evolved from the need to provide a framework to guide the forensic nurse in a new arena of nursing practice. It has offered a basic and living reference for the clinical investigation of trauma and death and the prevention of similar future events. The evidence contributed by investigation is evaluated according to the criteria of validity and utility to assess the methodological rigor of investigative studies as well as to recommend a practice or technique as appropriate or not, according to the scientific evidence available (Bario, Lopez, 2001). Forensic nurse examiners are active in an extensive range of subspecialties requiring investigation in the Emergency Department, Department of Public Health, Surgical Suites, long term healthcare facilities and other areas within the judicial system, including Offices of State Attorney Generals, County and District Attorneys, community jails, and state prisons.

By2002, the State Supreme Court of Virginia affirmed the expert witness testimony of the Sexual Assault Nurse Examiner (SANE) in criminal and civil litigation, based on the extensive clinical forensic education, experience, and qualifications these specialized nurses possess. Concurrently, the ANA recognized forensic nursing as one of the four dominant areas for future nursing advancement.
In 2014, the U.S. Congress and President Obama signed into law a provision recognizing that forensic Sexual Assault Nurse Examiners (SANE) should work with military physicians to help reduce and prevent sexual assault in the U.S. Armed Forces.
The SANE has become the primary face of forensic nursing roles based on the predominance of sexual violence worldwide.
Forensic nurse examiners within the discipline's membership are active in an extensive range of subspecialties: pediatric and adult forensic health, psychiatric mental health, nursing jurisprudence, death pronouncement and investigation, intimate partner violence, child and elder abuse, human trafficking, refugee health, and other areas where forensic assessments are analyzed, including genocide, torture, and mass disaster response.
Reporting of suspected criminal acts is essential and may be required by laws specific to various countries.
Attention to patient and public education regarding human violence, the forensic nurse specialist practices prevention, thus assisting his or her partners in social justice management of the social order in life and in death.

The State of Forensic Nursing

Forensic nursing was designed with a purpose. Science and its conceptual foundations have created new roles within the milieu of healthcare based on the medicolegal needs of patients, forensic education, and consultation with a mutual investigation of the cause and effect of trauma (justice) and research for clinical practice (health) interventions with prevention at the core. Both concepts embrace the philosophies of the forensic and nursing sciences to indicate confidence of human reasoning.

The significance of this purpose has been to create an additional resource to supplement and support the identified shortage of forensic medical practitioners worldwide. Differences in law regarding the recovery of clinical forensic evidence in near-death cases in Pakistan require that evidence be recovered first before any medical or lifesaving treatment is performed. Because the forensic physician is not on duty at all times the patient may bleed to death before the physician arrives. This has been referred to as "Death by Red Tape". The presence of a forensic nurse clinician at all times, skilled in evidence recovery and wound documentation may be critical to allow the emergency physician to proceed with lifesaving intervention and prevent imminent deaths.

This concept evolves from the belief that role flexibility within nursing is essential in developing a theory that advanceswith time as trends in crime, violence, and laws continually change. As culture and traditions continue to change with time so must laws that govern healthcare practices to meet and manage the methodologies of a post modern world to reduce and prevent human violence, for a better world. That would include the science of forensic nursing as a postmodern strategy.

Traditionally, falling within the purview of criminal investigation, these concerns were not previously designated as specific to nursing scholarship and role behaviors. Thus, the Integrated Model for Forensic NursingScience (1988), a conceptual model for theory development and the Constructed Theory of Forensic Nursing Care (2018) defines a middle-range nursing theory developed to affirm the evidence and scientific based-practice of forensic nursing care. Flexibility allows for traditional roles in nursing while adapting innovative functions, allowing the specialist to provide forensic services at the same time as applying nursing principles and role behavior, Pasqualone (2015) identifies 27 categories of forensic patients that are admitted to clinical areas on a regular basis, emphasizing preparedness in forensic nursing education is essential.

Conclusion

Forensic nursing is a dynamic discipline that recognizes violence through a contemporary perspective of nursing knowledge, life and death, healthcare and human rights, social justice and injustices. The science of forensic nursing encompasses the forensic case management of victims of crime, both survivors and decedents, the accused, and the condemned. The AAFS has fostered further growth and development of a forensic specialist in nursing science and supported strong legislative mandates, healthcare regulatory requirements, and advocacy. Forensic nursing science is being sought globally and the demand for services of nurses with forensic expertise is great as we confront clinical issues related to global human violence.

Over the past 30 years forensic nurses have developed, evolved, and adapted to the multidisciplinary Academy Sections - together with the scientists – and have identified mutual areas of interest. It has been a stimulating adjustment to become familiar with the forensic terminology, unique legal issues, scientific research, categories of crime, and causes of death. Forensic nurses are not criminal investigators or social advocates; rather they serve as the clinical examiner of trauma and patient advocates who liaise with criminal justice agencies, patient advocates, and courts of law. Forensic nurses are recognized as expert witnesses based on academic qualifications, specialty education, certifications, publications, and the professional associations to which they belong.

With the acceptance of Forensic Nursing Science as the 12th Academy Section, our members continue to reflect contemporary nursing practices in a changing world of endless violence and human abuse. This discipline affords the long-awaited opportunity to achieve what was an initial outreach — to provide a resource in nursing that did not previously exist as a formal educational and experiential concept — into a restructured, refined, and recognized model applicable to the tasks at hand for the professional forensic nurse.

Section Chair Joyce Williams, DNP, RN, has provided a strong leadership role in the development and success of establishing a new section with significant aplomb and assurance that we will fulfill the requirements and approval of the AAFS Board of Directors as a noteworthy addition to the history of the Academy with honor. Dr. Williams contributes the following insight of establishing a new science.

As the 12th and newest section, the Forensic Nursing Science Section is off to a robust start. Joyce Williams, DNP, RN, the inaugural chair of the Forensic Nursing Science Section (FNSS) has been valiantly leading the charge with over 40 other current forensic nurse members who transferred from the General Section to establish a section of our own. The FNSS will intensify its efforts, not only to showcase the plethora of work specific to our discipline, but also to highlight the contributions that we make when collaborating with many of the eleven other scientific disciplines within the Academy.

As a forensic nurse educated in forensic science at Oklahoma State University (OSU) (Go Cowboys) and University of Tennessee, (UT) Memphis (Go Vols), the AAFS conferences add depth and vital networking opportunities when interfacing with high-level experts across the globe. The synergy that is created at each Academy meeting cannot be underestimated. Important elements of my practice have been creating graduate forensic nursing education courses, analyzing injuries across the lifespan, investigating death scenes, disaster prevention efforts, and researching how to prevent morbidity and mortality in combat. Each of these experiences has broadened the scope of opportunities for forensic nurses to make a positive impact in limiting scenarios of violence throughout the world.

The FNSS goals strive to defend and strengthen the gamut (breadth, scope, extent, scale) of work within our membership. More recently many of our members have been involved in humanitarian efforts to assess and serve populations in war torn countries in addition to third world countries where medical services are stretched thin or even non-existent. It is those contributions that are bold, audacious, fearless, courageous and spirited. We cannot underestimate the value and importance of these nurses.

Forensic nurses are now working in partnership with a team of other forensic science professionals who have begun the journey to draft forensic nursing standards related to the collection and storage of physical evidence from victims of sexual assault and sexual assault examinations. They will endeavor to encourage research to develop and validate new strategies for the training and continuing education of practitioners. Numerous AAFS FNSS members are participating in this work initiated by the Organization of Scientific Area Committees for Forensic Science (OSAC). Looking to the future, it is our desire to join the Academy Standards Board (ASB) Consensus Body (CB). Once the proposed standards are reviewed, commented on publicly and published in the SDO-and OSAC, we look forward to these proposed standards to be included on the Registry. As chair of the FNSS and chair of the forensic nursing subcommittee (FNS) we are committed to reaching out to other professional nursing organizations, seeking full implementation by all practitioners.

2021:

One of the most recent advances where the forensic sciences and forensic nursing have established a joint venture is through the National Institute of Standards and Technology (NIST) and the established Organization of Scientific Area Committees for the forensic sciencesto facilitate the development of sound technical forensic standards and encourage their adoption across the forensic science community. These standards define minimum requirements, best practices, standard protocols, and other guidance to help ensure that the results of forensic analyses are reliable and reproducible.
OSAC launched a Forensic Nursing Subcommittee in October 2021 to draft standards for the evaluation and intervention of forensic patients. The initial goal of the subcommittee is to draft standards that pertain to all aspects of sexual assault; the future will include additional guidelines that support all aspects of forensic nursing. The ultimate goal is to improve the quality of care for victims, prevent wrongful convictions, and help ensure that injuries and evidence are properly identified, collected, and preserved.
It all about relevancy. Forensic nurses distinguish themselves using not only their unique knowledge of the nursing process and proficiencies, but also their experience with the legal system to obtain occult forensic details. The aim of a scientist is to allow the facts to speak the truth. Forensic practitioners contribute to communities by advancing direct and indirect services to victims caught in the surge of violence in today's world. As healthcare professionals, forensic nurses are positioned to meet the needs of our environment where episodic terror, gun violence, pandemics, and rage are ever present. Forensic nursing began as a more singular movement; but now, the discipline has revolutionized into a paramount force without limitations.

The following comments are from Dr. Jessica Volz, one of our most recent members of the Forensic Nursing Science Section. Dr. Volz is the director of the Forensic Medical Unit program at Adventist HealthCare Shady Grove Medical Center in Rockville, Maryland.

Nurses comprise the largest health care profession in the United States and have cared for victims of violence across the span of history. Historically nursing has been a predominately female profession and has faced many hurdles in advocating for itself as well as it does for its patients. Today, we celebrate that the nursing profession is growing in diversity and strength.

The establishment of Forensic Nursing as a formally recognized specialty is the result of the hard work, dedication, innovation, and scientific contributions of trailblazers like Ms. Virginia Lynch, Dr. Joyce Williams, Dr. Patricia Speck, Ms. Diana Faugno, and countless others. Since the early work done by Ms. Virginia Lynch in the 1980s, Forensic Nursing has experienced tremendous growth. These founders continue to contribute to the specialty through development of the science and mentorship that shapes their legacy.

Initially, while practicing as a forensic nurse examiner, I cared for those who had been sexually assaulted. I had the opportunity to meet Dr. Williams and through her mentorship, engaged with other visionaries within the discipline. These mentors have helped shape my practice and the practice of many of my colleagues. They help us to grow without unnecessary hard lessons learned and give guidance and stability when the waters are tough to navigate.

Their patience (and willingness) to share their experiences, wisdom, and guidance has encouraged many. It is because of this mentorship that I joined the Academy. I quickly came to know that The American Academy of Forensic Sciences has a rich history that supports forensic disciplines in rigor, integrity, and promotion of justice. The recognition of forensic nursing by the Academy gives legitimacy to our profession, validates our utility and practice, and provides a forum for development of the future. The Academy provides forensic nurses now and those of the future with a place to learn about their history, share ideas, and add depth to their practice. I am honored to have the privilege of being a forensic nurse and look forward to being part of the next generation of forensic nursing science.

Academy Aperçus—January 2023