Resources for Evidence Management in Health Care Settings
Written by Patricia M. Speck, Kathy Gill-Hopple, Rachell A. Ekroos & Diana Faugno   

Academy of Forensic Nursing founding members contribute to the establishment of evidence management guidelines

FORENSIC NURSING is a nursing specialty (ANA, 1995) reflecting a theoretical nursing framework of practice that is scientifically sound and supported by published evidence (Speck & Peters, 1999). Forensic nurses work in a variety of practice settings providing nursing care to patients who intersect with legal systems. For years, sexual assault victims sought care in emergency departments, to be overlooked or passed-by for patients who had emerging physical needs (Speck & Aiken, 1995) (Speck & Patton, 2010). Little was understood about the emergent condition of the sexually assaulted patient, and often, patients left the emergency department without receiving care (Aiken & Speck, 1991).

Significant advances occurred over the last 40 years, including the emergence of forensic nursing in 1992 (Lynch, 1990). When health care and legal systems intersect (Speck & Peters, 1999), the responsibility for management of evidence of crime rests solely on the institution and the health care providers specially trained to gather, handle, and transfer the evidence (OVW, 2013). These items include not only sexual assault evidence collection kits (SAEKs), but also foreign objects removed from bodies, clothing, trace evidence, body fluids, and other items attached to the patients they serve (OVC, 2016). However, registered nurses in health care settings are rarely aware of standards that influence evidence handling, relying instead on word-of-mouth and organizational listservs.

Several Academy of Forensic Nursing charter members are working closely with the National Institute of Standards and Technology (NIST) to ensure the methodologies and techniques used to gather, process, and handle evidence incorporates the science supporting the procurement and handling of evidence in health care settings.


Evidence neatly stacked at the evidence storage facility of the Las Vegas Metropolitan Police Department Forensic Laboratory.

Sound nursing foundations and principles are implemented in the handling of items—including evidence—where the handling ultimately affects the item’s meaningfulness, relevance, and admissibility in a courtroom. These forensic nursing authors often teach nurses that their professional nursing and forensic nursing expertise is useful to judicial proceedings, first as a fact witness and then as subject-matter expert or expert witnesses. The process begins with the registered nurse, who observes, documents, and reports findings (ANA, 2018) for the purposes of gathering information for the medical diagnosis determined by a physician or nurse practitioner. Handling the samples in medical settings requires using forensically sound standards for samples ultimately used as evidence in an adjudicated case. This reflects the essence and use of the nursing skills of accountability (signing off to another), safety (avoiding self-contamination and giving the right dose to the right person at the right time), and knowledge of health and health outcomes defined in nursing as biopsychosocial and spiritual—all health-related concepts (ANA, 2010). Appropriate safeguards must exist throughout the nursing process of assessment, nursing diagnosis, planning, intervention, and evaluation (ADPIE) to provide assurance to the patient and the system that the lifecycle of samples holding potential probative value is forensically sound. The forensic and legal systems will call these samples evidence. The nursing professional will call them samples collected at the request of the patient. The fact is, even though it is called evidence during investigation and adjudication, the sample may or may not hold probative value once analyzed as an item of evidence.

Evidence-based, research-informed forensic nursing skills were desperately needed when President George W. Bush signed “Advancing Justice Through DNA Technology” in 2003, setting aside over $1 billion for the initiative. The purpose was to eliminate SAEK backlogs, strengthen crime and laboratory capacity, stimulate research and development, and provide training (CRS, 2003). Despite this focus on DNA technology that would convict and exonerate the accused, there was one problem: If the health care provider did not understand the nuances of evidence collection while providing trauma-informed and patient-centered care, the victim/patient often did not follow through (Darnell et al, 2015). Herein lies the conundrum.

From the earliest collaborations, the Sexual Assault Response Team (SART) had difficulty with sharing information, role conflicts (Ekroos et al, 2019), and autonomy limitations (Maier, 2012). These misunderstandings, among other factors, contributed to the lack of sustainability in forensic nursing programs serving patients who complained of sexual assault. Also, education of forensic nurses was not taking place in nursing programs, but instead was provided by non-nurses during the first decades of forensic nursing care (Speck & Aiken, 1992). This resulted in the mislabeling of forensic nurses as “evidence collectors” (Ekroos, 2019). These early nurses were “flying by the seat of their pants” (personal conversation between Drs. Speck and Ledray, 2013). Evidence handling was never an early issue for forensic nurses because law enforcement would take the SAEK when it was sealed, and laboratories would develop the evidence posthaste. However, as the numbers of victims increased, the numbers of untested SAEKs greatly increased. During the forensic science development of standards and funding priorities, particularly in technical working groups, the occasional token nurse was a participant (personal conversation with Dr. Speck). The science eventually trickled down to the masses of practicing forensic nurses who also wanted to effect change and participate in federal processes. Advocates supported the activity, and within ten years of defined forensic nursing practice, nurses were participating in the development of multidisciplinary standards (OVW, 2004). Recent activities include the NIJ SAFER Working Group:

“The SAFER Working Group was developed to address the SAFER (Sexual Assault Forensic Evidence Reporting) Act of 2013, which recommends, in part, the development of best practices and protocols for the collection and processing of DNA evidence in sexual assault cases (The Sexual Assault Forensic Evidence Reporting Act of 2013 (Reauthorized 2016) (SAFER Act), P.L. 113-4, § 1002, (o)(1)).

“The SAFER Working Group, which convened over the course of more than two years, consisted of subject matter experts empaneled by the National Institute of Justice (NIJ) and representing victims, victim advocates, forensic nurses specializing in sexual assault, medical examiners, forensic laboratories, law enforcement agencies, prosecutors, and the judiciary. The working group considered issues relating to evidence collection; prioritization of evidence and time periods for collection; evidence inventory, tracking and auditing technology solutions; investigative and policy considerations; and communication strategies. With the diversity of backgrounds and views, the SAFER Working Group successfully reached substantial agreement on a variety of complex issues.”

—National Institute of Justice, National Best Practices for Sexual Assault Kits: A Multidisciplinary Approach, p. iii (2017)

The collaborative activities around the SAFER legislation identified gaps in evidence management affecting forensic nursing and SART team members alike. Consequently, there are significant documents to guide forensic nurses in hospitals and health care systems developing agency policies and procedures in compliance with recommendations. There is also a Department of Justice (DOJ) funded National Institute of Standards and Technology (NIST) group meeting regularly to establish evidence management guidelines. The rollout is planned for October 2-4, 2019 in Gaithersburg, Maryland, outside Washington, DC. See https://www.nist.gov/news-events/events/2019/10/evidence-management-symposium for more information and to register.

A variety of evidence management guidelines follow and may be useful in forensic nursing practices with patients who experience violence. These guidelines are also useful to other professionals in Table 1.

Table 1. Professionals who benefit from Guidelines and Best Practice

Forensic Nurse
Correctional Nursing Specialist
Forensic Clinical Nurse Specialist
Forensic Nurse Investigator
Legal Nurse Consultant
Sexual Assault Nurse Examiner
Forensic Gerontology Specialist
Forensic Psychiatric Nurse
Nurse Coroner/Death Investigator

Evidence management guidelines allow forensic nurses in the variety of different nursing roles to apply principles in work settings to ensure compliance with basic principles of evidence management. The legal support for current activities in forensic nursing practices includes a variety of laws, guidelines, and protocols, seen in Table 2.

Table 2. Legislation and purpose

Useful to practitioners is the Forensic Compliance website (EVAWI) that provides information designed to:

(a) communicate the requirements of the Violence Against Women Act (as reauthorized in 2005 and 2013); and,

(b) offer recommended practices for implementation.

The goal is to highlight examples of communities striving to achieve a higher standard of the “spirit of the law,” rather than simply meeting the “letter of the law” for VAWA forensic compliance.

Other guidelines useful to providers include:

The Guidelines for Evidence Management are developing, and the workgroup hopes nurses will embrace the science of handling samples, a.k.a. evidence, to ensure that the outcomes result in justice for all. As the evidence is assembled by nurses working with the experts in evidence management, join us in Gaithersburg, Maryland for the NIST meeting—free—October 2019!


About the Authors

Patricia M. Speck (DNSc, APRN, FNP-BC, DF-IAFN, FAAFS, DF-AFN, FAAN) is a professor and coordinator of Advanced Forensic Nursing at the University of Alabama at Birmingham School of Nursing’s Department of Community Health, Outcomes & Systems.

Kathy Gill-Hopple (PhD, RN, SANE-A, SANE-P, DF-AFN) is the coordinator of Forensic Nursing Services at the Medical University of South Carolina.

Rachell A. Ekroos (PhD, APRN, FNP-BC, AFN-BC, DF-IAFN, FAAN) is an assistant professor at the University of Nevada, Las Vegas School of Nursing, and a clinical forensic expert and consultant for the Center for Forensic Nursing Excellence International.

Diana Faugno (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN, DF-AFN) is a forensic nurse consultant in Dallas, Georgia and the founding president of the Academy of Forensic Nursing.


References

Aiken, M.M. and P.M. Speck, “Confidentiality in Cases of Rape: A Concept Reconsidered,” Journal of Clinical Ethics, 2(1):63-5; discussion 66-71 (1991).

American Nurses Association, “Scope of Practice” (2018). Available from: https://www.nursingworld.org/practice-policy/scope-of-practice/

American Nurses Association, Nursing's Social Policy Statement: The Essence of the Profession. Silver Spring, MD: Nursebooks.org (2010).

Congressional Research Service, DNA Sexual Assault Justice Act of 2003 (2003). Available from: https://www.congress.gov/bill/108th-congress/senate-bill/1700

Darnell, D., et al., “Factors Associated with Follow-Up Attendance Among Rape Victims Seen in Acute Medical Care,” Psychiatry: Interpersonal & Biological Processes, 78(1):89-101 (2015).

Ekroos, R.A., et al., “Role Confusion, Conflict, and Clarity in Forensic Nursing: From Dual Roles and Loyalties to an Integrated Specialty Role,” (submitted) (2019).

Lynch, V.A., Clinical Forensic Nursing: A Descriptive Study in Role Development, University of Texas Arlington: Arlington, TX (1990).

Maier, S.L., Sexual Assault Nurse Examiners' Perceptions of Funding Challenges Faced by SANE Programs: “It Stinks”, Journal of Forensic Nursing, 8(2):81-93 (2012).

Office for Victims of Crime, “SANE Program Development and Operations Guide,” 2016 [retrieved 2017 December 30]. Available from: https://www.ovcttac.gov/saneguide/introduction/

Office on Violence Against Women, “A National Protocol for Sexual Assault Medical Forensic Examinations: Adults/Adolescents,” U.S. Department of Justice, Washington, D.C. p. 141 (2004).

Office on Violence Against Women, “A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents,” U.S. Department of Justice, Washington, D.C. p. 144 (2013).

Speck, P.M. and M.M. Aiken, “20 Years of Community Nursing Service: Memphis Sexual Assault Resource Center,” Tennessee Nurse, 58(2):15-8 (1995).

Speck, P.M. and M.M. Aiken, “Education, Scope and Standards of Practice for Sexual Assault Nurse Clinicians,” at Sexual Assault Nurse Council Meeting (AKA 1st meeting of International Association of Forensic Nursing), August 13, 1992, University of Minnesota: Minneapolis, MN (1992).

Speck, P.M. and M.M. Aiken, “Standards of Practice for Sexual Assault Nurse Evaluators,” at Sexual Assault Nurse Council Meeting (AKA 1st meeting of International Association of Forensic Nurses). August 13, 1992, University of Minnesota: Minneapolis, MN (1992).

Speck, P.M. and M.M. Aiken, “University Based SANE Training,” at Sexual Assault Nurse Council Meeting (AKA 1st meeting of International Association of Forensic Nursing). August 13, 1992, University of Minnesota: Minneapolis, MN (1992).

Speck, P.M. and S.B. Patton, “Qualifications of the Forensic Nurse in Sexual Assault Evaluation,” Medical Response to Adult Sexual Assault, L.E. Ledray, A.W. Burgess, and A.P. Giardino, Ed. G. W. Medical Publishing: St. Louis, MO (2010).

Speck, P.M. and S. Peters, “Forensic Nursing: Where Law and Nursing Intersect,” Advance for Nurse Practitioners, p. 10 (1999).

Speck, P.M. and S. Peters, “Forensics in NP Practice,” Advance for Nurse Practitioners, 7(11):18 (1999).

This article appeared in the Summer 2019 issue of Evidence Technology Magazine.
Click here to read the full issue.

 
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