A New Model for Comprehensive Medical Forensic Care
Written by Angelia Trujillo & L. Diane Casto   

ALASKA IS UNIQUE and shares similarities with other Arctic regions across the globe. The state is the largest in the union and is one-fifth the size of the entire lower 48 states. It is often referred to as the “Last Frontier”. The population of the entire state is approximately 735,0001 and only 14% of communities are connected by road to other places. In fact, Alaska’s communities are considered “the most remote and rural in the nation, scattered across vast tracts of undeveloped land and separated by challenging topographical features.”2

Alaska has consistently ranked in the top five states for per capita domestic violence rates over the past two decades. Alaskan women are sexually assaulted at 2.6 times the national average and killed by intimate partners at 1.5 times the national average3,4. In 2018, Alaska Natives comprised approximately 15% of the population; however, 84% of Alaska Native women have experienced violence in their lifetime5,6. Curtis, Kvernmo, and Bjerregaard (2005) noted a high rate of violence and sexual abuse amongst Arctic populations, with the abuse often being associated with chronic illness and mental health problems. Healy and Meadows (2007) noted that women’s health is “a crucial part of the health of their communities” and called for research to identify the actual rates of IPV and its effects on women’s health in the Arctic.

Interpersonal violence (IPV) comprises a spectrum of sexual and physical violence against individuals that are often interconnected and share similar root causes throughout life stages9. Specifically, IPV includes intimate partner violence along with domestic violence, sexual assault, child physical and sexual abuse, or elder abuse. The various categories of IPV are not limited to any one country or culture but are endemic around the world9,10,11, although they are frequently associated with cultural differences12,13.

IPV, in all its forms, has been associated with sequelae including death, physical trauma, short and long term disability, poor health, chronic pain, unexplained pelvic pain, post-traumatic stress disorder, depression, substance abuse disorders, and an increased rate of health care utilization over the general population14,15,16,17,18,19,20. An additional concern is that the “hidden trauma” from IPV during childhood translates to IPV in later life, including the potential for the childhood victim of IPV to become an adult IPV perpetrator21,22. Economically, IPV is responsible for $900 million in lost productivity. Healthcare costs for abused women are reportedly 50% higher than for non-abused women15.

Care for victims of IPV is further complicated by the fact that healthcare providers have reported a lack of training regarding the issues of IPV at rates ranging from 33%23 to 61%24. Barriers toward screening attitudes and practice have been identified in both quantitative and qualitative research regarding lack of time, lack of education and HCP estimate of the prevalence of abuse17,25,26,27,28,29,30. Waalen, Goodwin, Spitz, Petersen, and Saltzman (2000) noted that barriers to screening for violence are similar to barriers to screening for other conditions (i.e. smoking, weight loss, substance abuse) — all complex and sensitive issues that can be difficult to discuss.

This is in contrast to the fact that nurses and healthcare providers are in a unique position to recognize, report, and intervene proactively in IPV10. It is also in contrast to the fact that patients typically have a positive view towards HCP screening. Morse, Lafleur, Fogarty, Mittal, and Cerulli (2012) found that 66% of women (n=142) said they would admit IPV if asked, emphasizing the positive role that HCP can play in the assessment and response to IPV. Ramachandran et al. (2013) notes that not only do many of the major healthcare provider associations support screening, but that the U.S. Department of Health & Human Services recommends that all women be screened for IPV as part of preventive services. Boursnell (2010) noted that HCP are a gateway to health services, and training and awareness of IPV screening would result in practice improvements and patient outcomes.

Historically, Alaska has relied on the Sexual Assault Nurse Examiner (SANE) model to meet the needs of sexual assault victims. However, there are a number of issues associated with this model: 1) there is intermittent and limited training availability in Alaska; 2) this model focuses on nurse response only; 3) the response is limited to victims of sexual assault; and 4) there is often difficulty in recruiting and retaining nurses for this limited role, especially in rural locations.

Of importance, the skills typically associated with SANEs are the same skills that are also utilized for the care of victims of domestic violence, strangulation, child abuse, and other interpersonal violence related issues. However, in many areas of the state of Alaska, nurses and providers find themselves in situations in which they need to identify forensic evidence, collect and preserve that evidence, and accurately document a patient’s words and condition. Nurses and providers may be requested to function as fact or expert witnesses in medical legal investigations. This requires that they hold the necessary knowledge, skills, and abilities to do so from the onset of care of the patient.

Interpersonal violence in any form is emotional and trauma-inducing for victims, families of victims, perpetrators, and communities. Alaskans who are working to stop violent behaviors need more tools and resources, as well as better training, in order to provide healing to victims and accountability for perpetrators. In order to meet Alaskan needs, the University of Alaska Anchorage’s College of Health, the Council on Domestic Violence and Sexual Assault (CDVSA, part of the Alaska Department of Public Safety), and the Alaska Nurses Association collaborated in March 2019 to launch the Alaska Comprehensive Forensic Training Academy (ACFTA), a training for comprehensive forensic documentation that is the first of its kind in the nation. The ACFTA is a pilot program designed to promote and develop forensic training for nurses, physicians, nurse practitioners, and physician assistants in order to build a community’s capacity to respond to violence. The academy does not replace specialized sexual assault trainings. Rather, it gives participants important tools to assist victims of all forms of interpersonal violence, whether sexual assault, intimate partner abuse, child abuse, elder abuse, strangulation, or other forms of assault. Participants develop the skills needed to collect and preserve evidence from victims, and they learn to work in partnership with local law enforcement, advocates, service providers, and others to consistently assess and document victimization.

Because Alaska has the highest rates of interpersonal violence in the country, it is important to focus on broad, comprehensive assessments and care for all victims of violent crime. The ACFTA is designed to provide an evidence-based and trauma-informed care approach: Instead of simply treating and releasing a victim, a healthcare provider who is trained at the academy can more comprehensively evaluate a patient, document evidence with an awareness of forensic principles, and connect the patient to community resources. Additionally, the academy will increase community awareness of occurrences of violence that are not reported, investigated and, when warranted, prosecuted.

Building community capacity to respond to violence is especially important for small communities with limited human and fiscal resources. In rural Alaska, many communities cannot sustain a specialized sexual assault nurse examiner or a sexual assault forensic examiner, but have established health care, law enforcement, and advocacy roles. If the one health provider in a community is trained broadly to respond to many forms of violence and understands how to work with law enforcement and advocates, theoretically there is a better chance that victims of violence will be appropriately treated, and that forensic evidence will be collected to assist in the pursuit of justice.

The academy is a two-part program that includes approximately 25 hours of online training and 24 hours of in-person, hands-on training. The online training, offered on an ongoing basis, includes modules developed by national and Alaska educators and researchers in the fields of sexual assault, domestic violence, strangulation, sex trafficking, elder abuse, and pediatric sexual and physical abuse. The in-person training takes place at the University of Alaska Anchorage campus and is being offered every four months.

The hands-on portion of the curriculum focuses on experiential training to develop the ability to complete forensic exams that will help the victim and improve outcomes in the justice system. Participants work with actors and live models, using case studies designed to simulate cases that might present in the hospital, clinic, or outpatient setting. Attendees have the opportunity to practice trauma-informed screening and patient communication, evidence collection and preservation, medical photodocumentation, narrative and graphic forensic documentation, as well as network with other members of the multidisciplinary teams from around the state. CDVSA is also currently offering travel scholarships for nurses and providers in geographically remote locations of the state who would otherwise be unable to travel to Anchorage for a three-day training program due to costs of travel.

At the time of this writing, ACFTA has completed three in-person training sessions. Participants represented rural and urban communities from throughout the state and have diverse roles including nursing, community health, advocacy, legal, and advanced practice. Future cohorts have registrants that include physicians, physician assistants, emergency medical services, juvenile justice, and social workers. Participant evaluations have been overwhelmingly positive. Evaluation comments included: “These skills/knowledge will be helpful to me in my role,” “This should be a basic skill for nurses [providers],” and “I think all providers, ER, and clinical staff should receive this training.”

Participants reported that the most valuable portion of the training was the use of live models and also competency stations where they were required to demonstrate proficiency at tasks including evidence collection and processing, medical photodocumentation, and pelvic examinations. One participant summed up the general consensus of the attendees: “I've never done a pelvic exam or handled a situation where I can talk with or interview a victim. Being able to go through the process in detail definitely helped piece together everything that needs to be involved.”

 

The goal for this training is to develop a sustainable model of care for victims of violence, regardless of age, gender, or location. It is expected that this comprehensive forensic training will meet medical-forensic needs for victims, hospitals, law enforcement, and prosecution. The availability of this generalist training may also be more palatable to individuals who are not interested in solely being a SANE or for those individuals who reside in locations without ability to support dedicated SANEs. In communities who do not have dedicated SANEs or response programs, these forensically trained nurses and providers would then also be able to respond to local Sexual Assault Response Teams.

Having providers with forensic training strengthens documentation and evidence collection practices, improves future law enforcement investigation and prosecution, provides needed data for research to support response and prevention of violence, and improves ability of providers to adequately respond in difficult situations.

Reprinted in part from Alaska Justice Forum: A publication of the Justice Center, University of Alaska Anchorage, Volume 36(1), Fall 2019. Available here.


About the Authors
Angelia Trujillo is associate professor with the University of Alaska Anchorage School of Nursing.

L. Diane Casto is executive director of the Alaska Council on Domestic Violence and Sexual Assault.


References
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This article appeared in the January-February 2020 issue of Evidence Technology Magazine.
You can view that issue here.

 
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