Interview with an Expert

Working with forensic nurses in cases of
sexual assault and interpersonal violence

Jennifer Pierce-Weeks

An exclusive Evidence Technology Magazine interview with
Jennifer Pierce-Weeks, RN, SANE-A, SANE-P
Forensic Nurse Examiner at Memorial Hospital in Colorado Springs, Colorado
President-Elect of the International Association of Forensic Nurses

Evidence of sexual assault and various forms of interpersonal violence can be very difficult to detect, collect, and preserve. Fortunately, there are individuals who are specifically trained to do exactly that—although they are not part of the law-enforcement community. Instead, they are an integral part of the medical community. They are forensic nurses. And their specialty is something that all law-enforcement personnel will value when they get to know about it.

EVIDENCE MAGAZINE: Do you believe there needs to be a closer interaction between forensic nurses and those in law enforcement?
PIERCE-WEEKS: I certainly do. From a forensic-nursing standpoint, there are two issues that immediately come to mind. One: How do we get nurses more involved? And two: How do we get the wider criminal-justice community—crime-scene investigators, law-enforcement personnel, prosecutors, and attorneys general—to better understand what forensic nurses do? How do we get them to understand how forensic nursing can, in many cases, improve both the investigation and prosecution of cases involving sexual assault, domestic violence, child abuse, and elder abuse?

EVIDENCE MAGAZINE: Can you give us an example?
PIERCE-WEEKS: Certainly. Probably the most commonly recognized form of forensic nursing is the Sexual Assault Nurse Examiner (SANE) program, also known as Sexual Assault Forensic Examiner (SAFE). Since the 1970s, SANE has been offering patient’s evidence collection as one portion of the overall medical/forensic examination and treatment procedure. These programs can assist in the prosecution of sexual-assault cases because of the SANE’s documentation of patients’ history and injuries, as well as the nurses’ testimonies in court. But you have to remember that sexual assault is just one of many forms of interpersonal violence crimes. And while sexual violence is pervasive, there are other areas where forensic nursing care can benefit the criminal-justice system. Unfortunately, the system is not utilizing them in an effective way. Why don’t they utilize us? I think it’s because they don’t even know that we could be helping them.

EVIDENCE MAGAZINE: But what can law-enforcement personnel do to make themselves more aware of this topic?
PIERCE-WEEKS: Well, several things. They should establish a closer, more collaborative relationship with the local forensic nurses. Second, they should commit to a minimal level of education on this topic. It is very important for police officers at all levels to be well-educated in these matters. Let’s look at the matter of sexual assault, for example. I cannot begin to tell you the number of cases where a patient has said to me, “Well, I went to the police two days ago but they said it had been 24 hours since the sexual assault so there was no way to get any evidence.” Not only is that not true, it flies in the face of the national protocol. But most importantly from my perspective, the response given by the officer has now caused the victim to make decisions that impact his or her health care. By the time he or she finally comes to the emergency department for care, it may be too late to begin HIV prophylaxis should he or she need it. She may have increased her risk of pregnancy significantly by waiting to receive care. Unfortunately, in many cases, you have a person who is not fully informed about the subject—in this case, a law-enforcement official—making a determination that is going to impact the case in a negative way. If every law-enforcement official was as educated as SANEs are on the facts of when, where, and how often to collect evidence… Well, that would be great. But it is unrealistic to expect that level of education when there are so many more crimes than sexual assault that law enforcement is responding to. Maybe a more appropriate first step would be to ensure that the most educated party is the one informing the victim.

EVIDENCE MAGAZINE: Sexual assault is not the only thing you look for, is it?
PIERCE-WEEKS: No, not at all. Forensic nurses care for all patients who have been impacted by interpersonal violence. There are a lot of such cases in hospital emergency rooms across this country. And unless there is a forensic nurse present to ask the right questions and to take a history in an educated way, nobody will ever know that many of those patients who are thought to be the victims of simple assault are actually victims of something that is much more serious: domestic violence that includes strangulation, a life-threatening event.

EVIDENCE MAGAZINE:
What?
PIERCE-WEEKS: Unfortunately, very seldom is there any effective documentation for a strangulation that occurs during domestic assault.

EVIDENCE MAGAZINE:
Are you saying that strangulation is common in many domestic-violence cases? Does that move up the event to another level?
PIERCE-WEEKS: It certainly does. It goes beyond the misdemeanor charges that are seen so often in domestic-violence cases. Let me explain. There are two issues here. First: In many domestic-violence cases, the criminal-justice system responds, but they may not recommend medical care unless an ambulance is required. They don’t necessarily understand the merit of having that patient examined, both from the perspective of making sure the victim is truly okay, and from the perspective of their own liability. Second: When a victim is seen by a forensic nurse, he or she is more likely to be asked questions and will give answers that relate directly to the violent episode and its relationship to the patient’s current state of health. Law-enforcement personnel may have talked with the victim, but that doesn’t mean the victim was asked enough questions for law enforcement to even understand that the victim was strangled. There would be no documentation that would define the risk to the patient’s life, no documentation to medically corroborate the event.

EVIDENCE MAGAZINE: Can you give us example of such a case?
PIERCE-WEEKS: Okay. Here’s one: The patient was assaulted by her husband. When police responded to the scene, both parties were arrested because both of them were fighting. For whatever reason, the police could not determine who the primary aggressor had been. So they brought both parties back to the police station and were questioning them. They were there for hours. When the woman was finally brought into the hospital’s emergency department, it was six hours after her arrest. She had a fractured trachea from the strangulation attempt that had taken place during the assault. The police did not even know that she had been a strangulation victim, much less that she had a life-threatening injury while she sat in front of them for six hours. Granted, that is an extreme example. But it happens.

EVIDENCE MAGAZINE: Perhaps everyone should be looking for cases where things like this happen…
PIERCE-WEEKS: Yes. We believe that it would be beneficial for law enforcement to ask—in all domestic-violence cases—if the victim was choked or strangled. And they could then follow that up with a recommendation that the patient receive medical/forensic care. It would also be beneficial if there were trained forensic nurses in every emergency department. The emergency-room staff may not know they have a strangulation victim and may not be properly trained in the identification and documentation of that event. But our forensic nurses see strangulation victims all the time. The reason that we see them is because whenever we know that there is a domestic-violence patient in-house at the hospital’s emergency department, our in-house team member goes to that patient and asks some direct questions. They discuss the violence, utilize strangulation documentation tools and danger assessments when appropriate, and they do a secure follow-up that includes effective safety planning. It is a simple fact: In-house forensic nurses benefit the patients, the hospital, the risk-management departments, and the criminal-justice system.

EVIDENCE MAGAZINE: Are the officers not asking the right questions?
PIERCE-WEEKS: It is not only the law-enforcement personnel but medical personnel, as well. You see, it is really only forensic nurses who are trained in the proper identification and response to intimate-partner violence—how to document it and how to treat it and how to refer the patient. It could be very beneficial to the people in the criminal-justice system if they understood how to work with the nurse examiners to have the victims seen in the first place.

EVIDENCE MAGAZINE: What can be done to get this message across?
PIERCE-WEEKS: As far as the Inter-national Association of Forensic Nurses (IAFN) is concerned, we will continue to work with our criminal-justice partners— as well as our advocacy partners—with collaboration programs and education programs so that our victim response and recovery can improve. We will continue to educate our nurses and the medical community at large to encourage the utilization of forensic nurses. In the coming years, I think you will see our organization truly incorporate forensic nursing into all aspects of health care…not just sexual assault or death investigation.

EVIDENCE MAGAZINE: Okay…
PIERCE-WEEKS: Those are the two most focused-on areas of forensic nursing right now and they currently receive a lot of resources. But there are many, many more patient populations that are being impacted by violence. And if forensic nurses were available to make connections with law enforcement, the criminal-justice process would be improved dramatically.

EVIDENCE MAGAZINE: And in the future what will you be doing?
PIERCE-WEEKS: Personally, I will be coordinating a comprehensive emergency-department-based forensic-nursing response to violence in Colorado Springs, Colorado. And as the in-coming IAFN president, I will be working toward a number of things, including the achievement of an internationally accepted forensic-nursing certification examination.

EVIDENCE MAGAZINE: What do you see as your biggest challenge?
PIERCE-WEEKS: That’s easy: Nursing must maintain its integrity. One of the major challenges that we have faced over the past 15 years—and one we continue to face—is maintaining our professional integrity. Nursing is a profession in and of itself, with its own scope and standards of practice. Our work is patient- and community-centered. But sometimes, there is a tendency on the part of the criminal-justice system to want to change who we are. There are some people who want to make us a part of law enforcement. And that would be a mistake.

EVIDENCE MAGAZINE: Why?
PIERCE-WEEKS: The reason a forensic nurse benefits the criminal-justice system is because the nurse is an unbiased healthcare professional diagnosing and treating a patient.

EVIDENCE MAGAZINE: And how does that benefit law enforcement?
PIERCE-WEEKS: Law enforcement benefits from the forensic-nursing role because ultimately when we testify in court, it is as a medical professional testifying under some version of the medical exception to the hearsay rule in the Federal Rules of Evidence. If forensic nurses were to morph into law-enforcement officials, we would lose that exemption—and the criminal-justice system would no longer have our expertise at their disposal.

EVIDENCE MAGAZINE: In other words, forensic nurses do not work for law enforcement in the same way that an independent forensic laboratory does…
PIERCE-WEEKS: That’s right. In a sexual assault case, we will collect evidence
that eventually gets turned over to law- enforcement personnel. But I don’t view that action as collecting evidence for law enforcement. Instead, I am collecting evidence for that patient so the patient can then determine whether or not they will be moving into and through the criminal-justice system with this sexual assault case. And if the patient decides—today or two months from now—that they are prepared to go through the criminal-justice system, then the forensic nurse has given the patient all the tools possible that can be helpful from the medical perspective.

EVIDENCE MAGAZINE: What about the future for forensic nursing? Are things moving forward?
PIERCE-WEEKS: The IAFN is now more than 3,000 members strong—and our membership has been steadily growing. More universities are offering forensic-nursing tracks than ever before. The challenge we face is getting the various healthcare systems to invest in these specially trained nurses, to see the benefit they bring to the institution. This is one of the many reasons our focus at IAFN has really shifted from being the SANE organization to being the nursing organization that is focusing on patients who have been impacted by any form of violence.

EVIDENCE MAGAZINE: And what do you mean by that?
PIERCE-WEEKS: If you consider what we know in medicine about violence victims, it is quite likely that the woman in the emergency room who is complaining of a migraine—or who is having a panic attack or who has attempted to commit suicide or who is self-injuring—really has the potential for being a victim of violence. You see, there is a long list of symptoms ranging from the psychological to the physical that can suggest a history of violence, past or present. Despite this knowledge, healthcare professionals often look for obvious physical injury before they even suspect violence in the lives of their patients. And because of this, a patient may be sitting there, waiting to be asked the right questions about what is going on at home—and nobody asks them.

EVIDENCE MAGAZINE: Is the IAFN in the process of providing hospital personnel with information and questions to ask so they’ll know what to look for?
PIERCE-WEEKS: Yes. There are members of IAFN across the nation who are providing that type of information. And there are other organizations that also do that, such as the Family Violence Prevention Fund.

EVIDENCE MAGAZINE: And what could our readers do to learn more about this important topic?
PIERCE-WEEKS: There are many things they could do. The best way to get the knowledge is this: If there is a forensic-nurse examiner group in their community, they can ask that group for more information. If they don’t have such a group, they can reach out to the IAFN. If it’s a community that is specifically dealing with issues of sexual assault, they should reach out to SAFE-ta (Sexual Assault Forensic Examiner Technical Assistance) through the IAFN, although it has its own website address: www.safeta.org. But in addition to that, I do not see any problem with the criminal-justice people simply telling their superiors, “We are not well-enough educated about this topic and we need to learn more about it.” And with more education, they will be able to make legitimate decisions when it comes to evidence collection in these matters.

EVIDENCE MAGAZINE: Do you have any other suggestions?
PIERCE-WEEKS: Just this: Working with forensic-nursing medical professionals in your community can be extremely beneficial. I don’t know any forensic nurses who wouldn’t go out of their way to help educate crime-scene investigators, detectives, or beat officers on appropriate response and evidence collection in assault cases.

EVIDENCE MAGAZINE: Thank you for speaking with us today.

A brief look at the background and experience of Jennifer Pierce-Weeks

Jennifer Pierce-Weeks has 21 years of nursing experience and is currently fulfilling two roles in that profession. She is a Forensic Nurse Examiner at Memorial Hospital in Colorado Springs, Colorado and she is a Sexual Assault Nurse Examiner at SAFE Passage Child Advocacy Center in Colorado Springs. Prior to that, she served for 12 years as the Director of the State of New Hampshire Sexual Assault Nurse Examiner Program. Pierce-Weeks is the President-Elect of the International Association of Forensic Nurses (IAFN) and has served on the IAFN Board since 2006. She is also an educator and an expert in the areas of child and adult sexual assault, as well as domestic violence. She was a contributing author for several attorney general protocols in New Hampshire and has been published in The Journal of Emergency Nursing and The Journal of Forensic Nursing. Pierce-Weeks has extensive experience as a clinician, as well as a local and national trainer. She has also written numerous items for both the adult and pediatric Sexual Assault Nurse Examiner certification programs of the IAFN. Her e-mail address is: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

To learn more about the International Association of Forensic Nurses, go to their website:
www.iafn.org


ORIGINALLY PUBLISHED:
  July-August 2008 (Volume 6, Number 4)
Evidence Technology Magazine
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