Caring for Justice
The overlap between nursing and forensic science is more prominent than one might think. Equipped with cameras and tripods, ultraviolet lights to identify specific places to swab for biological evidence, and even specialized cameras that allow the user to see bruising beneath the skin when no visible marks are apparent, forensic nurses provide high quality care for crime victims, suspects and perpetrators. Within the Harris Health System, the community-owned health care system for the nation’s third most populous county, the forensic nursing program allows nurses to treat patients, interface with law enforcement officials, and pave the way to accommodate legal needs through the collection and preservation of evidence.
“Our program was established in 2008,” explained Stacey Mitchell, DNP, director of the forensic nursing program for Harris Health. “There was a community need that was identified to address sexual assault patients, but after looking, learning and identifying gaps, we realized that there were other victims of crime, violence and injury that we could focus on as well.
We expanded rapidly and extensively to include various types of patient populations.” Mitchell was instrumental in establishing the department and expanding its range of treatment— Harris Health’s forensic nursing program now sees patients who have been victims of adult sexual assault, child sexual assault, elder abuse, domestic violence, physical injury, human trafficking and even occupational injuries.
Sitting at the intersection between health care and the legal system, forensic nursing is one of the fastest growing nursing specialties in the world, generating interest among both practicing and prospective nurses. Blending biomedical knowledge and critical thinking skills with an understanding of both the principles of law and human behavior, forensic nurses are poised to address physiological needs, acknowledge psychological trauma and prioritize legal concerns.
“Our focus is on that intersection,” said Mitchell. “We have the responsibility to not only look at the medical needs of the patient, but any potential legal needs and responsibilities, as well. That’s where forensic science and the legal system interact with health care. If a forensic nurse can collect evidence and clothing and preserve them, so that down the road they can be processed in a potential case, and maybe have a positive outcome or some sense of justice for that patient, then we’ve done our job.”
“It’s kind of a neat collaboration— we do everything that we can to stay oriented towards not re-victimizing the patients,” added Khara Breeden, M.S., BSN, one of the nine forensic nurses at Harris Health System. “It’s really a multi-pronged partnership between us, the physicians, who we work with to guide the patient’s care, and law enforcement officials, as well as different partners and advocates from our community.”
Trained to collect medical evidence in instances where a crime may have occurred and communicate those findings to law enforcement officials, when necessary, forensic nurses begin their work in the examination room. “The first thing we do is to interview our patients, and write down whatever they say, word for word,” said Breeden. “As we go through that process, I’m making a mental checklist of all the places that I need to look for evidence— it helps guide my physical exam. After the interview, I might look at particular body parts for bruising, abrasions or visible trauma, using my camera or any other necessary equipment. By the time we collect swabs of specimens for evidence, we’ve established a real relationship with our patients.”
The personalized care that forensic nurses can provide, and the ability to devote hours to patients, differentiates them from other nursing specialties. “Our forensic nurses are taking care of only one patient at a time for as long as they need our help,” said Mitchell. “An emergency room nurse may have five, ten or fifteen patients depending on the size of the emergency room and how busy they are. We’re solely focused on that one person, which allows us to take the time to identify the things that they might need and help coordinate those resources.”
An invaluable aspect of the care they offer, forensic nurses are able to provide resources that can help patients even after leaving the hospital, from a phone number for a women’s shelter to the location of support groups for sexual assault survivors. “Coordinated care allows us to understand the role of everyone else in that investigation who’s going to intersect with that patient,” said Mitchell. “We have a great advantage because we’re right in the middle of everything—we know where everyone is and what they’re doing.”
This past year, Harris Health’s forensic nursing program consulted on over 778 criminal cases. Although they work closely with the Houston Police Department, as well as other jurisdictions within Harris County, Breeden and her colleagues are careful to distinguish themselves from law enforcement. “It’s a common misconception, and I don’t want a patient to think that we’re playing a different role,” she said. “While we mostly see victims of violent crime, we see perpetrators and suspects, too. Our role is objective—we’re not on anybody’s side, we’re just here to gather information. The story tells itself.”
The information and treatment that they provide is nonetheless a huge asset to law enforcement agencies. “Harris Health’s forensic nurses help the Houston Police Department with our follow up investigations involving victims of sexual violence and domestic abuse,” said Shamara Garner, lieutenant of the Adult Sex Crimes Unit, Special Victims Division at the Houston Police Department. “The trauma informed services that they render help the complainant be at ease with the medical and emotional aspect, which filters its way up to the investigation by furthering their recovery and making it easier for us to come alongside and take care of the criminal investigation. Their specialty helps strengthen our case, and their scope of involvement extends from the victim to the community at large by helping us possibly identifying perpetrators.”
Harris Health’s forensic nurses are also expected to testify in court, both as a fact and expert witness, when called upon. “We’re able to provide an opinion about those injuries and what they mean in the overall scheme of the case,” said Mitchell. “We’re bound by the same rules as anyone else who testifies in court, even though we’re often qualified as experts, and don’t testify outside of our scope of practice.”
Maintaining objectivity and reserving judgment are both prerequisites for this unique nursing specialty, although they both pose their own set of challenges. “As nurses, we are patient advocates, but as patient advocates within this context we have to adopt a different perspective, because we’re also an advocate for the process itself,” reflected Mitchell. “We want to ensure that all of the procedures are followed so that the patient can have justice. At times, it can be challenging to sustain that objectivity, but it’s something that, consciously, a forensic nurse has to ensure that they do—it’s essential.”
For Breeden, the necessity of keeping emotional distance was a skill that she had to learn to cultivate. “You really have to learn to put it somewhere else,” she said. “My first few months, I didn’t think I was going to be able to do it because it was too hard; you see too many things that make you question how people can do this to each other. After a particular patient interaction, I realized I was doing the right thing. Once you know that, you’re able to put it in a different box. I just do the best I can and treat everyone with kindness.”
As the field of forensic nursing continues to expand, so does the necessity of community engagement and education. Harris Health’s forensic nursing program provides community education to both law enforcement officials and victim advocates like the Rape Crisis Center and Child Protective Services. According to Mitchell, the medical component can be complicated in terms of the significance of their findings. “Educating community partners can help make their jobs easier,” she said. “Our nurses are also required to take two classes, totaling over 80 hours of classroom time, to learn about the types of patients that they’ll be seeing and how to collect and preserve evidence, as well as provide proper documentation.”
With four full time nurses on-site at Ben Taub Hospital’s emergency center and five nurses who take calls, and respond to cases at Lyndon B. Johnson Hospital and any other community health centers within the Harris Health System, Mitchell and her team are expecting even more consults in the next year. As the only program in Houston to focus on all victims of crime, violence, abuse and neglect, rather than just sexual assault patients, Harris Health’s forensic nursing program is uniquely positioned to benefit their community.
“The biggest value that we provide is that we’re here for the citizens of Harris County,” concluded Mitchell. “Having these services is so important. An emergency room nurse is thinking about all of the lifesaving treatments that need to be done. We’re thinking about that, but also addressing the other areas, from legal needs to resources, that need to be encompassed. We’re here for our patients.”