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Nursing:
doi: 10.1097/01.NAJ.0000392855.52189.ce
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Examining the role of the forensic nurse death investigator

Romano, Connie MSN, BSN, CRNP, CEN

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Connie Romano, a former ED and trauma nurse, now works as a CRNP in cardiac surgery at the Hospital of the University of Pennsylvania in Philadelphia, Pa.

AT 0300, THE BEEPER rouses Jenny O'Connell, RN. She fumbles for the button that alerts her to a death in the community. She arrives at the scene to find the pajama-clad body of an older man lying supine on the floor of a neat, dimly lit living room. A small puddle of blood has seeped from his head. The TV volume is low. The room is undisturbed except for the coffee table, which is askew, its contents on the floor. A remote control is clutched in the man's right hand. A woman wearing a nightgown is sitting in the next room quietly crying. She has blood on her hands.

What happened here? What (or who) killed this man? These are the questions Ms. O'Connell is here to answer. This is the job of a forensic nurse death investigator.

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Changing field

Forensic nursing blends nursing science with medicine, law, and criminology. At its core, this specialty seeks to address healthcare issues that have a medicolegal component.1

Forensic nurses are patient advocates and resource people, coordinating the care and efforts of all disciplines involved in the response to acts of human violence. When employed by the coroner or medical examiner's office, these nurses can investigate deaths. Structured around the nursing process, the framework for forensic nursing is based on planning, intervention, and evaluation.

Clinical forensic nurses care for survivors of violent crime.2 Sexual assault nurse examiners (SANE) are specially trained to provide the forensic and medical examination and evaluation of victims of sexual trauma. Legal nurse consultants provide consultation and education to judicial, criminal justice, and healthcare professionals involved in civil and criminal cases.1

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Advocating for the specialty

The International Association of Forensic Nurses (IAFN) has 3,000 members in 24 countries. One of its core initiatives is the education and advancement of forensic nursing practice. IAFN is presently developing educational standards and curricula for the creation of an advanced practice forensic nurse graduate program and for inclusion in undergraduate nursing programs.

The IAFN offers certifications in both adult and pediatric sexual assault examination (the SANE programs). The American Nurses Credentialing Center and IAFN have partnered to offer the advanced practice forensic nurse portfolio credential, which will be available once eligibility criteria is complete.3

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Duty calls

When called to a scene, forensic nurse death investigators must document their findings of the body and its surroundings both in writing and in photographs. They must interview witnesses and document the information provided, especially that provided by the first person or persons at the scene. Forensic nurse death investigators collect evidence from the body and the surroundings, knowing what evidence may be pertinent as the investigation progresses. They may also notify the next of kin of the death.

Throughout the collection of evidence, including body fluids collected during autopsy, the proper chain of custody must be followed for the evidence to be admissible in court. Chain of custody is the detailed and chronological documentation of the handling of evidence from collection to analysis to disposition. Every transfer of possession of a piece of evidence must be documented. Transfers should be kept to a minimum to avoid jeopardizing the strength of the evidence.

The forensic nurse death investigator's documentation is crucial. It must be detailed and descriptive, factual, and free of opinion and assumption. As the representative of the medical examiner or coroner's office, the forensic nurse death investigator has jurisdiction over the body at a scene and must work in collaboration with the police and other officials involved in the case.

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Going to court

Forensic nurse death investigators are called to testify in court as expert witnesses in civil or criminal cases. An expert witness is one who by experience, education, and professional training has knowledge in a particular area beyond that of a lay person, judge, or jury.2

The U.S. Department of Justice's research report, Death Investigation: A Guide for the Scene Investigator, lays out guidelines for the person conducting a death investigation. These federal guidelines help regulate the role of the forensic nurse death investigator and give it a scientific basis.

The American Board of Medicolegal Death Investigators (ABMDI), accredited by the Forensic Specialties Accreditation Board, promotes the highest standards of practice for medicolegal death investigators.4 The ABMDI offers initial registry certification followed by an advanced board certification. The registry is an examination that covers topics such as interacting and communicating with agencies and families, identifying and preserving evidence, and coping with job-related stress.4 Registry eligibility includes 640 hours of death investigation experience. Board certification requires an associates degree and 4,000 hours of experience investigating death. Recertification, done every 5 years, requires documentation of employment with a medical examiner or coroner's office with the responsibility of investigating death, completion of an ethics statement, and 45 hours of continuing education.4

Certification as a forensic death investigator demonstrates a standard of knowledge required to competently perform the tasks of the profession in an ethical and consistent manner.5

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Taking steps to assume this role

For the nurse interested in the mystery and investigation of injury, trauma, and death, becoming a forensic nurse death investigator is a good choice. For those with a clinical background in emergency and trauma nursing, the transition is easier. A common first step is to become SANE certified and begin the ever-important process of networking with the law enforcement and judicial systems in your area. Networking is key to getting into forensics.

Forensic programs, including online curricula, are offered throughout the country. Most are supported by the National Association of Medical Examiners (NAME). Being an active member of the Emergency Nurses Association, IAFN, ABMDI, and NAME can help with networking and staying abreast of the latest in the world of forensics. The IAFN offers nationwide job postings of forensic positions.

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Pros and cons

The benefits of working as a forensic nurse death investigator include the variety of cases, the methodical process of an investigation, and the fact that there's always something new to learn and discover. The negative side includes a lack of recognition for the profession throughout the medicolegal arena, lower salaries than those of hospital-based nurses, and the stress of dealing with death every day.

A forensic nurse death investigator must be emotionally strong to deal with the results of violence. Solving a case, bringing justice, identifying a lost loved one, and providing an explanation so someone can move forward from tragedy are the great rewards of the job.

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Back to the scene . . .

In the opening scenario, the decedent was identified as the husband of the crying woman. Interviewing the woman, Ms. O'Connell learned that the decedent had said he was having trouble sleeping because of indigestion and a headache and had gotten up to watch TV. His wife went back to sleep and awoke several hours later.

When she entered the living room, she found her husband on the floor with blood under his head. She quickly went to him and discovered that he was blue and not breathing. She immediately called 911. The paramedics responded and pronounced the man dead at the scene, noting no electrical cardiac activity on the monitor. The man's skin was cool to the touch and they found that lividity and rigor mortis had begun. The pool of blood had congealed.

An autopsy revealed that the man had an undiagnosed abdominal aortic aneurysm that had ruptured. As the sudden pain ripped through his body, he fell forward, striking his head on the corner of the coffee table. By examining the size of the scalp laceration and the small pool of blood, the medical examiner determined that he died almost immediately after landing on the floor.

The forensic nurse death investigator gathered the details of the scene while keeping an open mind to all possibilities. This professional didn't make any preconceived notions about the cause and manner of death. This case was solved. Will you solve the next one?

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References

1. Hammer RM, Moynihan B, Pagliaro EM, eds. Foren sic Nursing. A Handbook for Practice. Sudbury, MA: Jones and Bartlett; 2006.

2. Lynch VA, Duval JB. Forensic Nursing. St. Louis, MO: Elsevier Mosby; 2006.

3. International Association of Forensic Nurses. History of IAFN. http://www.iafn.org/displaycommon.cfm?an=1&subarticlenbr=149.

4. American Board of Medicolegal Death Investigators. http://www.slu.edu/organizations/abmdi/.

5. Vessier-Batchen M. Forensic nurse death investigators. Web Mystery Magazine. 2003. http://www.lifeloom.com/I2MelissVB.htm.

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RESOURCE
National Association of Medical Examiners. So you want to be a medical detective. 2009. http://thename.org/index.php?option=com_frontpage&Itemid=1.

© 2011 Lippincott Williams & Wilkins, Inc.

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