Over the last few years, Portuguese nurses have noticed a rise in care-seeking by victims of violence, leading them to increase and update their knowledge of forensic science (Santos, 2013). Crime and violence are overlapping parts of both the health and justice systems, directly affecting the well-being and safety of all societies. Preventing and reducing criminal activity calls for a multidisciplinary approach (Caixinha, 2014; Pyrek, 2006; Silva & Silva, 2009). Forensic nurses can partake in a wide range of cases, including mistreatment, sexual abuse, trauma and other forms of violence, and death investigations. They also practice as forensic mental health nurses, preserve evidence, testify as expert witnesses, or act as consultants during mass disasters (Associação Portuguesa de Enfermagem Forense, 2015; Gupta, 2011; Sekula, 2005). Furthermore, the development of forensic practices by nurses in emergency services affects the quality and results of care administered to patients affected by violence, both victims and perpetrators (Sekula, 2005).
Several studies in forensic nursing have been conducted in Portugal over recent years, significantly contributing to the establishment of this area of forensic science in our society (Caixinha, 2014;Canelas, 2008; Coelho, 2013; Da Silva, 2010; Gonçalves, 2011; Libório, 2012; Lourenço, 2004; Santos, 2013). Even though most nurses are not qualified to identify and care for victims of violence and determine exactly what evidence should be collected and preserved, they are often the first professionals to assist the victims (Libório, 2012; Pyrek, 2006; Sekula, 2005).
In clinical practice in Portugal, protocols for dealing with forensic situations exist only in some adult emergency services, and only a few have nurses with forensic education and training. Furthermore, the number of people who use emergency services for forensic situations is not available. However, it is worth noting that, in 2016, 35,411 people were supported by the Portuguese Association for Victim Support (APAV), representing an increase of 8.1% between 2014 and 2016. Crimes against people were most prevalent (93.3%), with physical and mental abuse (77%) being the most significant (Ribeiro, 2016). Of the 9,347 victims of crime who had contact with APAV services in 2016, victims were mainly female (81.9%), aged between 25 and 54 years (40.6%), married (29%), and in a nuclear family with children (35%). About 82.4% of victims of sexual crimes were female, with 42.6% being children or youths. It should also be noted that 76% of victimization situations are unremitting (Ribeiro, 2016). This justifies rethinking nurses’ education and training and their role in crime scenes and alongside victims of violence (Simões, 2010).
Nursing practice, particularly during emergency services, often involves situations that call for an effective response based on knowledge that allows attending nurses to perform competently. After their emergency service internships, students should be taught forensic nursing to complete and enrich their academic studies (Coelho, 2013; Drake & Adams, 2015; Freedberg, 2008; Libório, 2012; Pyrek, 2006; Sekula, 2005). Teaching forensic nursing has enabled educational development, with implications for education, practice, and policy (Kent-Wilkinson, 2011). For this reason, we previously surveyed the directors of the 41 public and private schools of nursing in Portugal. Of the directors of the schools who answered the survey, 20 of the 26 (76%) were able to confirm that no curricular unit in forensic nursing was offered in their programs. In the six schools that answered affirmatively, we found that the contents were taught as part of various nursing curricular units, and in one case, the students were able to choose an elective unit in forensic nursing (Ribeiro, 2016).
In a study carried out on 183 third- and fourth-year nursing students, Kalayci et al. (2014) confirmed that they did not possess sufficient knowledge of forensic medicine and nursing. Integrating forensic concepts into nursing students’ studies helps them to provide culturally sensitive care and properly refer the victims and perpetrators, making these professionals’ approaches more effective in preventing and reducing violence (Freedberg, 2008). Citing the American Association of Colleges of Nursing (1999), Freedberg (2008) recommended that nursing curricula include theoretical and practical content related to the prevention of domestic violence and to use active teaching methodologies that included observational experiments on cases of domestic violence.
The International Association of Forensic Nursing (IAFN, 2015) also recommends the use of methodologies that allow for better learning by future nurses. Knowles’ theory holds that active involvement is the key to success, because the learner retains more information, is quicker in understanding how the information can be applied, and learns faster, understanding the reasons that led up to decision-making.
According to the IAFN (2015), learning during the Sexual Assault Nurse Examiner course involves didactic practices that includes lectures and reading support manuals. In short, successful learning in forensic nursing implies coordination among various teaching methodologies, including classroom teaching and Internet use, namely e-learning and simulations. Simulated practices allow nurses to improve their forensic practices (Drake & Adams, 2015; Drake & Ayers, 2013; Freedberg, 2008; Kent-Wilkinson, 2011; Sekula, 2005).
In view of the above, the main objectives of this study were to determine the differences in knowledge of forensic nursing practices according to students’ year of study and gender, and to assess the efficacy of a structured intervention in improving nursing students’ knowledge of forensic nursing practices.
Type of Study and Intervention
This pretest/posttest quasi-experimental quantitative study without a control group took place over 3 days in February 2016 and included a theoretical and a practical component. During the study, active teaching methodologies were used, incorporating observational experiments on cases of domestic violence. More active methodologies were also used, with simulated practice scenarios where students were faced with clinical cases and invited to solve them. Manuals designed by the researchers, with content developed during the intervention and based on the manuals recommended by the IAFN and the Portuguese Association of Forensic Nursing (Associação Portuguesa de Enfermagem Forense), were distributed to students at the beginning of the study.
During the sessions, the following topics were covered: forensic situations, communication and documentation, general nursing care, and preserving trace evidence.
During the last day of the intervention, simulated scenarios were set up with practical cases designed by or based on Drake and Adams’s (2015) forensic nursing simulations and related bibliography. Case I was a multiple trauma victim. Case II consisted of a situation with a victim of assault with a firearm. Case III consisted of a situation with a victim of assault and attempted choking.
The target population of this study was composed of fourth-year (final) and third-year nursing students of the Leiria School of Health Sciences during the 2015/2016 academic year. By the beginning of their fourth year, students had already completed their internships in medical-surgical units and specialty units. By the end of their fourth year, the students had also completed their internships in an emergency service. A total of 220 possible students were invited to participate in the intervention, of which 84 students volunteered (38.2% of the total population). This low percentage was due to the fact that the training took place when classes were not in session.
Survey instruments were applied before and after training, Before training, the instrument comprised two parts: the General Questionnaire on Forensic Nursing (Questionário Geral sobre Enfermagem Forense), which included sociodemographic characterization and training questions, and the Questionnaire on Knowledge of Forensic Nursing Practices (Questionário de Conhecimentos sobre Práticas de Enfermagem Forense [QCPEF]; Cunha et al., 2016).
The QCPEF contains questions about forensic nursing training, including 74 true-or-false statements, and aims to assess knowledge of forensic nursing practices in six important areas: the definition of forensic nursing (10 items), forensic situations (12 items), communication and documentation (10 items), general nursing care (10 items), and preserving trace evidence (20 items). The higher the global score, the better the level of knowledge. The students earned 1 point for every correct answer and no points for wrong answers, meaning that the level of knowledge could range from 0 to 74 points.
After the structured intervention was over, a new questionnaire composed of the variables from the QCPEF (Cunha et al., 2016) was administered.
All the principles of the Declaration of Helsinki were followed, and informed consent forms were collected before the study began. To allow data to be paired (T0 and T1) on both occasions when data was collected, students were asked to include a code (self-chosen) that should be the same for both T0 and T1 questionnaires. No student left the study between the collections of the T0 and T1 questionnaires. T0 was filled out in an average of 30 minutes and T1 in 20 minutes. Both were filled out in a classroom.
The project was approved by the ethics committee of the Health Sciences Research Unit: Nursing of the Nursing School of Coimbra (Process No. 328-02-2016).
Absolute and relative frequencies, measures of central tendency (mean, median), and measures of dispersion (maximum, minimum, and standard deviation) were used to process the data. Because the variables studied did not exhibit a normal distribution, as determined by the Kolmogorov–Smirnov (p > 0.05) test, and the sample for some groups was n < 30, we could not use the central limit theorem (Pestana & Gageiro, 2014), so we used the nonparametric independent Mann–Whitney U test and the paired Wilcoxon test.
The mean age of the 84 participants was 22.8 ± 3.9 years, 72 (85.7%) of whom were female; 73.8% were completing the fourth year of their course, and 98.8% had not received training in forensic nursing during the course. None of the participants had carried out any projects in this field. During clinical practice, 97.6% reported that they had not witnessed situations involving the collection and preservation of forensic evidence. Only seven students (8.3%) reported that they did not have any contact with forensic cases. We also found that 89.3% of the students considered that they had little or no knowledge of forensic practices.
Differences in Knowledge of Forensic Nursing Practices According to Participants’ Year of Study and Gender
No statistically significant differences were observed between the level of knowledge of forensic practices before training according to students’ year of study and gender, not only for all 74 indicators but also throughout the different topics. The only exception was in the definition of forensic nursing (p = 0.034): Female students possessed more knowledge than male students, and in forensic situations, fourth-year students demonstrated better knowledge in the practical section (see Table 1).
Efficacy of the Intervention on Students’ Knowledge of Forensic Nursing Practices
By analyzing the results in Table 2, it is possible to confirm that, for all 74 questions, both at T0 and T1, the results obtained were higher than 37, the median of the scale. The results from T1 (69.15 ± 3.05) were higher than those from T0 (62.95 ± 4.47).
By applying a suitable statistical test (the Wilcoxon test), we confirmed that the differences found between T0 and T1 provided support for the intervention as successful, not only when considering total knowledge (p < 0.001) but also for all other areas, except the definition of forensic nursing (p > 0.05).
In a sample of 84 students, 72 were female (85.7%), which is similar to samples in studies by Libório (2012) and Coelho (2013). These samples are also in line with the distribution by gender of nurses in Portugal, as reported by the Portuguese Nurses’ Association (Ordem dos Enfermeiros, 2016), with 81.82% of the nursing population comprising female nurses. Also significant is the fact that 98.8% of participating students claimed to have received no training in forensic nursing during their nursing degree and none claimed to have carried out any projects in this field, which is similar to data found in Libório (2012).
This lack of training explains why 89.3% of participants considered they had little or no knowledge of forensic practices. This number is similar to data found in Libório (2012) and Coelho (2013). The fourth-year students answered, on average, more questions correctly (63.45 ± 4.22), revealing a higher level of knowledge than third-year students (61.27 ± 4.77), as in Libório (2012). These results could be explained by the fact that, at the school where this study was carried out, fourth-year students had already completed during the first semester the curricular unit in nursing for patients in critical situations, as well as internships in emergency services.
Except for the definition of forensic nursing, no statistically significant differences in knowledge were observed between genders, as in studies by Libório (2012) and Coelho (2013). The subject with the worst results was preserving trace evidence. In a study by Kalayci et al. (2014), participants did not possess sufficient information on the definitions of forensic medicine and nursing, whereas in this study, they mostly lacked knowledge on preserving trace evidence.
Throughout their internships, the most commonly reported cases were associated with motor vehicle accidents and cases of trauma, which 53 (63.1%) and 59 (70.2%) students, respectively, claimed to have had contact with. Also relevant is the fact that 82 students (97.6%) had not witnessed cases that involved the collection and preservation of forensic evidence, leading us to question whether nurses actually perform these actions. Cases of motor vehicle accidents (73.7%) and trauma (83.7%) were the most commonly reported, as was the case in Libório (2012).
As for knowledge of forensic practices, from a total of 74 questions, we obtained results higher than the median of the scale, both at T0 and T1. The results for total knowledge at T1 (69.15 ± 3.051) were better than at T0 (62.95 ± 4.479), as well as in all statistically significant subject areas, except for the definition of forensic nursing. This could indicate a need to deepen or restructure some of the relevant indicators during the intervention. By analyzing some indicators by subject area, we were able to demonstrate an improvement for trace evidence between T0 and T1 for all items.
It is important to note the marked improvements, such as in total knowledge of forensic practices and on preserving the trace evidence area, which illustrate the importance of this training for the improvement of care given to victims. By properly gathering and preserving forensic evidence, nurses will also contribute to establishing the perpetrators’ liability and the consequent application of justice. Most students demonstrated knowledge in the documentation and communication and general nursing care areas, although there were insignificant drops at T1, when compared to T0, in 4 out of a total of 20 items. According to Sheridan et al. (2011), “the nurse should date and sign the tape after sealing the paper bags,” thus guaranteeing the inviolability of the bags. Only 74 participants (88.1%) correctly answered this statement after training, which is indicative of the level of knowledge.
Item 73, which read “The victim’s body should not be handled when it arrives as a corpse, it should only be covered with a sheet and placed in a body bag” is, of all questions, the one with the worst results and greatest drop from T0 to T1. This was answered correctly by 47 students at T0 (56%), but only 20 at T1 (23.8%). Manipulating the victim’s corpse will lead to the destruction and deterioration of trace evidence. In the event that the patient is admitted as a corpse or dies after admission, all clothes, including shoes and everything else that had been in contact with the patient, must be kept in their original position until the medical examiner arrives. Indeed, all physical evidence must be kept in its original position (Lynch & Duval, 2011). These results can be explained by the fact that students observed this practice during their internship in Portuguese emergency services, because most protocols in place in these services do not envisage forensic exceptions (Gonçalves, 2011).
Some limitations need to be acknowledged. This study was conducted with a small sample from only one Portuguese school. Larger, experimental studies with a control group, using randomized samples, are still needed. Without a control group, it is difficult to attribute improved knowledge to the intervention. Another limitation was the lack of follow-up. An extended follow-up is recommended to confirm that the skills acquired were incorporated into the participants’ practice over the long term. Because few hospitals in Portugal have a forensic protocol, a further limitation was the lack of access to data regarding the number of victims of crime and victimization under the care of the emergency services.
Including forensic content in undergraduate nursing degree programs is a growing necessity. The content taught during the learning process in this intervention was effective and could constitute a good starting point for developing a syllabus intended for nursing students and/or nurses, whether for the nursing degree or postgraduate courses, master’s degrees or advanced courses. However, we consider it important to set a 40-hour load for this type of course and a reduced number of trainees per group to allow trainees to practice forensic procedures throughout the practical scenarios, which they viewed as a good way to learn. Finally, although not directly related to our study, this study enabled us to make suggestions for consideration when planning structured training in forensic nursing, specific to the unique and pioneering role of forensic nursing in Portugal (refer to Table 3).
We are grateful to the nursing students who participated in this study.
All authors have agreed on the final version and meet at least one of the following criteria:
• substantial contributions to conception and design, acquisition of data or analysis, and interpretation of data;
• drafting the article or revising it critically for important intellectual content.
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