What is forensic nursing: history and introduction
Medical death investigation in medicine shows root/have been noted in early Egyptian and Hindu cultures. Forensic nursing first appeared as a career in the UK in the 1950s. In the 1970s, forensic nursing spread to the US. Forensic nurses work closely with law enforcement to bring justice to the victims. The role of the forensic nurse is to take precise injury documentation, obtain medical history, take forensic samples, administer medication, interview a patient, create a legal document for law enforcement and serve as an expert witness in court.
There are several forensic nursing specialty areas such as sexual assault nurse examiner (SANE), crime scene and death investigator, the correctional nurse and psychiatric nurse. Much of the forensic nursing deals with the victims of domestic violence and sexual assault.
The International Association of Forensic Nurses (IAFN) has members all over the world, setting international standards for protocols and guidelines for nurses.
Meet Lana, a practicing forensic nurse
Lana’s* nursing career spans almost 20 years. She started her nursing career as an LPN, and became an RN a few years later. As an RN she wore many hats, from Orthopedic nursing, NTICU, Cardiac stress test nursing, accreditation and quality improvement, and lastly as a forensic nurse. Lana has been interested in law enforcement topics since she was a teenager watching shows like Law & Order. A victim of domestic abuse, she set on a course to help others. Her forensic nursing career began when she took an IAFN-certified professional certificate in forensic nursing. She is currently studying for a SANE-A exam.
*(Lana’s name and all identifying information has been changed to protect patients’ identities)
The interview: all about forensic nursing
Jelena:
Hello Lana, thank you for agreeing to do this interview. What is forensic nursing? Describe some of the things that you do as a forensic nurse.
Lana:
When people think of forensic nursing, they typically think of sexual assault. Forensic nurses work with a wide variety of victims.
When your patient comes in, you do a head-to-toe physical assessment, like you would do on the floor to look for any injuries. You gather their medical history, document what happened and collect the DNA. The patient’s body is a scene of the crime, and you are trying to preserve that crime for posterity.
To collect accurate history, every state has different forms that they use. They are designed to probe the brain and trigger memories the patients might not be able to recall because they’ve blocked out the trauma. The patients get what’s called “trauma brain,” because they were either in flight, fight, or freeze response, so they have trouble forming coherent memories.
Some things the patients say may not make sense. It doesn’t mean that they’re lying. It’s just that they were so traumatized when the assault happened. So, you take their history, and then depending on their history, that’s how you determine how you’re going to treat the patient.
What does a forensic nurse do? common tasks and cases
Lana:
The vast majority of assault victims that come in have been using substances. Most commonly, they’ve mixed alcohol and THC, or they’ve used some street drug, so they don’t have a whole lot of memory about what happened. A lot of times, they’re not even sure that they were raped, but they have reason to believe that they were. What they remember determines the types of swabs that should be taken.
In a nutshell, you collect their history for prosecution. There are strict legal guidelines about how to approach and document the case. The forensic samples and documentation help law enforcement determine how to proceed with finding the person that did committed the crime.
So you do that part. You do the swabbing. You take the history. You also take photographs. A lot of times when there’s loss of memory, we always do photos of the mouth because during a sexual assault, there tends to be a lot of injuries on the inside surfaces of the cheek. So you do mouth pictures. You perform a careful head to toe assessment; you look for injuries on the body. You photograph those injuries.
One of the questions when you first start interviewing is to ask the victim if they have any injuries that were there before the assault. What happens next depends on the type of setting where you work.
Because I work in a hospital-based setting, we do STI testing, HIV testing, pregnancy testing. We start them on prophylaxis. We can give them pregnancy prophylaxis if they’re within the window. We make referrals for therapy and advocacy. We also refer them to what’s called the victim’s compensation board, where they can get reimbursed for any expenses that they incur, like therapy or if they need to move or anything really a hospital bill that they get is to help reimburse them.
When you’re done collecting all that information and the DNA, the case gets sent to law enforcement. After that, it’s out of your hands unless it goes to trial, so we may get involved in the case again. But generally, once the patient leaves the exam room, that’s the end of your interaction.
So with forensics, it’s just really important that you carefully document everything the victim says, because they may end up dying. It doesn’t happen often, but it does happen. Forensic nursing can also include domestic violence cases. It is unusual for programs to do both sexual assault and domestic violence exams, but we do them, and we also do what’s called felony assault exams when the law enforcement requests them. When you do a felony assault exam, that means that the assault was so bad that the intent was to either kill the person or maim them to the point of disability.
Jelena:
Do you see gunshot wounds?
Lana:
No. We don’t do gunshot wounds. A felony assault usually involves a beating. For example, an item was used that could have been a deadly weapon, not necessarily a knife or a gun. The law enforcement has their own protocol for dealing with gunshot wounds, because those are overt and obvious. Usually, when we do felony assault exams, strangulation is involved. Or, for instance, somebody may have taken a frying pan, like a cast iron pan and used it on somebody’s head, or attacked someone with a baseball bat. The intent was to kill with the first available item they could get their hands on.
So when it comes to stabbings and gunshots, that falls under a different realm because it’s just a different set of laws.
How to become a forensic nurse
Jelena:
Okay. Remember when we met a nurse who thought she had to have a master’s degree to become a forensic nurse, and you went ahead and did a certification of some sort to get into forensic nursing? What did you go for? What was it called?
Lana:
I actually haven’t yet finished that certification, it’s a certificate program in forensic nursing. I am doing it online. Typically, the minimum to get into forensic nursing is a 40-hour course on sexual assaults. When you’re looking for that kind of training program, it’s really important to make sure that it is endorsed by the International Association of Forensic Nurses, IAFN.
There are a lot of 40-hour programs out there that are called SANE, sexual assault nurse examiner programs, but not all of them are necessarily endorsed by the IAFN. If they’re not, it’s pointless to take them. The best resource is to get on their website and look for those programs—they have them all over the country.
So the way I got into forensic was by finding a certification program through a university. I had only taken a couple of classes when we got a job announcement that this hospital was looking for forensic nurses, and I just decided to apply, because I had so many years of nursing experience under my belt.
Jelena:
How many years did you have total so far?
Lana:
At the point that I applied for the job, I had 18 years. The best way to look into forensic nursing is to get on the IAFN’s website. It is a wealth of information. It is the international standard setting body for the entire world when it comes to forensic nursing. There are other forensic nursing organizations, but they tend to be either country based or even state based. They just don’t have as much credence as the international body does.
You can also look for jobs on the IAFN website. The vast majority of them around the country are county-based. A lot of times, you can apply for those jobs with zero experience, and they will train you.
When I applied for the hospital job, I only had 2 classes under my belt, and they trained me.
The master’s program is geared towards leadership, for example if you’re the kind of person that wants to start up a county-based or hospital-based forensic programs. Really, the only reason to get that master’s is if you’ve already been working as a forensic nurse, you live and breathe it.
The “what I wish I’d known before” about forensic nursing
Jelena:
What was the most surprising thing about forensic nursing that you didn’t anticipate?
Lana:
That I was surprised by? There are a lot of transgender people in this area. It just wasn’t really on my radar that transgender people were at such high rates of sexual assault and domestic violence. The anatomy differences of the victims of sexual assault, both trans males and females, the hormones that they take, that was not something that was really on my radar.
When I got into forensic nursing, I didn’t know that it could include felony assaults or domestic violence.
Interestingly, I get a lot more professional fulfillment from doing the felony assault and domestic violence exams because those do go to trial. I’ve yet to do a sexual assault case that went to trial.
Jelena:
Are you serious!?
Lana:
I’ve worked more sexual assault cases than I have domestic violence and felony assault, but I’ve yet to see one go to trial.
Jelena:
Is that because there’s a backlog of rape kits?
Lana:
It’s because the victims often don’t know what happened, so it makes it difficult to prove. So, you must look at it from a prosecutor’s point of view. I always thought once I sent the file and test kit to the law enforcement, there would be prosecution. One of the things that has been so surprising to me is they don’t prosecute unless they’ve got a good, solid case. Because so many people that have been sexually assaulted were mixing drugs and alcohol, it’s hard to prove.
Jelena:
I think it’s especially challenging for your area because there are many festivals around the hospital where you work.
Lana:
I’ve only done a few sexual assault cases where the case would have been a slam dunk.
Jelena:
What’s the percentage of men that get sexually assaulted in your area?
Lana:
Because of the large LGBQT community where I live, I see a significant number of men. I would say probably 15% of my patients are men, and it’s the same scenario – they get drugged. We have had some serial predators. One of the cases that happened right before I started my job was a victim of a serial rapist. Luckily, the victim had the courage to go to the police and get a kit done right away, and the assailant’s DNA was linked to several other cases, because they got a hit in CODIS, a national DNA index. So, eventually the perpetrator was convicted and went to jail.
A forensic nurse’s schedule, forensic nurse certifications, and the complexity of sexual assault cases
Jelena:
What’s your schedule like? Do you get a lot of on-call?
Lana:
I work in an ER-based setting, so I am scheduled in 12-hour shifts. However, most programs, around the country tend to be county-based, and those are on-call. In the more rural areas, there are outpatient clinics where patients get interviewed. The patient will go to law enforcement, and then they’ll get sent to this outpatient clinic that is open 8 am to 5 pm where they get interviewed, swabbed and photographed.
Some people are just on-call for X number of hours if they work in a county-based program.
There are also private forensic investigations. Some counties use a privatized forensic program where the nurses are on-call. They do both perpetrator exams and victim exams.
Jelena:
Oh, interesting!
Lana:
Yes, they swab the perps too. We don’t. Then, there are privatized programs where the nurses go to different hospitals, or police stations to swab perps, or they go to the hospital to swab the victim.
There are not a whole lot of hospital-based programs, which is unfortunate. I feel like when it’s hospital-based, you can address the whole person. It’s a one stop shop, whereas when it’s county-based, you go to the victim wherever they might be at the police station, or a hospital, a family justice center, a safe house. So you have to make all these outpatient referrals for STI testing and prophylaxis. There’s pros and cons to every type of setting.
Jelena:
I think one big con to seeing multiple providers is that the patient has to relive what they’ve been through with every provider, so the trauma keeps getting thrown in their face.
Lana:
For sure. Yes, they have to keep reliving it.
The International Association of Forensic Nurses offers two certifications, separate from what I’m doing. After you’ve been working as a forensic nurse for and you’ve done X number of victim exams you become eligible to sit for an internationally-recognized certification. There’s SANE-A and SANE-P, adults and pediatrics.
My department does exams on ages 12 and up, which falls under the “adult/adolescent” umbrella. We get training on recognizing if clients are victims of incest, which is common in that age group.
And so, as part of that 40 hour training, you look at the TANNER scale to see where they are in their development. SANE-P covers babies up to 11 years old. A lot of forensic nurses do end up getting both certifications. Where I work, the expectation is that I get both.
Jelena:
And you said, like, it takes a while to get those certifications.
Lana:
Yes, because they only offer the exam a couple of times a year, and there’s a minimum requirement of not only the number of exams that you’ve done, but also the number of hours that you’ve spent in those exams. The sexual assault exams take a lot longer than the domestic violence exams do.
Jelena:
Do they take longer to document?
Lana:
Well, in general, you’re going to spend a lot more time with the sexual assaults, because you have to draw their blood, send their labs up for STI testing, give them all these meds. You have to make sure that they eat. A lot of them don’t want to eat because they’re in a state of shock, and we give them meds that make them really sick. It’s not unusual to spend 5 or 6 hours on a sexual assault exam, and there’s never a routine exam.
There’s always a surprise, the more you probe, the more you might find out. For example, the person may not remember they were being strangled until mid-exam. So then you have to add a strangulation addendum, and that’s a separate protocol. Then you’ve gotta take all these pictures of the neck and of the eyeballs because you want to look for the petechiae and bruising and, so the sexual assaults tend to take a lot longer.
Domestic violence exams usually take around 3 hours. When they take more than 3 hours, it’s because their body is so battered.
Jelena:
Oh.
Lana:
I’ve had cases where I took 300 pictures. The reason why you’re taking 300 pictures is because, when you take the injury photos, you take a landmark one so that you know exactly what part of the body it is. Then, you get closer to it with a ruler to measure the area. After that you take the ruler away, and then take another picture. That way, you can prove that you’re not obscuring any injury with the ruler.
It can be tricky to take those photos because I have to work with an angled ruler, called ABFO ruler (American Board of Nursing Odontologists). When you are photographing a flat ruler over a rounded surface, it will create a cast. so there’s a lot of maneuvering so that you don’t create, like, an artificial cast. It’s not as easy as it sounds. It really isn’t. It takes a lot of experience. People have different complexions, and so sometimes you’re having to change the settings on the camera, the lighting, and the room because of different skin tones. So that’s something else that can add to the time of doing these.
Work environment: mobile exams vs working at the hospital
Lana:
We also do mobile exams because our program covers the eastern half of the county and I work in a very large geographical region. We go to outlying hospitals as well. If it’s domestic violence, we’ll go to the police station if they don’t want to come into the hospital.
Jelena:
Do you have a mobile cart that you have to take with you?
Lana:
We do. We have a big, mobile tackle box that holds our camera, tripod, our evidence kits, and the tools to perform any type of exam. When we do those mobile exams, we’re relying on the hospital we visit to take care of their STI testing, prophylaxis, etc. We make recommendations to the ER physicians on prophylaxis based on CDC Guidelines.
Jelena:
When you come into work, do you know if you’re going to be doing mobile exams or stay at your hospital?
Lana:
It is a surprise because, either law enforcement will call us and let us know that there’s a patient at one of these hospitals, or the hospital itself will call us and say, “Hey we have an assault, can you come do the exam?” We say, yes, and call to notify law enforcement. In my state, if it’s a domestic violence or a felony assault, you’re not entitled to an exam. You’re obviously entitled to medical care, but not a forensic exam because law enforcement has to do their investigation first. A lot of times, when we get domestic violence cases, law enforcement will do their investigation, and they’ll find out that the person reporting it was actually the perpetrator. That happens a lot.
Jelena:
Interesting. So if they’re the perpetrator, they are not entitled to a forensic exam?
Lana:
No, because they’re the ones that are going to be prosecuted.
Jelena:
So the forensic exam is only for the people who are victims.
Lana:
Correct.
Jelena:
Okay, so if you’re getting these phone calls, like, say, hey, here is a person at The Regional or there’s a person out in some little clinic, do you coordinate with that clinic for the person to show up at the time when you’re gonna be there, do you schedule them or are they just waiting?
Lana:
They just basically have to wait until we can get to them.
Jelena:
Wow. Okay.
Lana:
Because if we have somebody already at our facility, we have to examine them first. So, basically, they have to wait until we can get to them. When I get those calls, I triage over the phone. First of all, I need to know has it been 120 hours or less? Are they sober? They have to sign an informed consent to get one of these exams done, which means they cannot be under the influence when they’re signing it. So a lot of times, we’ll get these calls at 2 o’clock in the morning, and the patient’s ethanol level may be 400. I will tell them “Well, they need to sober up. I’m not coming till they’re sober. You need to hydrate them. You need to feed them. You need to get them sobered.” Because, legally, I can’t do an exam on somebody that can’t consent.
Workload and seasons
Jelena:
So when it’s the “off season,” when things are slow here, how many people do you normally see in a shift?
Lana:
It’s feast or famine.Sometimes we just get slammed all day long, even in the off season. We get tons of patients, especially in the summer. We get a lot of assaults and domestic violence in the summer. There’s something about this heat here. So, it doesn’t matter whether it’s in season or not. It doesn’t matter the time of year. We see patients year round.
We might go 3 or 4 days where we don’t see a single patient that comes through the ER, but we’re still busy because we have to get our cases finished up for law enforcement. We have to peer review each other’s work. You want to have a second set of eyes to look at it and look for spelling errors or maybe help clarify something that was written.
Another part of the job: CPS referrals
Lana:
Something else I forgot to mention as part of my job is that I do a lot of CPS referrals. I do a lot of reporting to CPS. Especially with domestic violence cases if there were kids in the house when the assault happened. I have to notify CPS if a sexual assault is under 18 because that’s child abuse.
I would say probably with 40% of the cases that come through the door, I have to make a CPS report. So that also adds to your time spent.
I do occasionally make APS reports – Adult Protective Services.
Jelena:
Oh, I didn’t know that existed. Okay.
Lana:
Adult Protective Services generally is for ages 65 and up, but it’s also for incapacitated adults. People that are too mentally challenged to function on their own, who require a caregiver to ensure that their ADL’s get done. So, I do occasionally have to make APS reports. We’ll have incapacitated patients that come through the ER with a friend or a caregiver, and the ER staff will call and say “This ‘friend’ is acting really weird, we’d like for you to come in and talk to him, and see what you think,” and I’ll evaluate whether APS needs to be notified or not.
Doing forensic reports and medical documentation
Jelena:
I’m guessing a lot of the forensic classes have to do with teaching you to document from a legal standpoint, rather than a nursing standpoint.
Lana:
Exactly. When we get the patient’s history, we put everything in quotes. And we use verbiage like “Patient states that…” and then you directly quote it. You try to avoid using anything inflammatory, like “patient refused.”
Jelena:
I see.
Lana:
We also document in the medical record too, which is discoverable by the defense. The other thing is you have to make sure that not only you write a separate forensic report, it needs to mirror what’s in your medical documentation as well.
Jelena:
Do you do the medical documentation, then the forensic report?
Lana:
You’re doing that simultaneously. There’s not that much from the medical record that actually goes in the forensic report. Pain scales will go in the forensic report. Vital signs will go in there. Any lab tests that you did, any abnormal values will go in the forensic report. So you are double- documenting, and you want to make sure that they mirror each other because the defense will tear that apart.
Jelena:
Tell me, what does a forensic report mostly focus on?
Lana:
The history. It’s long. It’s very detailed. This is what I do: When I get a patient, I open up my sexual assault supplement, and I will ask the patient “In your own words, tell me what happened,” and I’ll just start typing away. And that will help guide me through those individual questions because by having them tell it in their own words, I’ve already gotten a lot of those questions answered.
That way, I don’t have to re-ask the same thing. So, if there’s a topic in the report that they didn’t mention, those are the ones I will ask about. We also have to ask questions about anything that could affect their exam.
For instance, I’ll ask, “Have you seen a doctor in the last 30 days?” because that will help answer questions like have they been to the gynecologist, have they been sick, have they had any surgeries? Anything that might affect the interpretation of the results. Another thing we have to ask during these exams is, “Have you had any consensual sex in the last 5 days?”
Jelena:
I see. Ok.
Lana:
I always preface it with, “I’m going to ask you a lot of questions that will be really personal. Those are the questions that I’ll ask everybody, and it’s to help my interpretation of my findings. It’s to help figure out what is an injury from the assault and what could have already been there.”
We also ask them about recreational drug use. The laws in our state say that recreational drug use can’t be held against them. We do a urine tox screen no matter what. It goes to the crime lab. Especially when they state they have loss of memory after having taken a drink from some random person, or when they say “I only had one drink and I don’t remember anything after that.” Well, the urine goes to the crime lab.
We do our own in-house testing, but we also send the urine to the crime lab where they test for metabolites, because a lot of these drugs are broken down so fast, they’re out of the bloodstream within 6 hours. For example GHB – It’s out of your bloodstream so fast, but there are certain metabolites it breaks down into, so we send it to the crime lab, and that can help the crime lab determine if maybe they were given something like Rohypnol. Even though Rohypnol was banned in the United States, we’re right by the Mexican border. You wouldn’t believe the amount of Rohypnol on this side of the border. It’s just so easy to get it across, because we’re right there. So, we do a lot of Rohypnol testing. But, yeah, the sexual assault questionaire is very long, very detailed.
The domestic violence ones are completely different. When you do the domestic violence exam, you’re going into history of prior assaults, things that were said, things that were done, events that led up to it. What’s their relationship to the perpetrator? How long have they been together? Did they have kids?
Emergency protective orders and keeping people safe
We also do a form called “The Danger Assessment,” and it’s a tool that was developed at John Hopkins in the eighties. It’s a validated tool that has been tested over and over, and it’s used as a predictive tool to determine the risk of a patient being murdered by the person that assaulted them. Depending on where they rank on this hierarchy, there are different interventions. The highest is “extreme danger.” The vast majority of our patients fall on the extreme because they’ve all been strangled. Studies have shown that once a man has decided to strangle a woman, her risk of being murdered by that man goes up 600%. There’s also, strong correlation between men that strangle and men that murder law enforcement officers. The vast majority of men that have killed cops have strangled a woman.
Jelena:
Interesting. So if they fall into extreme danger, do you then refer them to adult protective services, or a shelter program?
Lana:
That’s all part of our hospital based program. There are a number of things that we do. First of all, when we get the call from law enforcement that they want an exam done, when I’m on the phone with law enforcement, I ask them if they have caught the perpetrator? Are they locked up? Have you gotten an EPO for the victim?
Jelena:
What’s that?
Lana:
An emergency protective order. Emergency protective orders are good for 5 days.We refer them to the Family Justice Center where they can get an advocate that will help them get a permanent VPO, victim’s protective order filed. The advocate will go with them to court. They don’t have to do this alone. The Family Justice Center will go through- and do the paperwork with them. They will accompany the victim to court. They will make arrangements for them to get therapy.
During normal business hours, we’ll reach out to the Family Justice Center because they have safe houses, to see if we can get them into a safe house or a shelter. Outside of those hours, our social workers will find them a shelter. The vast majority have a place they can go.
Jelena:
That’s scary because if they are staying with family or friends, the other person can find them.
Lana:
That is true. That they can. But the vast majority say they have a place they can go. The ones that typically don’t have a place to go are new immigrants. They are the ones that we end up having to find a shelter for.
Something else that was really surprising to me is, the number of undocumented immigrants that get trapped in these relationships because they’re so dependent, because they’re not here legally. They are often here alone, working an illegal job to support their family on the other side of the border. They usually don’t have a car. So, predators look for women that are vulnerable, that don’t have any family on this side of the border, and they can do whatever they want to them. There is a definite pattern, because the MO is always the same. They look for people that are good natured, vulnerable and isolated, or they isolate them. When I do these domestic violence exams, I hear the same story over and over and over. It’s the exact same MO. They start with this early love bombing. Then they start isolating you. Then they start gaslighting you and making you doubt yourself. Then they start manipulating you financially. It’s this vicious cycle, and it happens in stages.
The victims get stripped of their identity. So, yeah, that was another surprising thing – I never thought about the types of people that would be vulnerable to domestic violence, but undocumented immigrants are just disproportionately at risk.
Jelena:
That makes sense.
Why should I become a forensic nurse?
Jelena:
What prompted you to pursue forensic nursing?
Lana:
When I was in high school, one of my classmates’ mom was a forensic chemist for the Police Department. We used to have the best conversations. She would tell me about her job, and it all sounded so fascinating. So, she was my first inspiration. Years later, when I was working in the trauma ICU, I was working with this little gal who apparently, unbeknownst to me, was also working at another hospital as a sexual assault nurse. She would just tell me that she was moonlighting on the weekends for extra money.
Listening to her talk about what she did reignited that passion I felt when I was in high school, and it just kind of became a goal of mine that eventually I would want to go into forensics.
One of the reasons why forensic nursing is appealing to me is because when you work in the hospital setting as an ICU nurse, you don’t really get to see the end result of what you do. But in this, you do.
I’ve had patients that called me and thanked me months down the line and said “You doing that exam was the first step in my healing.” Or, if you end up having to go to court and there’s a conviction, you get to see the end result.
Testifying in court and seeing cases through to the end
Jelena:
You told me in the past that if there’s a trial, you get to testify.
Lana:
Yes, you’ll get a subpoena to testify, because the report by itself isn’t really enough for a jury. It’s best to have the person. The forensic exam is just a tiny piece of the whole puzzle, when it comes to law enforcement and securing a conviction. There’s the investigation done by whoever takes the report, and then depending on the severity of it, it might get escalated up to a detective.
We have a kit that we send to the Department of Justice. We pick the 3 swabs that we think are going to yield the most DNA. Those get tested within 90 days. Then there’s the big kit that goes to police lockup. During the course of the investigation, they’ll then determine if they want to test the whole kit. Sometimes those kits will include the clothes that they were wearing. After law enforcement has done their investigation and they’ve reviewed what we’ve done, they also interview witnesses, and the person that’s being accused. Then, they send it off to the district attorney’s office, and then the DA will determine what kind of charges they can press, if any. Because, they have to determine based on the entirety of everything that they have what charges are going to be the most likely to stick in front of a jury.. And then it goes from there.
Most cases don’t even go to a trial because the perps will plead out for a lesser charge. But you do have the occasional case where the perps aren’t even given a choice to plead out because the case will be that heinous. There is no plea bargain. A couple of mine have been that way, where the domestic violence cases were so heinous.
Jelena:
Do you find yourself working after hours, or working extra to finish the reports?
Lana:
Because we’re not a 24/7 operation, If I get called to a mobile exam towards the end of my shift, then yes, I might end up working 16 hours. The main thing that I have to do is make sure my evidence is packaged appropriately. The report can wait. The turnaround time on our reports is a couple of weeks.
It takes that long because we have to include the images. We have specialized software that we put our photos on, and we store the photos encrypted. We have enhancements that we can use to look for very fine injuries. Then, we have to wait for a peer review. That is why the turnaround time on our reports on average is a couple of weeks, depending on how slammed we are. Sometimes it takes a little bit longer. Quite honestly, it doesn’t matter because the turnaround time just on testing the kit, the rapid kit, could be up to 90 days. So you have the time. These things just don’t move fast.
Domestic violence ones can, I mean, I’ve been subpoenaed 3 months after I did a domestic violence case, because they were that bad. Either it was that bad or the perpetrator went on to commit a different crime and they really needed to get him locked up, or the victim went back to the perpetrator and they got beaten again. These are the ones that get fast tracked.
Protecting your own mental health
Jelena:
How do you deal with this type of work? When you work as a forensic nurse, you carry stuff home sometimes. I feel like this is really heavy.
Lana:
Honestly, It’s something about my personality. Last year, around this time, was the first time I had to do young adolescent exams on victims of incest. I did 3 in one week. I had never done any, and then all of a sudden, I had 3 in one week. It bothered me a lot. It really, really bothered me. It was like festering in my mind, but after I did a few more exams over the course of the next couple of months, I was able to come to terms with it. I just started getting used to it.
So, it takes a certain personality type to be able to do this kind of work. If you’re the kind of person that takes stuff home with you, then you shouldn’t do this job. You kinda have to be very clinical, and you have to be very good at compartmentalizing, you have to be the kind of person that violence just doesn’t faze.
Our department looks for people with an ICU or ER background, because any other profession is really going to struggle with this kind of work. So, my advice to anybody that’s thinking of forensics, you have to be the kind of person that does not take things home with you. People think they want do it, and in 6 months, they’re burned out.
This job is a commitment. Because if let’s say you leave this job and a case that you did 3 years ago suddenly goes to trial. You have to go. Legally, if you get subpoenaed, you are commanded to go. It doesn’t matter if you’re not even working as a forensic nurse, you’re legally obliged to show up.
Jelena:
Do you have access to the records that you have created when you were a forensic nurse?
Lana:
So, what will happen is nurses that have previously worked with us will call, and we’ll set up an appointment for them to come in and go through their records so that they can refresh their memory. We’ve had to do that quite a few times.
When you’re doing the exam, you’re so focused on the clinical aspect. You’re so focused on preserving your evidence and capturing the photographic evidence, a part of you is detached. We had a situation where a severely beaten patient was near death. We had to work very fast because we knew at any minute the patient was going to code and our crime scene was going to get contaminated. So, Anna was getting the DNA evidence, while I was taking pictures. When I left that night and I was driving home I had to pull over to the side of the road. I just went to pieces because that was the first time I had ever done a case where the patient was going to die. That one was hard. It really bothered me for a few months.
On working with law enforcement
Jelena:
Do you talk a lot to the law enforcement?
Lana:
Oh, yeah. I deal with law enforcement day in and day out. Either the police department or the sheriff’s office. The bigger towns here have police departments. In the smaller towns, we fall under the county sheriff’s office depending on your location and where it happened.
Jelena:
Do you work with them mostly over the phone, or do you have to go into the department sometimes?
Lana:
They come to collect the evidence because of the chain of custody. Sometimes they bring us the patients. Sometimes the patient will just show up in the ER, and they haven’t notified law enforcement, so we have to call law enforcement because ours is a mandatory reporting state. Not all states require you to contact law enforcement when somebody comes in for a sexual assault exam.
Jelena:
Interesting.
Lana:
The Department of Justice does not require mandated reporting, but our state does. So, for instance, when you sit down to take your SANE – A exam, there’s a question on there about mandated reporting. Those questions are based on Department of Justice recommendations.
Another thing about sitting for those exams is that you have to know what the national standards are, not only what your local jurisdiction’s, because they might be very different. Now that doesn’t mean that the victim has to cooperate with law enforcement. They don’t have to. But we still have to notify law enforcement.
Career paths in forensic nursing
Lana:
Something else I wanna say is there’s a number of different routes that you can take with forensic nursing. Some states have forensic nurse death investigators. The program I’m in has a capstone course where you can do forensic death investigation. Some states do not recognize nurse death investigators. You can still become a death investigator, but you lose your nursing title.
Jelena:
Interesting.
Lana:
So that is one avenue, you can take the avenue of doing death investigations. You can also specialize in human trafficking. And, you can start up programs in hospitals that, you know, screen for human trafficking. There are a lot of different avenues that you can take, it doesn’t just have to be sexual assault. It can be human trafficking. It can be death investigations. A lot of counties are now having nurses run for coroner. They work under a pathologist.
Jelena:
What do you do as a nurse coroner?
Lana:
You do autopsy.
Jelena:
As a nurse?
Lana:
Yes.
Jelena:
Wow.
Lana:
Coroners still do autopsy.But it’s under the supervision of a pathologist.
Jelena:
Right.
Lana:
But, yeah, there are county coroners that are forensic nurses. So there’s a lot of different avenues that you can take with forensic nursing. The most common one is sexual assaults. That’s how most people get their foot in the door and then they just branch out from there. Unless death investigation is your passion. Some of the people that are in my classes with me are doing the death investigation track. They’re in other states, because this program is an online platform. They’re from all over the country.
On the topic of money: cost of forensic nursing programs and forensic nurse salary estimates
Jelena:
I’ll have to look into the cost of the program.
Lana:
My hospital paid for my sexual assault training. The cost is very reasonable, though. You can do these 40-hour trainings for several hundred dollars. If a training isn’t offered online and you have to travel out of state, that may get expensive. There are programs where you do 40 hours of online training first, and then 40 hours of in-person training.
Jelena:
Do you get paid extra for having this certification?
Lana:
Once I get nationally certified, I will get an extra $1,000 a year. I make more than the nurses in the ER. I get a higher pay scale. County based nurses don’t make very much money. This is not a field where you’re going to make great money. It’s not like working in the ICU or something like that where you’re gonna get time and a half and all that.
Majority of forensic nurses are county-based, so most of them get county wages. It’s not very much. Hospital based is the way to go if you want to get your regular RN wages. I have heard that the nurses in private investigation firms make pretty decent money as well. I don’t know what figure, but I know that they’re definitely making more than the county nurses.They may be on par with hospital nurses. So yeah, it just depends on the part of the country you’re in and what setting you’re in.
One of the reasons why I’m doing this university certification course is because, when we go to testify, we don’t give a resume, we give a CV. When you show that you have taken that extra step of learning as much as you can about forensics, it gives you more credibility in the eyes of the jury, and it gives the defense less ammunition against you if you can show that commitment. Anybody can do the 40 hours and then try to find a job. Taking a certificate course shows commitment to the profession. You’re getting courses in forensic photography, pathology, documenting blunt force injuries, how to manage mass casualty events, and how to testify in court. So that’s one of the benefits of actually trying to find a certification program instead of just doing the 40 hours because that’s just the bare minimum.
Jelena:
That’s what I’m learning about everything nursing related. Thank you very much.
Quick FAQs & answers
What is a forensic nurse?
A forensic nurse is a registered nurse (RN) who specializes in caring for victims of trauma and violence, using both healthcare and legal systems knowledge to provide more specialized care.
What does a forensic nurse do?
Forensic nurses conduct medical examinations that include collecting and preserving evidence from victims of crime. They also provide testimony in court cases, offer care to incarcerated individuals, and collaborate with legal authorities on proper documentation and handling of medical evidence.
How to become a forensic nurse
While in principle, every registered nurse is qualified to work as a forensic nurse, there are various additional certifications available and may be required for some positions. Make sure the certification is accepted by the International Association of Forensic Nurses (IAFN).
How long does it take to become a forensic nurse?
The timeline to become a forensic nurse can vary. Initially, one must complete a nursing program, which takes 2-4 years depending on whether you pursue an ADN or BSN. Gaining sufficient clinical experience typically requires at least 2-3 years. Specialized forensic training or certification programs may be very quick, such as a week-long course on sexual assault cases, or take up to a few months or a year.
How much does a forensic nurse make?
The salary of a forensic nurse can vary widely depending on location, experience, and the specific employment setting. On average, forensic nurses can expect to earn between $56,000 and $96,000 annually, with higher salaries typically seen in larger metropolitan areas or specialized roles that require more experience or advanced certification.
