Forensic nursing: Finding work-life balance

USA and Canada are the only two countries that have officially recognized forensic nursing as a specialty. Sheila Early, President at the International Association of Forensic Nurses (IAFN)* took the time to speak to us about the evolving role of the forensic nurse, challenges in gaining proper international recognition for the specialised profession and managing the balancing act between work and personal lives in a demanding role.

IIR Healthcare: What are the greatest challenges when it comes to taking universal access to forensic nursing care to the next level?

Sheila Early: First and foremost forensic nursing needs to be recognized as part of healthcare systems globally.  USA and Canada are the only two countries that have officially recognized forensic nursing as a specialty. It is a constant struggle to convince the healthcare sector that forensic nurses are a necessity in healthcare and not a luxury. Australia, Kenya and the United Kingdom have associations promoting forensic nursing as well, however this remains our biggest challenge. If a country does not have any knowledge about forensic nursing it is very difficult to provide even the fundamentals of universal access to forensic nursing care.

Moreover, nursing education in general has not accepted that forensic nursing principles and skill should be part of basic nursing training.  I teach many third year nursing students in Canada and the idea of not cutting clothing through a bullet hole or a stab wound is completely new to them.  Yet, clothing is the most frequently destroyed example of potential forensic evidence in cases of violence, trauma and crime.

These challenges will continue into the next decade. One positive factor is that the members of the IAFN come from approximately 22 countries. And even if there is only one member in a country, they are and will continue to be the champions of forensic nursing locally. Take for example the Netherlands:  We have one member there, Piet Machielse, who in 2007 invited the President and two IAFN members to come to the Netherlands to help with the promotion of forensic nursing.  We did this on our own funds, giving presentations on forensic nursing.  Last year, after several years of long and hard struggles, Piet was able to deliver the first forensic nursing courses in the Netherlands.   This is the challenge that delineates forensic nurses and their dedication to the specialty from other specialties.  They lead others, care for patients, have a specialized expertise and they are determined to be forensic nursing champions.

Another challenge is that role of the forensic nurse is not going to survive and thrive as a casual position.  Many forensic nurses have two jobs – their paying job and then their forensic nursing job which unfortunately is often casual or part time.  Until there is recognition that forensic nurses are needed in full time positions, the specialty will continue to struggle.

Lastly the funding of forensic nursing education and the need to provide that education to those who embark on the journey into forensic nursing remains problematic.  IAFN has tiered membership fees which allow those in developing countries to become members at a reasonable rate.  We also offer grants to attend the annual conferences. Usually 3-4 individuals from around the world receive at least partial funding.   The challenge is to offer education that is accessible to many members that is appropriate on a global standard and is as current as possible.

IIR Healthcare: Science and technology around forensics are constantly evolving. How have recent developments in forensic influenced the role of the forensic nurse?

Sheila Early: Forensic nursing is greatly affected by developments such as rapid DNA testing, targeted toxicology testing, refinement of techniques for analysing samples such as swabs and clothing. Photography and videography have also enhanced the skills of the forensic nurse.  The key is to always remember the patient – living or deceased. It is the primary concern of the forensic nurse and consent is the vital issue that enables the forensic nurse to perform the specialized skills needed in the care of the forensic patient population.  That is why procedures and protocols are constantly being evaluated by research and then moved into best practice.

IIR Healthcare: How are these advancements reflected in nursing training?

Sheila Early: In mainstream nursing, they are not reflected as forensic nursing is not part of the mainstream yet.  In forensic nurse education, it too is constantly changing and evolving. That is why our standards and educational guidelines have been revised and updated.  We have targeted minimum standards for all Sexual Assault Nurses Pediatric, Adolescent and Adult populations and based our certification examinations on these standards. The IAFN is the only credentialing body for forensic nurses in these fields.

Over the last two decades, the length of training course for sexual assault nurse examiners has continued to increase. Now, the minimum length of a course is 40 hours plus a preceptor ship. Some programs require a pre-requisite course of 45 hours in general forensic nursing before they can enter a specialized course.  We have nurses prepared on all levels up to the doctorate level. However, the majority are still more likely to be prepared at a Bachelor’s level with additional education in forensic nursing. Where once was one seminal forensic nursing text, there are now several and more being published as we speak.  The accessibility to high quality education through texts, webinars, and online courses has increased the ability for even rural and remote nurses to expand their knowledge and expertise.

IIR Healthcare: Forensic nursing is a personally and professionally demanding role. What do you see as the biggest challenges that practitioners face?

Sheila Early: I think the personal challenges I still face are not unique to me but are unique to the specialty.  There is a personal price that is paid with every patient interaction when you are caring for someone who has undergone violence or trauma or been the victim of a crime.  The immense and overwhelming realization that human beings are cruel and destructive to each other is overpowering. How do you deal with a society that devalues human lives to the point that children and elders are harmed often by those closest to them?  The fact of the matter is that forensic nurses care for individuals and families that are torn apart, damaged beyond belief and often will never return to their former self.  Sexual assault is a life altering experience and yet 1 in 3 women globally will have such an event happen to them. The forensic nurse must not only be able to care for these individuals professionally, but also not become the victim of vicarious trauma themself.  It is very, very difficult to learn that balance between personal and professional boundaries.  I have lost many, many forensic nurses from their forensic nursing roles due to vicarious trauma, burnout, and inability to recognize their own changes in world views and in their personal lives.

There is also the effect forensic nursing roles have on one’s family. As I have said previously, often the forensic nurse holds an on call or casual position. You never know when you will be called to care for a patient. Someone must be on call on Mother’s Day, Christmas, Hanukkah or any other cultural holiday. The role of the forensic nurse is not well known as we have said, so there is still a certain amount of reticence to say what you actually do in social settings. The CSI effect certainly helps overcome some of this. Our families did not choose this particular path, we did and often they pay just as huge a personal price as we do.  I recently talked to an IAFN member who told me her small business which she worked at with her husband was failing because she spent so much time on call in her forensic nursing role.

Research has shown that if we prepare individuals for the effects of their chosen role in a realistic and factual manner, they are more prepared for when such entities as vicarious trauma, post traumatic stress and personal changes do occur.

The challenges of maintaining one’s own understanding of the world of violence and trauma, finding a balance of work and home life that works for the individual, the realization that you cannot prevent what has happened to the individual you are caring for, but you can make a difference in their lives from this moment on is a never ending struggle facing forensic nurses globally.

On a professional level the challenges are a little more concrete. The first challenge is to actually obtain a position to work as a forensic nurse in whatever sub specialty the nurse has chosen AND earn a wage to provide a stable income.  Forensic nursing programs have exploded in the last 10 years. However, they too have been hit by the recession. Many may wish to become forensic nurses only to find the educational opportunities are limited and they may have to relocate for positions even after they have obtained their education.

The basic education for a forensic nurse is only the beginning as forensic nursing sciences; forensic sciences and the legal system which are the interactive systems specific to forensic nursing are constantly undergoing revisions and reviews. Keeping up with the changes in this very specialized body of knowledge is unique to the specialty and can be time consuming and expensive. Healthcare facilities no longer pay for employee education on a regular basis and since many forensic nurses are casual or part time, they may not even qualify for educational funding.

Educational opportunities in forensic nursing have been affected by the recession as well. Many post secondary educational institutions have completely cut their forensic nursing offerings in recent years.  The impetus to reinstate them will only come when the demand for forensic nurses becomes more apparent in healthcare.

As I have said earlier, the professional challenge of being recognized as a specialty and a valuable member of the healthcare team is faced by forensic nurses globally.   Many forensic nurses I have worked with tell me that it would make such a difference if their skills, dedication and experience were recognized and acknowledged by their facility.

The last challenge I will add is one that crosses both personal and professional lines. The forensic nurse often chooses to take on a personal role as well as a professional role in the war against violence and trauma. Forensic nurses can be found leading changes in their facility, their community and their society in the prevention of violence.  They choose to no longer be a bystander in their community when it comes to violence prevention.  Unfortunately, sometimes this can have a negative aspect particularly if they are frequently court witnesses in their professional role. So once again, the forensic nurse must find that unique balance between personal and professional lives.

*The International Association of Forensic Nurses is an event partner for the 2014 Forensic Nursing conference, to be held on the 20th and 21st February in Sydney. IAFN acts as a catalyst for universal access to forensic nursing care for patients impacted by violence and trauma. Some of the Association’s greatest achievements, include:

• Forensic Nursing recognized as a specialty of nursing by American Nurses Association           (1995) This gave us credibility in mainstream nursing with the publishing of  Scope and Standards of  forensic Nursing Practice
• Development of the first Sexual Assault Nurse Examiner Educational Guidelines, now revised to be the Sexual Assault Nurse Examiner Education Guidelines, Adult and Pediatric  (2013)
• First Certification Examination for Sexual Assault Nurse Examiners Adult/Adolescent  2002
• First Certification Examination for Sexual Assault Nurse Examiners Pediatrics 2006
• Forensic Nurse Death Investigator Education Guidelines (2009)
• Intimate Partner Violence Nurse Examiner Education Guidelines (2012)
• Successful annual Conferences since 1992 to present in USA and Canada
•  The outreach by Association members both in groups and individually at promoting and disseminating forensic nursing principles and practice guidelines globally in many nations including but not limited to  Australia,  South Africa, Kenya, Peru, China, Japan, Netherlands, Sweden, Italy, Portugal and Israel.
• Establishment of the Journal of Forensic Nursing which is celebrating its 10^th anniversary this year.