Maria Nittis - Division of Medicine, NSW Health - Future Training of Forensic Nurse Examiners in NSW: Is it Possible?

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Dr Maria Nittis, Department Head Forensic Medical Units, Division of Medicine, NSW Health presented this at the 2nd Annual Forensic Nursing Conference.

This is the only national even of its kind promoting research and leadership for Australia's Forensic Nursing Community. The program addresses future training of forensic nursing examiners, forensic mental health consmers, homicide and its aftermath, ethical dilemmas in clinical forensic medicine, child sexual abuse, providing health care to indigenous patients in the forensic arena and more.

To find out more about this conference, please visit http://www.healthcareconferences.com.au/forensicnursing

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Maria Nittis - Division of Medicine, NSW Health - Future Training of Forensic Nurse Examiners in NSW: Is it Possible?

  1. 1. Forensic Nurse Examiner Training in NSW Lessons Learnt - Dr. Maria Nittis maria.nittis@health.nsw.gov.au
  2. 2. SANE OR INSANE
  3. 3. BACKGROUND FOR THE SANE PROJECT • Labor’s Public Safety Plan: Stage 5 for DV and SA announced changes to enable nurses to perform forensic examinations and appear as expert witnesses. (?2003)
  4. 4. BACKGROUND FOR THE SANE PROJECT
  5. 5. BACKGROUND FOR THE SANE PROJECT • Background work for the project was undertaken by MoH – based on a report produced by Churchill Fellow and scholarship recipient - Jo Spangaro – 2004
  6. 6. REGIONAL HEALTH DISTRICTS
  7. 7. REGIONAL EXAMINATION SITES
  8. 8. BACKGROUND FOR THE SANE PROJECT • Background work for the project was undertaken by MoH – based on a report produced by Churchill Fellow and scholarship recipient - Jo Spangaro – 2004
  9. 9. BACKGROUND FOR THE SANE PROJECT • The Health Minister’s Office asked Primary Health and Community Partnerships Branch to develop a funding proposal for SANE in 2003. Department of Health provided costings for 20 new positions across the state: $1.9 million • Deputy Director-General operations committed seed funding $200,000 in January 2003.
  10. 10. DoH ADVERTISEMENT FOR SANE • See those aged 14 and above. • Assess injury • Objectively document health history and history of the crime Written by • Collect forensic data policy • Prevent psychological and physical health risks • Facilitate client control over assault issues maker or counsellor • Facilitate healthy reorganisation and readaptation or clinician following sexual assault.
  11. 11. ESSENTIAL SELECTION CRITERIA - 2003 • 5 yrs or more experience clinical nursing • Willingness to attend one week training in Sydney and if necessary, an additional week placement • Ability to be flexible and be placed on 24 hr on-call roster
  12. 12. DESIRABLE SELECTION CRITERIA • Extensive experience in conducting pelvic examinations on women • Training in Midwifery, Sexual Health, Family Planning or Women’s Health • Experience of taking, handling and documenting pathology samples • An interest in working in the area of sexual assault.
  13. 13. TRAINING • August 2005, 27 nurses commenced their SANE training • One week of face to face training conducted by VIFM in Sydney • Requirement to observe 5 sexual assault examinations and perform 5 supervised sexual assault examinations.
  14. 14. OUTCOME 26%
  15. 15. DAL (FASS) Results – Since Dec. 2010 Area Health Service Sydney West Sydney West Sydney West Sydney West Taree Newcastle Newcastle Newcastle ACT Nowra / Wollongong Nowra / Wollongong Nowra Nowra / Wollongong Albury Tamworth Bathurst Broken Hill Armidale Port Macquarie Greater West Greater West Cowra Hunter New England Greater South Greater South Lithgow Wagga Result 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 58 Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner 16 2 4 1 1 5 Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner SANE - resigned Never practised as Forensic Nurse Examiner SANE - resigned Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner SANE - resigned Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner SANE - resigned Never practised as Forensic Nurse Examiner Never practised as Forensic Nurse Examiner SANE - resigned
  16. 16. WHAT WAS MISSING FROM CHURCHILL REPORT 2008
  17. 17. FUNDAMENTAL FLAWS 1500 km
  18. 18. LESSONS LEARNT FROM SANE NSW
  19. 19. FUNDAMENTAL FLAWS No forensic medical infrastructure: i. No support ii. No mentoring iii. No review of Examination records or Certificates iv. No training or supervision
  20. 20. FUNDAMENTAL FLAWS No positions created: i. No guaranteed award ii. Did not necessarily have Health Services support iii. Extensive delays because working another job
  21. 21. FUNDAMENTAL FLAWS – ESSENTIAL CRITERIA Incorrect Selection Criteria: • 5 yrs or more experience clinical nursing • Willingness to attend one week training in Sydney • and if necessary, an additional week placement • Ability to be flexible and be placed on 24 hr on-call roster
  22. 22. SANE certification • • • • If you are asked to witness 5 examinations and do 5 examinations In a Unit that sees 40 adult examination per year And 70% of those patients presented after hours A Trainee Forensic Nurse Examiner would have to be placed at a unit for 10 months – full time (if no on-call work) OR • On call for 4.25 months 24/7 – if only done in the after hours period. OR • Working 3 months permanently and on-call 24/7
  23. 23. SANE certification • There are 50 Sexual Assault Units in NSW • There are an average of 800 kits submitted to the forensic laboratory for analysis per year • Ratio of 2: 1 – exams performed for results returned • Assumption: Each unit, on average, has 32 patients per year
  24. 24. FUNDAMENTAL FLAWS – DESIRABLE CRITERIA • Extensive experience in conducting pelvic examinations on women
  25. 25. FUNDAMENTAL FLAWS – DESIRABLE CRITERIA • Extensive experience in conducting pelvic examinations on women
  26. 26. FUNDAMENTAL FLAWS – DESIRABLE CRITERIA • Extensive experience in conducting pelvic examinations on women • Training in Midwifery, Sexual Health, Family Planning or Women’s Health or ED or GP or Drug Alcohol or Mental Health
  27. 27. FUNDAMENTAL FLAWS – DESIRABLE CRITERIA • Extensive experience in conducting pelvic examinations on women • Training in Midwifery, Sexual Health, Family Planning or Women’s Health or ED or GP or Drug Alcohol or Mental Health • Experience of taking, handling and documenting pathology samples Immunisation Certificate or Venepuncture
  28. 28. FUNDAMENTAL FLAWS – DESIRABLE CRITERIA • Extensive experience in conducting pelvic examinations on women • Training in Midwifery, Sexual Health, Family Planning or Women’s Health or ED or GP or Drug Alcohol or Mental Health • Experience of taking, handling and documenting pathology samples Immunisation Certificate or Venepuncture • An interest in working in the area of sexual assault.
  29. 29. FUNDAMENTAL FLAWS – DESIRABLE CRITERIA • Extensive experience in conducting pelvic examinations on women “I think that stuff is over-rated” Dr. Christine Bassindale Perth SARC
  30. 30. THE WSLHD EXPERIENCE
  31. 31. Forensic Nurse Training from 2008 • We have trained three nurses and two more are in training or about to be trained since 2008 3. Worked at Unit for 9 1. Worked at Unit since 2008; FTE 0.8; 2nd busiest examiner in the state; ED and SH background; Grad Cert Forensic Nursing / SANE 2. Worked at Unit since 2012; FTE 0.4; 30 yrs nursing experience; ED and Research background; Worked independently with haemodialysis patients months; FTE 0.4; Defence force background; 2 yrs in HDU. ICU. CCU Resigned 4. Worked at Unit since January; FTE 0.4; Extensive ED background
  32. 32. Know what the Nurse will be Required to Do • • • • • • • • • • See victims of sexual assault aged 14 or more; Assist with paediatric sexual assault examinations; See victims of domestic violence aged 16 or more. Consents Gather forensic and medical history Documentation of injuries including photography Collection forensic evidence Prophylactic meds e.g. HIV PEP, MAP, Hep B Expert Certificates with opinions Expert witness at Court
  33. 33. Our Selection Criteria Job is for a forensic nurse • Registered Nurse with APHRA and postgraduate qualifications in forensic nursing or willingness to obtain same Presenting • Expert Opinions in Oral and High level interpersonal skills, both verbal and written and forms Written demonstrated ability to work independently Hepatitis B • Must be a NSW accredited vaccinator or willingness to obtain same • Computer competency (including Microsoft Word, Power Point and Email) and reasonable typing speed)
  34. 34. Our Selection Criteria 34km between both units • Current driver’s license and willingness to use same for work • Demonstrated clinical experience with assessing immediate health care needs of patients and the ability to determine need for referral if appropriate • Demonstrated ability in effective time management • Experience with female genital examinations including speculum or willingness to learn.
  35. 35. Our Interview • Typing test where we observe speed and ability to correct spelling and grammer.
  36. 36. Our Interview • Typing test where we observe speed and ability to correct spelling and grammar. • Observe their fluency skills and confidence levels – someone who is easily flustered in an interview is likely to be easily flustered in court • We get them to fill out, on a weekly chart, which evenings and days they are free and which evenings and days they have commitments
  37. 37. If successful We paid for the Family Planning Course – learn about female genital examinations, speculum examinations, STIs and Contraception - $2,300 • • Replacing this with a tailor made course for nurses where they are taught speculum examinations and practice on a paid volunteer: $130 Looking at in house teaching at the hospital gynaecology clinics
  38. 38. If successful We paid for a unit of study at Sydney University in Sexual Assault - $3132.37 • Impact of sexual assault on health and community • Anatomy of men and women • Basic forensic science including DNA and Toxicology • History and Examination • Follow Up • Counselling • Medico Legal Issues: consent, chain of evidence and court reports In Australia other courses include Flinders University new online course (in association with John Hopkins): Fundamentals of Forensic Health Care available for health care practitioners including nurses and paramedics:$1100 • Covers topics such as Legal Overview, When injuries speak, Sexual Assault, Details, Documentations and Decisions, Evidence Collection
  39. 39. If successful We paid for the Expert Witness Training Course - $1000 • ACLM runs Basic Law Intensive – 2 days - $880 or $680 if member • ACLM runs Expert Witness programme – 2 days - $1175 or $950 • Unisearch run course with Hugh Selby – 1 day - $650 TRAINING COST: $6,432.37
  40. 40. In House training • Provide Reference Material for Everything
  41. 41. In House training • Provide Reference Material for Everything
  42. 42. In House training • Provide Reference Material for Everything
  43. 43. FNE Competencies • • Drew up a list of competencies Stops the learning process from appearing overwhelming Where to look Web address AAFP www.forensicphysicians.org National Occupational Standards http://www.colinwrightassociates.co.uk/pr ojects/national-occupational-standardsnos IAFN www.iafn.org
  44. 44. In House training • • We broke examinations up into sections and as they became competent they would complete that part of the examination. Learn nothing from observations after the first case if you are a pure observer Decontamination Procedure Consent History Decide what samples to collect Speculum examinations Collect Samples Injury Interpretation Injury Documentation Photography STI prophylaxis Toxicology Collections Pack Up Generate Expert Certificate How to Provide an Opinion
  45. 45. In House training • If you are asked to do 5 examinations or 5 Expert Certificates with the feedback at the end
  46. 46. WHAT SKILLS DOES A FORENSIC NURSE EXAMINER TRAINEE REQUIRE AT YOUR UNIT
  47. 47. Way Forward - Skills • Need solid clinical judgement and knowledge of when to refer • Emotional toughness and confidence • Need to be able to collect blood and provide immunisations • They need to be able to type quickly and ability to learn to use new software systems • Ability to participate in after hours’ roster – flexibility and a car • Need to be able to perform genital examinations including speculum • Need to have good verbal and written communication skills
  48. 48. Way Forward - Training • Post Graduate Training • Skill Fill e.g. imaging, vaccinations, speculum examinations etc – need a list of skill fill opportunities • In house training where trainee is involved in the examination from an early point and made responsible (Placement in busy unit for a 6 month term) • Training of nurses does not end once they are working independently – need a way of doing this e.g. review case notes, expert certificates and images (e.g. photos of injury etc.) / provision of training and updates / “phone a friend” • Every now and then, once training completed, assist a graduate trainee in an examination ( 2 examples).
  49. 49. The Forensic Nurse Examiner – God’s Gift maria.nittis@health.nsw.gov.au
  50. 50. Backdrops: www.animationfactory.com - These are full sized backdrops, just scale them up! - Can be Copy-Pasted out of Templates for use anywhere!

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