Multidisciplinary and Collaborative
Approaches:

        Bringing it All Together
          Working as a Team
Daniel J. Sh...
4N6 RN
   Forensic Nurse
   Forensic = Pertaining to the Law

   International Association of Forensic Nursing
   www....
UNDERSTANDING THE PROFESSION

   Nurse’s Aide – continuing education course
    and/or on the job training
   MA’s     M...
UNDERSTANDING THE PROFESSION
Vocational-Practical Nurse

   LVN’s        Licensed vocational nurse
    –   Licensed by th...
Staff Nurse

   Experience varies

   Few clinics or physician offices employ
    Registered Nurses – too expensive
UNDERSTANDING THE PROFESSION –
Registered Nurse

   RN         Registered nurse
    –   Diploma
    –   Two-year associat...
UNDERSTANDING THE PROFESSION
Advanced Practice Registered Nurses

  –   NPs        Nurse practitioner (independent v MD)
 ...
   Clinical Nurse Specialist versus Nurse Practitioner

   NP can prescribe medications. CNS cannot (CNS)

   NP can di...
CNS Role

   Expert in clinical area(s)
   Educator
   Consultant
   Patient, family, staff, administrators, APS,
    ...
Legal Nurse Consultant


   LNC = Legal nurse consultant (certified
    versus trained
    –   Can be any level of regist...
UNDERSTANDING THE PROFESSION
Physician’s Assistant

   PA’s       Physician’s Assistant
    –   Most Master’s prepared cl...
UNDERSTANDING THE PROFESSION
Physicians


          Bachelor’s degree

          Medical School – four years

         ...
What is Nursing?
Be able to discuss the Nursing Process




               A - assessment
               D – nursing dia...
Forensic Nursing

It’s the collision between the law and
   medicine
 It’s a lot more than Quincy or Diagnosis
   Murder!...
What is Forensic Nursing


   Forensic nursing is the application of the
    nursing process to public or legal
    proce...
Clinical Forensic Nursing

    The application of clinical nursing practice to
     trauma survivors or to those whose de...
Common Patient/Client Groups

     Treatment of patients (victims)
      (survivors) of
      –   abuse
      –   violenc...
History of Forensic Nursing

   1975 - John C. Butt, MD Alberta Canada
    –   Hired and trained RNs as medical examiner
...
Early Nursing Leaders

    Mid-1970’s Ann Burgess, DNSc, RN
      – Rape Trauma Syndrome
    Mid - 1970s Rape Victim Adv...
Early Nursing Leaders

   1981 - Domestic Violence Homicides –
    Ohio, New York
    –   Jackie Campbell, PhD, RN
   19...
International Association of
Forensic Nurses

   1992 - 74 nurses, mostly SANE formed IAFN
   1993 - First Annual Scient...
Forensic Nurse Provides

   Consultation services to:
     – Nursing, medical, law-related agencies
   Expert court test...
Can you read this? Need a
translator??

   85 y/o w/female w/h/o HTN, IDDM, CAD,
    PVD, MI x 2, multiple TIAs
   s/p T...
Or do you want a nurse to
translate to this……..

   85 year old white female with a history of hypertension
    (high blo...
Types of Forensic Nurses
   SANE/SAFE/FNE/SART
   Interpersonal Violence
    –   CA/CN
    –   DV/FV
    –   EA & DD Abu...
   Today’s USA Today p. 3A
Types of Forensic Nurses


    Crime Labs
    Criminalists - Scene Investigators
    Expert Witnesses
    RN to Police...
Role Differences – Forensic RN v
LNC

   Topic           Forensic RN   LNC
   Wound ID             +        -?
   Bed s...
Role Differences - 2

   Topic          Forensic RN   LNC
   Photo document      +        -?
   Evidence collection +  ...
Working with medical personnel


   So how can we work together?

   Physician’s who “get it” are rare.
    –   If you h...
Working with medical personnel


   What kind of information does the APS case
    worker need?

   Who can give that in...
Information needed



   DO NOT ASK FOR A “CAPACITY
    ASSESSMENT” OF YOUR CLIENT

    –   In most cases you will not ge...
Information needed

   What are the medical issues
    –   Ex. high blood pressure, diabetes

   Are they controlled?
  ...
   Complete copy of records from the most
    recent hospitalization(s) including:
    –   EMS-EMT-Paramedic transport fo...
   All dictated consultant notes
   All radiology reports & summaries
    –   Actual x-rays/scans may be needed later
 ...
Information needed

   Does the client have to take medication for his
    medical issues?
    –   If yes, which ones ?
 ...
Information needed

   Does the client keep clinic appointments
    –   If not, why not?
            Ex. forgetful, no t...
Who can give the information

   Can be obtained from:
    –   Secretary
    –   Office assistant
    –   Nurse
    –   C...
   Get a signed release of information from:
    –   The client/patient/victim
    –   Medical power of attorney
    –   ...
How to get the information

   Call the office and ask for:
    –   the fax number
    –   name of the nurse/MA/CNA


  ...
How to get the information


   Leave a number where you can be reached
    at all times (you might only get 1 phone call...
“Court” is Part of the Role

   Levels of Proof
   Preponderance
    –   > 50.1%
   Clear and Convincing
    –   > 75.1...
   Discuss my neck tie…….
Documentation Pearls

   If you did not chart it………
   You did not do it!!!!!
   Avoid personal opinion
   Avoid chart...
Forensic Documentation

   As verbatim as possible
   Do not sanitize
   Do not “medicalize”
   Avoid pejorative docum...
Avoid pejorative documentation

   Stop charting “refused”
   Stop charting “uncooperative”
   Stop charting “non-compl...
   An Oregon case…

   The importance of documentation!!
Decubitus Ulcers

Are they a sign of neglect?
Decubitus Ulcer

   Bedsores
   Decubiti (plural)
   Decubitus ulcer
   Pressure sore – ulceration of tissue deprived
...
Bedsores, Decubitus ulcers, Decubiti, Pressure
          ulcers, & Pressure sores




                         Caused by ...
The physiology:


   Pressure exceeds normal
    capillary-filled pressure of
    32mm Hg -> blood flow is
    obstructed...
Risk factors for Pressure Ulcers &
                 Neglect:

             Intrinsic         Extrinsic (Modifiable)
   Ac...
Locations of Pressure Ulcers


                                                          Bony
                           ...
Risk Factor Scales:


   Braden Scale (1987)
     – Activity
     – Mobility
     – Sensory
        Perception
     – Nut...
Assessment and Documentation



                  Measure (2 lengths)
                  Depth (sterile Q-tip)
          ...
Staging Pressure Ulcers



   National Pressure Ulcer Advisory Panel
   1989
   Skin, tissue layers, & depth
   Helps ...
Stage 1

   Intact skin,
   Erythema
   Change in skin temperature
   Tissue Consistency (Firm or
    Boggy)
   Sensa...
Stage 2
coa.kumc.edu/gec/images/ PressureUlcer/Ulcer1.jpg




                                                            ...
Stage 3


   Full Thickness
   Damage or Necrosis of Subcutaneous
    Tissue, not through fascia
   Deep Crater with po...
Stage 4




                      Full-thickness with extensive
                       destruction
                     ...
Stage 5 – Cannot stage (covered
with dead skin)
Location: Hand/Wrist




   www.worldwidewounds.com
Location: Ear




   www.worldwidewounds.com
Is it neglect? - The Great Debate


   Risk factors assessed?
   Prevention strategies        Proper referral for findi...
Take Home Points

   ALL Pressure ulcers are NOT preventable,
    but many are preventable…..
   ALL Pressure ulcers are...
Screening Questions


If at anytime a patient answers YES
say,

1. Thank you for sharing.
2. Can you give me an example?
3...
Why Forensic Nurses?


   18,000 violent crimes are committed or
    attempted each day in the US
   Those crime scenes ...
Why Forensic Nurses?


   Recognizes the evolution of nursing care
    within complex medical-legal systems

   Forensic...
In conclusion: What your client
wants to Hear from You

   That you believe her or him
   That he or she is not crazy
 ...
   Questions ?????
Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN


  –   Johns Hopkins University
  –   School of Nursing, Room 467
  –   ...
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Forensic Implications of Elder Abuse

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Forensic Implications of Elder Abuse

  1. 1. Multidisciplinary and Collaborative Approaches: Bringing it All Together Working as a Team Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor, Johns Hopkins University School of Nursing Forensic Clinical Nurse Specialist
  2. 2. 4N6 RN  Forensic Nurse  Forensic = Pertaining to the Law  International Association of Forensic Nursing  www.iafn.org  1-410-626-7805
  3. 3. UNDERSTANDING THE PROFESSION  Nurse’s Aide – continuing education course and/or on the job training  MA’s Medical assistants (report to MDs) – One to two months of training (HS-GED)  CNA’s Certified nursing assistants (report to LPN/LVN/RN) – Licensed by Board of Nursing – One or two months training
  4. 4. UNDERSTANDING THE PROFESSION Vocational-Practical Nurse  LVN’s Licensed vocational nurse – Licensed by the Board of Nursing – One year professional school – Must work under supervision of a RN or medical provider  LPN’s Licensed practical nurse – One-year professional school – Licensed by the Board of Nursing – Must work under supervision of a RN or medical provider
  5. 5. Staff Nurse  Experience varies  Few clinics or physician offices employ Registered Nurses – too expensive
  6. 6. UNDERSTANDING THE PROFESSION – Registered Nurse  RN Registered nurse – Diploma – Two-year associates degree (AD) – Bachelors degree (BSN) traditional/accelerated  Generic entry Master’s degree in Nursing – must have a previous degree + pre-reqs (Clinical Nurse Leader) (knowledge of a new graduate)  All must take NCLEX exam – – Licensed by the Board of Nursing
  7. 7. UNDERSTANDING THE PROFESSION Advanced Practice Registered Nurses – NPs Nurse practitioner (independent v MD)  Prescriptive privileges – CNS Clinical nurse specialist (hospital) – CRNA Certified registered nurse anesthetist – Master’s prepared clinicians  (two years post bachelors) but by 2015 must have clinical doctoral preparation – DNP Doctorate of Nursing Practice  (practice three years post bachelors) – PhD Doctorate of Philosophy  (research – average 5 years post master’s)
  8. 8.  Clinical Nurse Specialist versus Nurse Practitioner  NP can prescribe medications. CNS cannot (CNS)  NP can diagnose and treat illness.  CNS serves as an expert resource to everybody
  9. 9. CNS Role  Expert in clinical area(s)  Educator  Consultant  Patient, family, staff, administrators, APS, surveyors, ombudsman, police
  10. 10. Legal Nurse Consultant  LNC = Legal nurse consultant (certified versus trained – Can be any level of registered nurse – May or may not have any real expertise – Clinical competencies – Plus education – Plus experiences
  11. 11. UNDERSTANDING THE PROFESSION Physician’s Assistant  PA’s Physician’s Assistant – Most Master’s prepared clinicians – Military trained – Supervised by a physician
  12. 12. UNDERSTANDING THE PROFESSION Physicians  Bachelor’s degree  Medical School – four years  Residency – minimum 3 years  Fellowship – minimum 1 year
  13. 13. What is Nursing? Be able to discuss the Nursing Process  A - assessment  D – nursing diagnosis  P - plan  I - intervention  E - evaluation
  14. 14. Forensic Nursing It’s the collision between the law and medicine  It’s a lot more than Quincy or Diagnosis Murder!  It’s not as dramatic as CSI  Coroner versus Medical Examiner ???
  15. 15. What is Forensic Nursing  Forensic nursing is the application of the nursing process to public or legal proceedings: the application of the forensic aspects of health care to the scientific investigation of trauma.  (IAFN Website)
  16. 16. Clinical Forensic Nursing  The application of clinical nursing practice to trauma survivors or to those whose death is pronounced in the clinical environs, involving the identification of unrecognized, unidentified injuries and the proper processing of forensic evidence. (IAFN Website)
  17. 17. Common Patient/Client Groups  Treatment of patients (victims) (survivors) of – abuse – violence – criminal activity – Vehicle crashes
  18. 18. History of Forensic Nursing  1975 - John C. Butt, MD Alberta Canada – Hired and trained RNs as medical examiner investigators – Know medical terminology/pharmacology – Empathy/public relations – Over 60% of death investigator cases involve natural death – Fostered better police/health care roles – Based on England’s Police Surgeon Concept
  19. 19. Early Nursing Leaders  Mid-1970’s Ann Burgess, DNSc, RN – Rape Trauma Syndrome  Mid - 1970s Rape Victim Advocates - RVA  Forensic Sexual Assault Exams - – nurses training MDs, retrain, retrain….  Late 1970’s - 1980’s Domestic violence – Barbara Parker, PhD, RN - 1977 – Ginnie Drake, PhD, RN - 1982 – Jackie Campell, PhD, RN - 1979
  20. 20. Early Nursing Leaders  1981 - Domestic Violence Homicides – Ohio, New York – Jackie Campbell, PhD, RN  1986 -Family Violence Program, RPSLMC, Chicago – Daniel J. Sheridan, MS, RN  1987 - Death Investigations – Virginia Lynch, MS, RN, Georgia
  21. 21. International Association of Forensic Nurses  1992 - 74 nurses, mostly SANE formed IAFN  1993 - First Annual Scientific Assembly in Sacramento, CA 160 members – (My Member # 251)  1995 - Formally recognized by the ANA as a specialty of nursing  2009 - Over 3,000 members with next conference in Atlanta
  22. 22. Forensic Nurse Provides  Consultation services to: – Nursing, medical, law-related agencies  Expert court testimony: – regarding interpersonal violence, trauma, death investigations, unexplained injuries  Adequacy of health services  “Translation” or background information on routine medical care
  23. 23. Can you read this? Need a translator??  85 y/o w/female w/h/o HTN, IDDM, CAD, PVD, MI x 2, multiple TIAs  s/p TAH-BSO, CABG x 2, R-AKA  MMSE 15/30  Presents with +LOC, 0 x 1
  24. 24. Or do you want a nurse to translate to this……..  85 year old white female with a history of hypertension (high blood pressure), insulin dependent diabetes mellitus, coronary artery disease, peripheral vascular disease, and multiple transient ischemic attacks  Status post (History of) total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of her uterus, tubes and ovaries), coronary artery bypass grafts x 2 and a right above the knee amputation  Mini- Mental status test indicate possible dementia 15/30  Presents with + loss of consciousness, is oriented only to her name
  25. 25. Types of Forensic Nurses  SANE/SAFE/FNE/SART  Interpersonal Violence – CA/CN – DV/FV – EA & DD Abuse Investigator – Stranger to Stranger  Death Investigators -Deputy Medical Examiners - Coroners  Correctional Nursing - Prisons/Jails  Psychiatric Forensic Nursing - Criminally Insane, Malingerers in Workman’s Comp.
  26. 26.  Today’s USA Today p. 3A
  27. 27. Types of Forensic Nurses  Crime Labs  Criminalists - Scene Investigators  Expert Witnesses  RN to Police Officer  RN to FBI Academy  RN to JD to Assistant Attorney General Medicaid Fraud Prosecution Unit in DC
  28. 28. Role Differences – Forensic RN v LNC  Topic Forensic RN LNC  Wound ID + -?  Bed sores + +  Standards of care + +  Translation + +  Neglect of care + +  Capacity - -
  29. 29. Role Differences - 2  Topic Forensic RN LNC  Photo document + -?  Evidence collection + -?  Family violence + -  DV Grown older + -  Sex Assault issues + -  SANE + -
  30. 30. Working with medical personnel  So how can we work together?  Physician’s who “get it” are rare. – If you have one, nurture that role  Develop a cadre of nurse experts
  31. 31. Working with medical personnel  What kind of information does the APS case worker need?  Who can give that information  How can this information be obtained
  32. 32. Information needed  DO NOT ASK FOR A “CAPACITY ASSESSMENT” OF YOUR CLIENT – In most cases you will not get it
  33. 33. Information needed  What are the medical issues – Ex. high blood pressure, diabetes  Are they controlled? – If not, why not?  Ex. unable to afford medications, unknown  Is the client compliant with the medical plan – If not: why not ?  Ex. memory problems, no transportation, unknown
  34. 34.  Complete copy of records from the most recent hospitalization(s) including: – EMS-EMT-Paramedic transport forms – ED physician and nurses notes hand-written and typed – Any photographs taken by hospital staff/wound specialists/surgeons – Admission History and Physical – All progress notes including RN & social work notes
  35. 35.  All dictated consultant notes  All radiology reports & summaries – Actual x-rays/scans may be needed later  All laboratory results  Medication Administration Records  Discharge summaries
  36. 36. Information needed  Does the client have to take medication for his medical issues? – If yes, which ones ?  Ex. lisinopril for high blood pressure – If not, why not?  Ex. diabetes controlled with diet  Is the client able to obtain the medication(s) – If not, why not?  Ex. unable to afford medication, unknown
  37. 37. Information needed  Does the client keep clinic appointments – If not, why not?  Ex. forgetful, no transportation, unknown  What is the date of the last visit? – Ex. 10 month ago  Does the clinician have any concerns? – If yes, explain:  Ex. noticed disheveled appearance at the last visit
  38. 38. Who can give the information  Can be obtained from: – Secretary – Office assistant – Nurse – Clinician (MD, NP, PA) – HIPAA: – Health Insurance Portability and Accountability Act of 1996
  39. 39.  Get a signed release of information from: – The client/patient/victim – Medical power of attorney – Guardian  Court order – subpoena
  40. 40. How to get the information  Call the office and ask for: – the fax number – name of the nurse/MA/CNA  Fax your request – Ask for permission to talk with the nurse
  41. 41. How to get the information  Leave a number where you can be reached at all times (you might only get 1 phone call) – Cell phone number  Best time to call: – Early morning
  42. 42. “Court” is Part of the Role  Levels of Proof  Preponderance – > 50.1%  Clear and Convincing – > 75.1%  Beyond Reasonable Doubt – > 99%
  43. 43.  Discuss my neck tie…….
  44. 44. Documentation Pearls  If you did not chart it………  You did not do it!!!!!  Avoid personal opinion  Avoid charting arguments with co-workers  Avoid derogatory remarks about client, family, or other providers  Write legibly, legibly, legibly, legibly
  45. 45. Forensic Documentation  As verbatim as possible  Do not sanitize  Do not “medicalize”  Avoid pejorative documentation  Document excited utterances  Document medical exceptions to hearsay
  46. 46. Avoid pejorative documentation  Stop charting “refused”  Stop charting “uncooperative”  Stop charting “non-compliant”  Stop charting “alleged” and “allegedly”  Stop charting your feelings  Stop charting your anger
  47. 47.  An Oregon case…  The importance of documentation!!
  48. 48. Decubitus Ulcers Are they a sign of neglect?
  49. 49. Decubitus Ulcer  Bedsores  Decubiti (plural)  Decubitus ulcer  Pressure sore – ulceration of tissue deprived of adequate blood supply by prolonged pressure.
  50. 50. Bedsores, Decubitus ulcers, Decubiti, Pressure ulcers, & Pressure sores  Caused by ischemia due to pressure, shearing, and friction, from contact between the patient and an underlying surface.
  51. 51. The physiology:  Pressure exceeds normal capillary-filled pressure of 32mm Hg -> blood flow is obstructed  Pressure continues 2hrs, oxygen depleted & build-up of metabolic products -> irreversible tissue damage
  52. 52. Risk factors for Pressure Ulcers & Neglect: Intrinsic Extrinsic (Modifiable)  Acute illness  Long periods on  CVD stretchers, hard beds,  Decreased sensation chairs, & OR  Cognitive impairment  Restraint use  Malnutrition  Inappropriate  Paralysis compression stockings  PVD  Shearing forces of bed clothes or sheets  Failure of vasomotor reflexes  Incontinence  Decrease mobility  Fractures/Surgery  Diabetes
  53. 53. Locations of Pressure Ulcers  Bony Prominence  95% on lower half of body  Sacral area most common. http://www.health.nsw.gov.au/hospitalinfo/pressure.html
  54. 54. Risk Factor Scales:  Braden Scale (1987) – Activity – Mobility – Sensory Perception – Nutrition – Moisture – Friction/Shear  Adjunct to clinical assessment
  55. 55. Assessment and Documentation  Measure (2 lengths)  Depth (sterile Q-tip)  Stage estimate  Involved skin/tissue layers  Location  Odor  Drainage  Presence or absence of granulation or eschar
  56. 56. Staging Pressure Ulcers  National Pressure Ulcer Advisory Panel  1989  Skin, tissue layers, & depth  Helps keep consistent the assessment between observers  Certain concerns with use  Use as guide in addition to proper documentation.
  57. 57. Stage 1  Intact skin,  Erythema  Change in skin temperature  Tissue Consistency (Firm or Boggy)  Sensation(Pain/Itching) coa.kumc.edu/gec/images/ PressureUlcer/Ulcer1.jpg www.afmc.org
  58. 58. Stage 2 coa.kumc.edu/gec/images/ PressureUlcer/Ulcer1.jpg  Partial-thickness skin loss (epidermis and/or dermis)  Superficial  Blister or crater  Painful www.afmc.org
  59. 59. Stage 3  Full Thickness  Damage or Necrosis of Subcutaneous Tissue, not through fascia  Deep Crater with possibly undermining www.afmc.org
  60. 60. Stage 4  Full-thickness with extensive destruction  Necrosis or damage to muscle & bone  Tunneling www.afmc.org
  61. 61. Stage 5 – Cannot stage (covered with dead skin)
  62. 62. Location: Hand/Wrist www.worldwidewounds.com
  63. 63. Location: Ear www.worldwidewounds.com
  64. 64. Is it neglect? - The Great Debate  Risk factors assessed?  Prevention strategies  Proper referral for findings? initiated?  Initiation of proper treatment  Skin properly assessed? strategies?  Findings properly  Proper reassessment of skin? documented?
  65. 65. Take Home Points  ALL Pressure ulcers are NOT preventable, but many are preventable…..  ALL Pressure ulcers are NOT curable, but many are curable.…  HOWEVER….  ALL PRESSURE ULCERS ARE TREATABLE !!!!!!!!!!!!!!!!
  66. 66. Screening Questions If at anytime a patient answers YES say, 1. Thank you for sharing. 2. Can you give me an example? 3. When was the last time?
  67. 67. Why Forensic Nurses?  18,000 violent crimes are committed or attempted each day in the US  Those crime scenes travel to the health care setting  Meets minimal standards of care – CMS – Centers for Medicaid & Medicare Services – Joint Commission
  68. 68. Why Forensic Nurses?  Recognizes the evolution of nursing care within complex medical-legal systems  Forensic nursing provides much needed, specialized nursing care to vulnerable populations
  69. 69. In conclusion: What your client wants to Hear from You  That you believe her or him  That he or she is not crazy  That no one deserves to be beaten  That he or she is not alone  That abuse is a crime  That there is hope the abuse can end  That there is help in the community –There is a TEAM – Continue to Build your TEAM
  70. 70.  Questions ?????
  71. 71. Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN – Johns Hopkins University – School of Nursing, Room 467 – 525 N. Wolfe St – Baltimore, MD 21205 – 410 – 614 - 5301 – 410 - 955 - 7463 fax – Pager 1-888-390-8420 – dsheridan@son.jhmi.edu

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