Caring for Victims of Violence: Forensic Nurses Are on the Front Line

Helping patients heal from acts of trauma and abuse

It’s staggering to consider statistics on violence. In Cleveland Clinic’s home state of Ohio, there were nearly 70,000 victims of domestic violence in 20161, more than 7,800 incidents of sexual assault2 in 2015 and 135 human trafficking investigations by law enforcement last year.3 And many more of these events go unreported.

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Each day, thousands of individuals – ranging from law enforcement officials to community advocates and healthcare providers – work diligently to prevent crimes of violence and help victims. Among those making a difference are forensic nurses.

“We take care of anyone affected by violence. We see patients who have been victims of child abuse, domestic violence, interpersonal relationship violence, elder abuse, neglect, sexual assault and human trafficking,” says Laura Gaertner, BSN, RN, Forensic/Sexual Assault Nurse Examiner Coordinator at Cleveland Clinic Fairview Hospital.

The Cleveland Clinic healthcare system has more than 50 forensic nurses working on call 24/7 at three trauma centers – Fairview Hospital, Hillcrest Hospital and Akron General. These nurses provide specialized care for victims and perpetrators of trauma, focusing on both the physical and psychological well-being of patients. They perform medical exams, collect biological specimens for possible use in law enforcement (with consent), connect patients with appropriate after-care resources, consult with legal authorities and educate other healthcare providers on how to identify trauma victims. Sometimes they are called on to provide medical testimony in court.

Most patients enter the system through the Emergency Department, where the role of the forensic nurse is invaluable. “If you’re a busy ED physician, you can’t sit down for three hours and get a patient’s story,” says James Bryant, DNP, RN, CEN, Associate Chief Nursing Officer of Emergency Services at Cleveland Clinic. “But a forensic nurse can slowly work with patients to get their stories and make people feel comfortable enough to share stories, which is so important.”

A holistic approach to healing

Forensic nurses often spend several hours with patients, depending on the amount and types of injury. Their first priority is to ensure patients are treated medically, if necessary. Then they begin the forensic exam, which includes evaluation for collection of biological evidence, documentation of assault history and current injuries, photo documentation of injuries, assistance with reporting to law enforcement and referrals for follow-up care.

“We bring a trauma-informed approach to helping patients,” explains Christi LaPrairie, BSN, RN, CEN, SANE A/P, PH-C, Coordinator of Forensic Nursing Services and the SANE Program at Hillcrest Hospital. “With that background, knowledge and approach to patient care, one of the first things I think when I meet a patient is ‘What have you been through – today and throughout your life?’”

Connecting with patients helps during the exam and in the future. “We provide the path for patients’ healing processes,” says Lily Holderbaum, BSN, RN, SANE-A, Coordinator for the PATH Center at Cleveland Clinic Akron General. “Having one-on-one time with patients and walking them through the process really makes a difference.”

Forensic nurses also ensure patients are “connected with the next steps” when they leave, says Holderbaum. That may include lining up hospital advocates from the Victim Assistance Program or providing resources through a local rape crisis center. Cleveland Clinic also partners with Fear 2 Freedom, a nonprofit that aims to restore hope and dignity to survivors of sexual assault. The organization supplies after-care kits for patients leaving the hospital that include clothing (because a victim’s clothing is often collected as evidence), a toiletry kit, a journal, a “Freedom Bear” teddy bear and a letter of encouragement.

Training forensic nurses

Most forensic nurses at Cleveland Clinic work PRN and hold other positions, often in the ED or in women’s health. They complete 40-hour training programs established by the International Association of Forensic Nurses (IAFN) – one focused on adults and adolescents and the other on pediatric patients.

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The adult-adolescent program classes include information on forensic science, physical exams, forensic photography, documentation, medical management and the justice system. Participants also learn about other components of trauma care. For instance, they visit a rape crisis center and domestic violence center, talk to law enforcement about sex crimes and hear a forensic nurse testify at a trial. Afterward, nurses work alongside a preceptor until they are prepared and comfortable with working solo.

Forensic nurses at Cleveland Clinic work for at least six months prior to attending the pediatric training program. It covers some of the same topics as the adult training, but also delves into developmental stages, the dynamics of pediatric sexual abuse and working with diverse populations.

Once trained RNs have three years or 300 hours of experience, they may sit for board certification offered by IAFN to become a Sexual Assault Nurse Examiner – Adult/Adolescent (SANE-A®) or a Sexual Assault Nurse Examiner – Pediatric (SANE-P®). Nurses can also earn a portfolio in Advanced Forensic Nursing (AFN-BC) in collaboration with the American Nurses Credentialing Center.

Cleveland Clinic strives to keep its forensic nurses up to date through continuing education. LaPrairie led a weekly domestic violence nurse examiner training in September; it was funded by a Victims of Crime Act (VOCA) grant from the Ohio Attorney General’s Office.

Educating other healthcare professionals

Forensic nurses throughout the Cleveland Clinic health system cared for more than 1,100 patients last year. “We know there are patients in the ED or hospital who would benefit from our specialized care,” says LaPrairie. “But nursing and other staff may not recognize patients affected by violence who could benefit, or even realize we could be of assistance.”

To help ensure that patients receive appropriate services, Gaertner educates healthcare professionals throughout the hospital informally and at events; her counterpart at Hillcrest Hospital is Angelita Olowu, RN, SANE-A/P. Any hospital employee may spot a potential patient. Recently, a patient companion in a room of a patient with Parkinson’s disease saw his wife slap him across the face. The companion called a forensic nurse for a consult to make sure the patient was safe. “It is important that we educate all hospital employees about their role in identifying people who may be affected by violence,” says Gaertner.

Gaertner and her peers are committed to educating community partners in fighting violent crime. Last year, Gaertner’s team received a VOCA grant to share information about elder abuse and nonfatal strangulation with emergency medical services (EMS) coordinators at community fire stations. Gaertner assessed understanding of the topics using a six-item survey, and scores improved immediately after the education; however, research is needed to learn if knowledge was improved over time.

Helping patients regain control

Since Cleveland Clinic debuted its first SANE program at Hillcrest Hospital in 2003, services to assist victims of trauma have grown in scope and become more streamlined. “I believe we are innovators at Cleveland Clinic,” says Dr. Bryant. “We are striving to adopt the same standards at all EDs across our enterprise. We are focused on making identification of violence more transparent so people know where to get help.”

Training nurses, educating the community and adopting the latest forensic technology (see “Tools of the Trade” below) all contribute to a quality forensic nursing program that ultimately benefits victims of trauma – one patient at a time.

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“People always ask me why I do this job. When patients comes in, they might be curled up in a fetal position and showing no emotion. Then you build a rapport with them – you experience this intimate event with them,” says Gaertner. “When they leave, they are often able to look you in the eye and say, ‘Thank you.’ It’s such a heartfelt thanks for helping someone through the worst day of their life. That’s why I do what I do.”

Tools of the trade

An important part of a forensic nurse’s job is photo documentation of a victim’s injuries. Previously, nurses at Cleveland Clinic took photos of bruises, cuts and other injuries with a standard camera, then stored and distributed the images on CDs. But thanks to a Victims of Crime Act (VOCA) grant from the Ohio Attorney General’s Office, forensic nurses at Cleveland Clinic Akron General, Fairview and Hillcrest hospitals now have access to a Secure Digital Forensic Imaging (SDFI®) system.

The SDFI system includes:

  • High-resolution photography that shows micro details, as small as a hair follicle
  • A negative invert filter to show tissue damage below the skin
  • Contrast capability to show other hard-to-see evidence, such as dried semen (which fluoresces under ultraviolet light)
  • Military-level encryption for secure storage of images
  • A secure file portal through which to transmit court-ready photographs

“SDFI technology is the gold standard in forensic nursing,” says James Bryant, DNP, RN, CEN, Associate Chief Nursing Officer of Emergency Services at Cleveland Clinic. “We anticipate it will help further our forensic program and continue our success with helping prosecute crimes and secure justice for victims.”

For more on the Forensic Nursing Program at Cleveland Clinic, Enterprise Program Manager Michele Sorrell can be reached at MSorrell@ccf.org.

1 Ohio Bureau of Criminal Identification and Investigation, 2016 Domestic Violence Report

2 Ohio Office of Criminal Justice Services, Sexual Assault in Ohio – 2015

3 Ohio Attorney General’s Office, 2016 Human Trafficking Commission Annual Report