Evidence-based Forensic Nursing Practice: benefits and challenges
A couple of years ago, I was called as an expert witness to testify in a sexual assault case. The defense attorney asked for an opinion about false allegations of rape. Fortunately, I knew the question was coming so I had a chance to examine the literature beforehand. Even better–Dr. Margaret Aiken (1993) had published a concept analysis of false allegation in the context of rape. Her contribution to the scientific literature really helped me out.
We are hoping that the Journal of Forensic Nursing (JFN) will serve as the “go to” journal when people have serious questions like these about the nursing care of victims and those accused or convicted of committing crimes. With the first year of publication under our belt, I hope you’ll agree that the journal is well on its way.
Why is it so important that forensic nurses have access to current scientific knowledge? Because empirical knowing is a fundamental feature of nursing. In addition to aesthetic knowing, personal knowing, and ethical knowing, empirical knowing is a critical pattern of knowledge development and application in nursing (Carper, 1978). Without it, we’re left with speculation, tradition, and anecdote–not particularly helpful in a court of law.
As forensic nurses, a significant part of our practice time is spent providing expert testimony. Federal Rule of Evidence 702, the rule that guides testimony by experts, says:
If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise, if (1) the testimony is based on sufficient facts or data, (2) the testimony is the product of reliable principles and methods, and (3) the witness has applied the principles methods reliably to the facts of the case.
Expert testimony is only admitted if it is helpful to the jury. To be helpful it must be reliable. It would not be helpful to a judge or juror if an expert witness were to testify about unreliable theories. Determinations of someone’s guilt or innocence should not be based on something like the outmoded “science” of phrenology or the results of a consultation with a Ouija board (Stern, 1997). Instead, expert witnesses are relied upon to provide scientific, technical, or specialized knowledge to explain what certain events mean or how they may have occurred.
Nurses might become involved as expert witnesses in several ways. The nurse might be asked to explain something about the care they provided to a particular patient or to explain some basic aspects of health care that lie outside the understanding of the layperson. For example, an emergency department nurse might inform the court as to the normal range for a blood alcohol level. A forensic pediatric nurse practitioner might be asked to explain the significance of a particular bruising pattern. A legal nurse consultant might be called on to discuss the proper standards of care in the nursing home industry. A forensic psychiatric/mental health nurse could provide details about an individual’s behavior or condition and explain why the patient might demonstrate certain behaviors. All of these opinions should be based on a “critical appraisal of research findings and the decisions regarding whether and how to use the findings in the care of patients” (Brown, 1999, p. 3).
It should come as no surprise that Brown was defining evidence-based practice. In Federal Rule of Evidence 702, the courts are requiring expert witnesses to base their testimony on reliable information. The most reliable information currently available is information generated by systematically examining and interpreting what is actually happening. This scientific approach answers important questions: What do you know? How do you know it? How would you know if you were making a mistake? These fundamental questions are as important in a court of law as they are in clinical practice and that’s why forensic nursing, in particular, emphasizes evidence-based practice.
If evidence-based practice is such a good idea, why isn’t everybody doing it? Well, for one thing, it’s time consuming. Reading research studies takes time, and synthesizing them into a set of practice guidelines is something not everyone will take the time to do. We generally relegate that task to professional organizations such as IAFN. IAFN has developed the Sexual Assault Nurse Examiner (SANE) Standards of Practice, Scope and Standards of Forensic Nursing Practice, and Domestic/Intimate Partner Violence Standards of Practice. In addition, the IAFN Death Investigation (DI) council is drafting the Death Investigation Standards.
Other agencies and organizations, such as the United States Secret Service and the Law Enforcement Emergency Services Video Association have developed best practices related to seizing, auditing, and analyzing electronic information, which are readily available on the Internet. There are also published best practices in evidence collection, forensic linguistics, and forensic interviewing (see the box on this page for a partial list). Just finding these Web sites was time consuming for me. A nurse who is going to change his or her practice on the basis of this information will have to go much further, analyzing the scientific foundation for each of the guidelines and resolving conflicts among recommendations.
In some areas of nursing practice, the evidence base is in the developmental stage. Forensic nurses have primarily been focused on patient care. It is only recently that funding has been available for developing answers for clinicians. With a few exceptions, most of the currently funded research focuses on sexual assault–evidentiary findings after sexual assault, colposcopy, genital injuries in adolescents, and post-rape psychopathology are a few examples.
Evidence-based practice requires a specific skill set. Most IAFN members have received limited education in the area of scientific research and research utilization. About one-third of IAFN members (32.6%) earned diplomas or associate degrees. Only rarely do diploma and AD programs offer formal education in research. Another one-third have completed basic course work in nursing theory and research but only 25% of IAFN members have extensive training in research utilization or knowledge development. Most would agree that this skills deficit is a hindrance to evidence-based practice in forensic nursing but there are various approaches to remediating the deficit.
Here’s where JFN comes in. We’re working hard to disseminate findings of carefully conducted original research. We want to publish well-done literature reviews and concept analyses. In addition, we’re looking for ways to make this information accessible to professionals whose skills lie more in the arena of patient care than in the area of research utilization. The JFN Editorial Board has talked about offering continuing education opportunities through the journal. We would select a research study from each issue and walk people through the process of reading the study and analyzing the results. This would help all nurses who need CE hours, particular those who are in the process of re-certifying as SANE-As. It would add to the skill set of forensic nurses overall in a way that honors the strengths of clinicians. It would cost time and money to put together, and as always, we weigh these decisions carefully, but on the whole, it seems like a reasonable project.
What do you think? Let me know if you’d like to see CE articles in JFN in the future. As we continue our second year of publication, we want to make sure that we’re meeting the needs of IAFN members as well as the needs of forensic clinicians, educators, administrators, and researchers worldwide.
By the way, I was not allowed to offer an expert opinion on false allegation of rape because the scientific foundation for such testimony was just too shaky. It’s an important issue–and would make a great dissertation topic. Anybody interested?
Aiken, M.M. (1993). False allegation: A concept in the context of rape. Journal of Psychosocial Nursing, 31(11), pp. 15-20.
Brown, S.J. (1999). Knowledge for health care practice: A guide to using research evidence. Philadelphia: W.B. Saunders Co.
Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), pp. 13-23.
Stern, P. (1997). Preparing and presenting expert testimony in child abuse litigation: A guide for expert witnesses and attorneys. Thousand Oaks, CA: Sage Publications.
International Association of Forensic Nurses
(Go to “Shop IAFN” for standards publications)
Federal Rule 702
How to Seize Electronic Evidence
How to Analyze Videotapes
Sexual Assault Nurse Examiner Programs
Computer Retrieval of Information on Scientific Projects
Louanne Lawson, PhD, RN, FAAN, is an Assistant Professor, University of Arkansas for Medical Sciences (UAMS) College of Nursing, Little Rock, AR. She can be reached at LawsonLouanne@uams.edu.
COPYRIGHT 2006 Jannetti Publications, Inc.
COPYRIGHT 2007 Gale Group