Chapter 33: Forensic Nursing in Mental Health

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement, not replace the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Welcome to the Deep Dive, the place where we cut through the noise and give you the essential knowledge fast.

Today, we're plunging into a field that operates right on the fault line between crisis, care, and the law, forensic nursing.

It really is an essential field and tragically, it's driven by need.

I mean, when you actually look at the statistics, you start to understand why we need these specialists so badly.

Tell us about that.

Well, violent crime involving people 12 and older, it's spiked.

Went from about 2 .7 million victims in 2015 up to 3 .3 million in 2018.

Wow, that's a huge increase in just three years.

And I read something about sexual assault rates too.

Yes, exactly.

The sheer vulnerability shown in that data is, well, it's shocking.

The rate of sexual assault nearly doubled in that exact same period.

It went from 1 .6 per 1 ,000 people to 2 .7 per 1 ,000.

Doubled, good grief.

So when we talk about violence reduction as a goal, like in healthy people 20, 30.

It's a massive societal challenge we're talking about.

So where does forensic nursing fit into this picture?

Okay, so forensic science at its heart is basically applying scientific principles to answer legal questions.

Forensic nursing then is the specialty that takes traditional nursing skills.

Caring for people affected by violence and trauma.

Right, the core nursing.

Exactly.

And it fuses that care with the forensic knowledge you need to, well, preserve justice.

So they're kind of bridging that gap

between stabilizing someone after trauma and making sure the evidence isn't lost.

Precisely.

They're often the only ones who can do both effectively.

So our mission today is to unpack the key roles,

the core therapeutic approach and those crucial legal concepts that really define this world.

Okay, let's unpack this.

Well, the field really started to get formalized back in the 1990s.

The IAFN, that's the International Association of Forensic Nurses, was founded in 1992, mostly by SANEES, actually Sexual Assault Nurse Examiners.

Okay, SANEES, we'll definitely come back to them.

They will.

And then the American Nurses Association, the ANA, they recognize forensic nursing as a distinct specialty, just three years later, in 95.

So relatively new as a formal specialty.

And where do most nurses start out in this field?

Usually as a forensic nurse generalist.

This is an RN, a registered nurse, who might work across various settings.

Think the ED, trauma units, maybe corrections, women's health clinics.

So typical nursing environments, but their job isn't typical.

Right, they do the expected things assessment, developing treatment plans, making follow -up referrals, but they're also carrying this, well, this double burden.

The forensic part.

That's the one.

The critical forensic tasks, identifying and assessing victims, sometimes perpetrators too, and then the really crucial steps,

collecting potential evidence, documenting everything meticulously, and preserving that evidence properly.

Because if they miss a step there, The whole case could fall apart later in court.

It's high stakes.

But collecting evidence, documenting that, requires the patient to be able to participate, to tell their story clearly.

What if they're in shock or withdrawn?

Exactly.

And that's why the approach itself has to be different.

This brings us straight to the core therapeutic concept that all forensic nurses need.

Trauma -informed care, TIC.

Trauma -informed care, okay.

You absolutely have to use TIC in this field.

It's built on understanding the known,

profound impact that trauma has on the brain and body, on the neuroendocrine system.

So it's about recognizing what trauma does physiologically.

Yes, and then using that knowledge to create a culture of safety, empowerment, healing, making the patient an active participant, not just someone things are happening to.

And you mentioned trauma looks different on different people.

It's not always what you might expect.

Not at all.

Tears, distress, yes, sometimes.

But other times, patients might show behaviors that seem, well, inappropriate.

Like giggling, maybe.

Or this odd, almost unnatural calmness.

Giggling, that's surprising.

It is.

But it's understood now as a neurobiological response to overwhelming shock.

A trauma -informed nurse sees that and adjusts.

They don't judge it.

They adapt their immediate care strategy.

Can you give an example?

Sure, think about sexual assault care.

Based on this understanding, some police protocols have shifted.

They might now allow victims time to recover, maybe even complete a sleep cycle, before doing an in -depth interview.

Because they'll get a clearer account later.

Exactly.

After the initial shock response has subsided a bit, the victim can often provide a clearer, more sequential, and ultimately more accurate picture of what happened.

That makes sense.

So once a generalist gets the hang of the evidence side and tick, they might specialize further.

Often, yes.

And the largest subspecialty by far is the one we mentioned earlier.

The sexual assault nurse examiner.

The saner.

Or sometimes called safe sexual assault forensic examiner.

Sane or safe, and what does that involve?

These are generally RNs who've done specialized advanced training.

At least 40 contact hours, usually focused on caring for adult victims.

That's Sani A, or pediatric victim, Sani P.

It's very focused, very critical work.

And that specialized care needs to fit the community being served, I imagine.

Absolutely critical.

There's actually a really powerful example of adapting care, especially around intimate partner violence.

We know Native American women experience this at disproportionately high rates.

So researchers took an existing safety app, one developed by nurses called MyPlan, and they adapted it.

They created a new web -based version specifically for Native American women calling it Our Circle.

So more than just a name change.

Oh, much more.

The whole development of Our Circle was driven by input from the community itself, Native American survivors, practitioners.

And that input led to real changes, like different terminology.

Like what?

Well, for instance, instead of using terms like abuse or violence, the community preferred mistreatment.

So the app used that language, that kind of culturally sensitive adaptation driven by the users.

That's the gold standard.

That level of detail is impressive.

Now, shifting gears slightly, sometimes the evidence isn't from a living person.

What about investigating deaths?

Right.

That brings us to the nurse coroner or death investigator role.

This really started emerging around the mid 1990s.

And what does a nurse coroner do?

Well, traditionally, the coroner is the legal authority determining the how and the why of a death, cause and manner.

Nurses bring incredible strength to this role.

How so?

Because of their holistic background, their deep knowledge of AMP, pathophysiology, pharmacology, they understand disease processes.

Plus they understand grief and grieving.

All that clinical knowledge really sharpens their judgment when looking at the circumstances around a death.

Okay, so we've had the generalists dealing with evidence, the SAN focusing on sexual assault victims, the nurse coroner on death investigation.

What about the mental state?

The mind.

Ah, yes.

That leads us into forensic psychiatric nursing, or FPN.

This is where it gets really complex, I think.

How so?

Because FPN requires advanced skills in psychiatric assessment, evaluation, treatment, combined with a really thorough understanding of the criminal justice system.

You need both sides.

Here's where it gets really interesting.

Exactly.

The FPN acts like a behavioral expert, but operating inside that legal framework.

They can wear different hats.

Psychotherapist, consultant, sometimes even hostage negotiator or criminal profiler.

Wow.

But let's focus for a moment on the forensic nurse examiner, the FNE, their main job, conducting court ordered evaluations and providing an expert professional opinion.

Okay, an expert opinion.

But how hard is it really for an FNE dealing with maybe a very disturbing crime to separate their own personal feelings, their values, their background from that professional opinion?

It's arguably the biggest professional challenge in the role, but it's absolutely essential.

Their opinion must be based only on scientific principles,

their advanced education, and the objective standards of care set by research and the profession.

No personal bias allowed.

They have to strive constantly for neutrality and objectivity.

Even when their nursing instinct is pulling them towards just providing comfort or care, the legal context demands that unbiased assessment first.

And this objectivity is critical when they evaluate two specific legal concepts, right?

They sound similar, but are judged at different times.

That's absolutely right, huge distinction.

The first one is legal sanity.

Sanity.

Think of sanity as like a mental snapshot taken right at the time the crime occurred.

The question is, was the person at that moment able to tell right from wrong?

Did they have the capacity to actually form the intent to commit the crime?

And using that defense usually requires...

Typically, yes, it requires evidence of a major mental disorder, often one involving psychosis, but crucially, it's always the defendant's choice whether to use the insanity defense or not.

And the basis for this defense goes way back, doesn't it?

It does.

All the way back to an 1843 trial in England.

Daniel McNaughton.

That's where the McNaughton rules came from.

What did they establish?

Essentially that the accused either didn't know the nature and quality of the act they were doing, or if they did know it, they didn't know it was wrong.

Later on, other concepts were added, like irresistible impulse, meaning they knew it was wrong, but supposedly couldn't stop themselves.

And also the verdict of guilty, but mentally ill.

Which means?

Which usually means they're still found legally responsible, but are mandated to receive treatment, often within the prison system.

Okay, so that sanity judged at the time of the act.

What's the second concept?

The second one is competence to proceed, or sometimes just competency.

Competence.

Think of competence not as a snapshot, but more like a continuous mental video review.

It's assessed constantly during the legal proceedings, the trial, the hearings.

And what's it assessing?

It's asking, does the accused currently have the mental capacity to understand what's going on in court?

Can they rationally assist their own lawyer in their defense?

So it's about their current state right now.

Exactly.

Someone might be deemed competent on a Monday, but if their mental state declines significantly by Friday's hearing, their competence has to be reevaluated, it's fluid.

That makes the FPN's role incredibly important in court, not just for evaluations, but also as witnesses.

Definitely.

They can testify in two main ways.

As a fact witness.

Meaning?

Meaning they testify only about what they personally saw, did, or documented.

So a CIMIC, describing the steps they took during an evidence collection kit exam as being a fact witness.

Okay, just the facts.

Just the facts they observed or performed.

But they can also be called as an expert witness.

And the difference is?

As an expert, the court recognizes their specialized knowledge, education, or experience.

They can offer opinions based on that expertise.

They might explain complex medical records to the jury, interpret findings.

So they need to be trustworthy.

Absolutely.

Maintaining credibility is paramount.

They have to stay current with research, present information clearly and unbiasedly.

You also mentioned criminal profiler earlier.

How does nursing fit into profiling?

It's fascinating, actually.

Psychiatric mental health nurses are surprisingly well -suited for it because they use the nursing process, assessment, diagnosis, planning, intervention, evaluation, but they apply it differently.

They use it to try and reconstruct the crime.

Essentially getting inside the offender's reasoning process.

Analyzing behavior patterns, motivations.

And there's a famous nurse pioneer in this area.

Yes, Ann Wolbert Burgess.

She's a huge name.

Really, a founder of Forensic Nursing and the IAFN.

Dr.

Burgess was the first nurse criminal profiler to work with the FBI's Behavioral Science Unit.

No kidding, with the FBI?

Yes.

It was her groundbreaking work on rape trauma syndrome that initially got the FBI's attention.

Her insights into victim psychology were invaluable.

And her work even inspired a character in the TV series, Mindhunter.

Wow.

That really shows the unique perspective nursing brings.

It absolutely does.

Both for understanding victims and potentially understanding perpetrators.

That strong link between mental health and the justice system naturally leads us to our next area.

Correctional nursing.

Right, care for people who are incarcerated.

And the scale here is just enormous.

What are the numbers?

We're talking about roughly 2 .3 million people confined in jails and prisons in the U .S.

And the rates of mental illness are staggering compared to the general population.

How high?

Well, estimates vary, but somewhere between 14 % and 26 % of people in jails have a serious mental illness compared to maybe 5 % outside.

And substance use disorders, even higher.

Up to 51%, over half of incarcerated women have a substance use disorder.

Those numbers are overwhelming.

What's the biggest challenge for nurses working in that setting?

I think most would say it's the fundamental tension baked into the system.

Custody versus caring.

Custody versus caring.

Explain that.

Okay, so prisoners have a constitutional right to healthcare.

The nurse is ethically, professionally bound to provide care to be the patient's advocate.

But they're doing it inside an institution whose primary goals are punishment, security, control.

So the nurse is caught in the middle.

Constantly balancing the patient's health needs against the facility's rules and safety protocols.

And compounding this is what many call the criminalization of mental illness.

Meaning people end up in jail because they're mentally ill.

Often, yes.

Because maybe there weren't enough psychiatric beds available, or crisis services weren't accessible in the community.

So during a psychiatric emergency, the only place equipped to handle them securely is jail.

That sounds like an incredibly difficult environment to practice nursing.

The vignette about Susan Barnes really highlights this, doesn't it?

It does.

Susan Barnes has bipolar eye disorder.

She was incarcerated during an acute manic episode having stopped her medication.

David, the forensic psychiatric nurse practitioner in the vignette.

His first job is just stabilization.

Safety first?

Absolutely.

Getting her to the infirmary, ensuring her safety and the safety of others, starting appropriate medication, trying to establish even basic sleep hygiene.

In that acute phase, in that setting,

stabilization trumps everything else initially.

But the real work, the part that might actually impact public safety long -term, that comes later.

You mean the discharge planning.

Yes.

Yeah.

That's critically important.

Why is it so crucial?

Because comprehensive discharge planning is maybe the single most important factor in reducing recidivism, stopping people from cycling right back into jail.

For Susan, this meant assessing if she was suitable for something like a forensic mental health court.

What's that?

It's a specialized court docket that handles cases involving offenders with mental illness.

It mandates treatment, provides support services, intensive supervision, all aimed at keeping them stable and out of the system.

So the nurse's role isn't just treating the mania in jail.

No, it's about thinking ahead.

Can we link Susan to stable housing, to ongoing mental health care in the community?

Can we get her into a program that offers the structure she needs after release?

That linkage is key.

So wrapping this all up, what does this all mean?

What are the big takeaways here?

Well, I think it's clear forensic nursing is incredibly broad.

It's complex.

And frankly, it's desperately needed.

It lives right at that intense intersection of trauma, the law and medicine.

And the nurses wear so many different hats.

From the generalist carefully collecting physical evidence to the same charity providing specialized trauma care to the FPN interpreting really complex mental states like sanity and competency for the courts.

It's a huge range of skills.

It really is.

And if we connect this back to that correctional setting we just discussed, there's a final thought to maybe leave people with.

We know that things like PTSD,

complex trauma histories,

they're incredibly common among people who are incarcerated.

Yet the correctional environment itself, it's often just not set up for the kind of intensive long -term therapy needed to really address those deep -seated issues.

Right, the focus is custody, security.

Exactly.

So if the ultimate goal of correctional nursing includes reducing recidivism, making communities safer, it really forces us to ask a tough question.

Which is?

How can our health systems, our society, better advocate for and create effective specialized treatment alternatives outside of incarceration for people with severe chronic mental illness instead of relying on jails and prisons to be de facto mental health facilities?

That's a profound challenge indeed.

Finding ways to provide healing and justice simultaneously.

It truly is.

It cuts to the core of what this specialty tries to achieve.

Well, that's all the time we have for this deep dive.

We really hope this exploration of forensic nursing has been helpful, maybe giving you a new appreciation for the vital work these nurses do at such a complex crossroads.

Thanks for joining us.