An Interview with Jennifer Pierce-Weeks, manager of the Forensic Nursing Program at Memorial Hospital, Colorado Springs, Colorado.
What services does your program provide?
Pierce-Weeks: The Forensic Nursing program at Memorial Hospital is housed in a 79-bed emergency department. We have our own 24-hour services for victims of violence. There are 11 Forensic Nurse Examiners (FNEs), including the manager. FNEs are Sexual Assault Nurse Examiners (SANEs) who have special training on working with victims of other crimes, such as intimate partner violence, child maltreatment, elder abuse, and trafficking. Four of the clinical staff members are in-house, and six are on call. We are the independent providers for sexual assault patients, and we are consulted on the care of victims of other crimes.
On many of these cases-such as sexual assault and intimate partner violence where strangulation has taken place-we collect forensic evidence. We provide detailed, head-to-toe examinations and make recommendations to other team members such as physicians, child protection, and law enforcement. We photograph injuries and collect evidence, and what we collect depends on the circumstances. For example, we might collect evidence from a victim's fingernails if she says she has scratched her attacker.
For us, the long-term healthcare implications for the victims of these crimes are enormous. It is not uncommon for them to return to the emergency department because of suicide attempts, anxiety disorders, other physical complaints, and even further victimization. The patients we see who are kids are often also the patients who have serious healthcare consequences in adulthood-plus higher mortality rates. For us, it's about improving care and responding effectively the first time we see them in an attempt to reduce the chances of those long-term sequelae so often seen with these patients.
Can you tell us about the history of the program-how did it come about?
Pierce-Weeks: Our program started in 1995 for sexual assault victims in the community, providing a 24 hour on-call response by trained SANEs in the ER. In 2007, we started expanding the program, and now half the nursing staff is in-house, staffed by forensic nurses in the emergency room, and half the staff is on call. We started adding victim populations beyond sexual assault, such as intimate partner violence patients who are often victims of strangulation. We had to train the nurses on intimate partner violence, and we created a three-day forensic nurse examiner course offered through a local university. As the program has evolved, we have become part of a team for all crimes except sexual assault. The teams include emergency physicians and registered nurses (RNs), hospital social workers, nurse liaisons, in-house hospital MDs and RNs, outside clinics and physicians' offices, law enforcement, and crisis center staffs. The program has expanded dramatically, going from 250 patients a year when we started, and this year, 2010, it has been 500 so far. We will probably see 700 by the end of the year.
How do your program's services differ from those of other forensic nursing programs, and are there any other programs like yours?
Pierce-Weeks: Most programs are strictly Sexual Assault Nurse Examiner (SANE) programs addressing the needs of sexual assault patients specifically. Our program is different because it addresses the forensic patient population more globally because we do see patients other than sexual assault victims. Only a few other programs in the United States have expanded their practice beyond sexual assault. Like other SANE programs, we do evidence collection. That's an important aspect of our work, and we are trained to look for and collect evidence, as I mentioned with strangulation victims. We work with law enforcement and testify in court. Also, our nurses are trained to look for patients who might need our services-who have been treated in the emergency room or other departments but might not have been identified as crime victims. Our key focus, though, is patient care, responding to the needs of the whole patient who is also a victim of crime. There is a lot of research showing that SANE-specific programs that focus on overall healthcare produce better long-term patient outcomes and are more sustainable than those that focus too narrowly on evidence collection. So, strong programs need to do both.
What are the challenges for running these programs?
Pierce-Weeks: Maintaining and keeping staff is difficult. People are very dedicated to the patients, and sometimes they burn out from the work. They want justice for the patients. So, they are often disappointed about the low prosecution rate for these crimes. Many nurses come in with greater expectations of the criminal justice system than what it is able to produce. And it's even harder for the staff when you expand the practice beyond sexual assault. It's one thing to take care of child sexual abuse victims-where 90 percent of the time the child doesn't have any physical injury. But it's quite a different challenge to consult on child physical abuse cases where the children have such bad abusive head trauma that if they live, there is going to be severe brain damage. It takes some adjusting for staff to be able to deal with that, so it's hard to keep people in the work.
What kind of training do you require for staff?
Pierce-Weeks: This is not a job for new nurses, but for those who have some clinical experience. It's too easy to fall into the habit of just collecting evidence but missing some significant trauma. Also, when we first expanded the practice, we started with domestic violence. The in-house staff had no training on domestic violence except what they got on the job from me. This is how we ended up developing the advanced forensic nurse examiner course. It's not easy to figure out who these patients are because most victims do not come in complaining of domestic violence. They come in with about 40 other complaints-not necessarily physical assault. So, in the course, we lay out the health consequences of domestic violence, how to find them if patients are not presenting as domestic violence victims, and how to address their needs. Many patients do say they were beaten up, but many do not report that. So we need to know the many health consequences that go along with domestic violence that do not happen with other patient populations. We need to know what domestic violence looks like-it's not always the patient with the black eye. You need to know what child maltreatment looks like-because that is often hidden, how to identify those patients, how to talk to them, and how to talk to parents (who may be the offenders). We need to know how to separate the parents out so we can get distinct stories of what happened to children to get an idea of whether the story is true and whether or not we have to worry about the safety of the child. So, these are some of things that went into developing the foundational education of the advanced forensic nursing training.
We chose to focus on the patients we see the highest volume of-domestic violence, child maltreatment, and elder abuse. We looked at human trafficking, also. It's the rare healthcare institution that can identify trafficking victims because healthcare is just starting to learn about it, and law enforcement also has trouble understanding the health consequences of trafficking on the victims. We don't see many of these trafficking victims, and we know we need to address the problem more effectively.
We also do training on how to testify and how to prepare for the testimony. We teach and practice quality assurance by having more than one person look at the exam results, charts, and the photos so everyone is being evaluated by their peers to make sure the evidence is accurate. In regular SANE training, prosecutors train the nurses on how to testify and how to prepare you for what will be asked. Nurses support one another in helping to prepare for the testimony, as well as how to meet all the nursing requirements in preparing for testimony. Nurses with testimony experience can help the nurses who do not have any experience.
What personal characteristics do people need to do this job?
Pierce-Weeks: Most important is to have a passion for the patient population-that stands out for me. They also have to have the clinical background that's needed to care for the patient. Also, for anyone who has been victimized, they need to have worked through their own issues. Unfortunately, many come into the work without working through those issues, and that can make the job difficult. Our job is not to make sure offenders are successfully prosecuted-that's the prosecutor's job. Our job is to care for the patient, and if nurses have a hidden agenda, defense attorneys can use that vulnerability to challenge their testimony, which hurts the individual nurse and the profession. We have to be professional and unbiased.
Why is your work important to victims?
Pierce-Weeks: To me, the importance for victims is clear from the difference between the expressions on their faces when we first see them-and then when they are discharged from our care. They come in looking traumatized-sometimes angry and distrustful, not making eye contact. But they often leave, even the kids, laughing and smiling with their heads up and looking directly at people. That is what is important, especially because there is so much more they will go through when they leave. My hope is that will carry them through multiple connections with law enforcement, testifying at a trial, and they need a sense of self to get through that. Often when victims come in, they have lost their sense of self, or they are allowing the crime to define them. We try to bring them around to realize that a situation doesn't define them. We don't see them for long, but we make sure to connect them with community victim advocates so they have ongoing service providers they can meet with. Our goal is to make sure they meet the advocate when they are seeing the nurses. They see that we work with the advocates and trust them. They put a face with the name and realize that someone they have met before and that someone will be there for them when they walk out the door. We do that regularly for sexual assault and domestic violence victims.
Can you share an example of an actual case where a victim was helped?
Pierce-Weeks: I remember one woman we saw many times for domestic violence/ strangulation; she had moved here from a different country, and she could not go back to her country of origin. Her husband turned out to be a batterer, and he abused her horribly. We saw her quite a few times before she actually found the courage to leave him and was connected with services that could help her. She got out of the situation, and he was arrested. She found a way to get on her feet.
How have advances in forensic DNA affected your work?
Pierce-Weeks: DNA can have such a great impact on victims' cases. I wish we could get victims in faster and that there was a better understanding about how having good DNA evidence can affect their cases. (Of course, you don't think about that when you're traumatized.) We see so many cases that do not successfully make it through the criminal justice system, but so many of those that do succeed have DNA attached to them. For example, in the last case I testified in, the nurse examiner had collected a saliva sample from the victim's body-that was crucial in convicting the offender. We had that DNA evidence, the victim's testimony, the testimony of the medical community who had examined the victim and the suspect, and the crime lab testimony. It was a beautifully handled case and a very successful prosecution. DNA has a huge impact from a criminal justice perspective, and that can be very beneficial to victims.
The problem, though, is that so many victims are traumatized that it takes them a while to get into the hospital and the evidence can be destroyed or degraded-if they take a shower, for example. We need more public service messages that say, "if this happens to you, please get seen right away!"
What obstacles have you encountered to the success of your program or work?
Pierce-Weeks: One of the biggest challenges so far has been training the multidisciplinary community in issues like the lethality of strangulation. Let's say a law enforcement officer responding to a domestic violence call might not understand the need to think about whether the victim has been strangled. The victim will probably not tell them that. But if it's happening, the victim needs medical care right away, and we can corroborate the story of the strangulation and testify to the lethality of strangulation. We've done a lot of training lately, and law enforcement is doing much better in making sure patients make it to the hospital right away. The law enforcement community has come to realize this is important to see and document that crime. Prosecutors also need to understand that the forensic nurses have provided the care and actually train the physicians on strangulation, so we are appropriate witnesses-the medical experts on this crime. We've made such progress with law enforcement, though, that I'm hopeful we will make similar progress with the district attorneys.
Another internal issue is that it's important that hospitals recognize the need for in-house forensic nurse examiners. Now, in our hospital, half of our forensic nursing service is in-house, and the merit of that is becoming clear. I assume other communities have challenges in making the case for in-house forensic nurses.
How have you dealt with these challenges?
Pierce-Weeks: We show what we are doing and why it works well. We keep track of our work with excellent records and clear data on the patients we serve. We keep clear data on who is consulting with us-who is asking for us. The more we are seen in this emergency room and in this hospital as a part of the system-wide response, the more we are called.
What have you learned from doing this work?
Pierce-Weeks: I've learned that it is ridiculous to think that we would try to provide care to these patients without the assistance of advocates, without someone we can work with to provide an ongoing confidential relationship and services for victims. If a response to this patient population requires withholding advocacy, that's negligence. We would be denying them the possibility to heal and recover from the trauma, and if they don't have that support, they will be back with mental health disorders and suicide attempts. They will be back and will be revictimized. There is no one service that provides everything. It requires a team effort, and that team has to include advocates. It has to be real advocacy-services, shelter, temporary housing-whatever the victim needs. In communities where there is effective advocacy, response is crucial. Advocates need to come in and provide these services and by doing that, they show their worth. They need to be here.
If you had one message to share with victims and their families about your work, what would it be?
Pierce-Weeks: Healthcare should be a safe place for you to come to get the care you need. When you seek services, you will feel supported, not judged. Yes, our work is hard, and often patients and their families say things like "I don't know how you do this work." But the truth is there is great satisfaction in knowing you were able to provide services to someone who needed them. That they could leave your care knowing that what happened to them wasn't their fault. We're making a lot of progress, and every community should insist that crime victims receive the level of care they deserve and need. It works for everyone when communities make that choice.
Jennifer Pierce-Weeks, manager of the Forensic Nurse Examiner Program at Memorial Hospital in Colorado Spring, Colorado, is a past-President of the International Association of Forensic Nurses (IAFN) and has served on the IAFN Board since 2006. She previously served for twelve years as the director of the State of New Hampshire Sexual Assault Nurse Examiner Program. She has 23 years nursing experience and is an educator and expert in the areas of child and adult sexual assault, as well as domestic violence.