Multidisciplinary and Collaborative Approaches: Bringing it All Together Working as a Team Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor,

Multidisciplinary and Collaborative Approaches:

Bringing it All Together Working as a Team

Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAANAssociate Professor, Johns Hopkins University School of NursingForensic Clinical Nurse Specialist

4N6 RN

Forensic Nurse Forensic = Pertaining to the Law

International Association of Forensic Nursing www.iafn.org 1-410-626-7805

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

UNDERSTANDING THE PROFESSIONVocational-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

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 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

UNDERSTANDING THE PROFESSIONAdvanced 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)

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

CNS Role

Expert in clinical area(s) Educator Consultant Patient, family, staff, administrators, APS,

surveyors, ombudsman, police

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

UNDERSTANDING THE PROFESSIONPhysician’s Assistant

PA’s Physician’s Assistant– Most Master’s prepared clinicians– Military trained– Supervised by a physician

UNDERSTANDING THE PROFESSION Physicians

Bachelor’s degree

Medical School – four years

Residency – minimum 3 years

Fellowship – minimum 1 year

What is Nursing?Be able to discuss the Nursing Process

A - assessment D – nursing diagnosis P - plan I - intervention E - evaluation

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 ???

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)

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)

Common Patient/Client Groups

Treatment of patients (victims) (survivors) of – abuse– violence– criminal activity– Vehicle crashes

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

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

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

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

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

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

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

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.

Today’s USA Today p. 3A

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

Role Differences – Forensic RN v LNC

Topic Forensic RN LNC Wound ID + - ? Bed sores + + Standards of care + + Translation + + Neglect of care + + Capacity - -

Role Differences - 2

Topic Forensic RN LNC Photo document + - ? Evidence collection + - ? Family violence + - DV Grown older + - Sex Assault issues + - SANE + -

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

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

Information needed

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

– In most cases you will not get it

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

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

All dictated consultant notes All radiology reports & summaries

– Actual x-rays/scans may be needed later

All laboratory results Medication Administration Records Discharge summaries

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

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

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

Get a signed release of information from:– The client/patient/victim– Medical power of attorney– Guardian

Court order – subpoena

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

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

“Court” is Part of the Role

Levels of Proof Preponderance

– > 50.1%

Clear and Convincing– > 75.1%

Beyond Reasonable Doubt– > 99%

Discuss my neck tie…….

Documentation PearlsDocumentation Pearls

If you did not chart it………If you did not chart it……… You did not do it!!!!!You did not do it!!!!! Avoid personal opinionAvoid personal opinion Avoid charting arguments with co-workersAvoid charting arguments with co-workers Avoid derogatory remarks about client, Avoid derogatory remarks about client,

family, or other providersfamily, or other providers Write legibly, legibly, legibly, legiblyWrite legibly, legibly, legibly, legibly

Forensic DocumentationForensic Documentation

As verbatim as possibleAs verbatim as possible Do not sanitizeDo not sanitize Do not “medicalize”Do not “medicalize” Avoid pejorative documentationAvoid pejorative documentation Document excited utterancesDocument excited utterances Document medical exceptions to hearsayDocument medical exceptions to hearsay

Avoid pejorative documentationAvoid pejorative documentation

Stop charting “refused”Stop charting “refused” Stop charting “uncooperative”Stop charting “uncooperative” Stop charting “non-compliant”Stop charting “non-compliant” Stop charting “alleged” and “allegedly”Stop charting “alleged” and “allegedly” Stop charting your feelingsStop charting your feelings Stop charting your angerStop charting your anger

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

of adequate blood supply by prolonged pressure.

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.

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

Risk factors for Pressure Ulcers & Neglect:

Intrinsic Acute illness CVD Decreased sensation Cognitive impairment Malnutrition Paralysis PVD Failure of vasomotor

reflexes Incontinence Decrease mobility Fractures/Surgery Diabetes

Extrinsic (Modifiable) Long periods on

stretchers, hard beds, chairs, & OR

Restraint use Inappropriate

compression stockings Shearing forces of bed

clothes or sheets

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

Risk Factor Scales:

Braden Scale (1987)– Activity– Mobility– Sensory

Perception– Nutrition– Moisture– Friction/Shear

Adjunct to clinical assessment

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

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.

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

Stage 2

Partial-thickness skin loss (epidermis and/or dermis)

Superficial Blister or crater Painful

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Stage 3

Full Thickness Damage or Necrosis of Subcutaneous

Tissue, not through fascia Deep Crater with possibly undermining

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Stage 4

Full-thickness with extensive destruction

Necrosis or damage to muscle & bone

Tunneling

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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

initiated? Skin properly assessed? Findings properly

documented?

Proper referral for findings? Initiation of proper treatment

strategies? Proper reassessment of skin?

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 !!!!!!!!!!!!!!!!

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?

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

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

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

Questions ?????

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– [email protected]