Opportunities in Forensic Nursing

In the late 19th and early 20th centuries, many innocent black men were wrongfully lynched without trial in the Jim Crow South, often based on trumped-up charges of raping white women. Today, courts decide rape cases, and evidence collected by nurses can exonerate the innocent and identify the real perpetrators.

This careful work is the realm of sexual assault nurse examiners (SANEs), who make up the largest sector of forensic nursing, a specialty that blends nursing with the judicial system. In addition to working with victims of sexual assault, domestic violence, child abuse and elder abuse, forensic nurses collect evidence at crime scenes and assist with death investigations. They collaborate with police detectives and testify in court. Some forensic nurses work with prison populations and psychiatric patients. But regardless of their particular job focus, all forensic nurses have two key skills in common: unwavering objectivity and attention to detail.

SANEs work with victims of rape as well as other sexual assaults that do not involve penetration. They are trained to perform forensic examinations of victims, collect and package evidence for rape kits and counsel rape victims.

First recognized as a specialty by the American Nurses Association 13 years ago, forensic nursing still does not involve more than a thousand full-time jobs, by some estimates. SANEs and other forensic nurses typically work on a part-time, on-call or consulting basis, in addition to holding a full-time nursing job, usually in the same hospital. But nurses who have chosen this specialty say the work is unusually rewarding and contains future promise for more full-time career opportunities as the demand for these professionals increases. What’s more, acquiring training and skills in forensics can make nurses more valuable to their current employers, even if they are not able to work exclusively in the forensic nursing field.

A Day in the Life of a SANE

For more than a year, Geretha Diamond, MSN, RN, RN-BC, CASAC, SANE-A, has worked as a forensic nurse in the Bronx, which has the highest rape rate in New York City. Two to three times a week, she is on call for 12-hour blocks as a member of the Bronx Sexual Assault Response Team (SART) at North Central Bronx Hospital, in addition to her regular job as a nurse educator in the hospital’s psychiatric unit.

A SANE call comes in once or twice a week. One recent call awoke her at 6:30 a.m. on a crisp Saturday in mid October. Arriving at the emergency department, she met a withdrawn, visibly shaken 25-year-old woman. After making sure the woman had no serious injuries that needed treating, Diamond started the interview. The woman had been sexually assaulted by a man who was an acquaintance of one of her friends.

“Part of my job is to make sure she feels safe,” Diamond says. Victims who feel safe are more likely to give a full description of the crime and press charges against their attacker, she explains.

Diamond closely inspected the patient’s genital area for semen, hair strands, fibers and other evidence, packaged and labeled each piece, and put them in a rape kit for DNA testing. Looking for bruising and other signs of rape, she took photos with a digital camera and a culposcope, a microscope with a camera attached. She also gave the victim advice on how to deal with the possibility of sexually transmitted diseases and pregnancy.

The suspect in this case was arrested and the evidence Diamond collected was used against him in court. Studies have shown the courts prefer evidence that is collected by SANEs because it contains fewer errors than evidence gathered by other ED staff, leading to higher conviction rates and fewer wrongful convictions.

Not In It for the Money

Many nurses and students are intrigued by the idea of working in forensic nursing, viewing it as an exciting career alternative to bedside nursing. The reality, however, is that jobs for forensic nurses are still rare and the pay tends to be relatively low—about $2 an hour for on-call time and one to one-and-a-half times base pay for work on a case, which typically takes three or four hours.

SANE work is “time-consuming, it’s not paid that much and it’s stressful, particularly if you go to trial,” says Sultan Torshkhoez, MD, director of health and forensic services at the New York City Alliance Against Sexual Assault.

Karen Carroll, RN, SANE-A, NY-SAFE, associate director of the Bronx SART, agrees that it’s not easy to recruit forensic nurses, despite its glamorization in TV cop dramas. “It’s not for everyone to get out of bed at 3 o’clock in the morning when it’s snowing and it’s cold [to visit a crime scene or examine a victim],” she says.
Despite these drawbacks, nurses who do choose to become trained and certified as SANEs often do so because they are passionate about advocating for crime victims’ rights. Carroll, for example, is a survivor of sexual assault who did not want other rape victims to have to go through her unpleasant experience of being examined by a doctor who had no idea how to collect the evidence for her rape kit.

While the International Association of Forensic Nurses (IAFN) reports that SANEs are the largest group of nurses within the specialty, it estimates that only 600 to 700 of the 5,700 hospitals in the U.S. offer SANE services.

The problem is that cash-strapped hospitals are wary about financing programs they perceive as mainly helping law enforcement and not health care, Torshkhoez says. The U.S. Department of Justice is the primary funding source for SANE programs, but the pot has been shrinking under the Bush administration, he adds. Some states, like New York, provide extra funding for hospitals that want to offer SANE services, but it’s still not enough to cover the total cost of such programs—about $150,000 a year.

Health and Hospitals Corp. (HHC), New York City’s public hospital system, uses SANEs at all of its 11 hospitals, which include Carroll’s facility in the Bronx. But Torshkhoez reports that only seven of the city’s 45 private hospitals have SANE programs. To keep its programs cost-effective, HHC uses an approach in which one SANE program is shared by several hospitals—a solution that Torshkhoez would like to see the private hospitals adopt.

Minority SANEs Needed

While the job market for forensic nurses remains limited, there’s no denying that more minority nurses are sorely needed in this specialty. In a community like the Bronx, which is predominantly African American and Hispanic, Carroll says there is a great need for culturally knowledgeable SANEs who share the same ethnic background as their patients. At some hospitals, the forensic nurse may be the only caregiver of color that a rape victim sees.

Even though about one-third of the victims treated in Carroll’s program are Hispanic women, and half of them don’t speak English, she has not yet been able to hire a Latina SANE, so her team has to use interpreters or a language phone.

Cultural sensitivity and the ability to establish a trusting relationship with patients are important, because SANEs often deal with rape victims who are unwilling to report the crime. Carroll says this is a particular problem among African American women. She believes misogynistic rap lyrics legitimize rape and that black churches don’t encourage reporting. She was shocked when boxer Mike Tyson finished his prison sentence for rape and was greeted with what she calls “a hero’s welcome” in nearby Brooklyn.

Sexual violence against women is an even more daunting problem in Native American communities. American Indian and Alaska Native women have the highest sexual assault rate of any ethnic group in the country—fully 2.5 times higher than the national average, according to the Justice Department. Yet a 2007 research study by Amnesty International found that many Indian Health Service facilities have no nurses on staff who have been trained as sexual assault nurse examiners.

Desiree Allen-Cruz, domestic violence services coordinator for the Confederated Tribes of the Umatilla Indian Reservation in Pendleton, Ore., has cobbled together Justice Department grants to train two SANEs, one of whom is Native American. But she has not yet succeeded in convincing local hospitals to use them. For example, Allen-Cruz reports, one local Catholic hospital objects to use of the morning-after pill, which SANEs may recommend to a rape victim to prevent pregnancy.

Allen-Cruz, who is of Cayuse, Umatilla, Walla Walla and Nez Perce descent, believes Native American SANEs can help break down cultural barriers that might otherwise prevent Native rape victims from seeking treatment. “[Many Indian women have] a great deal of distrust of [Caucasian health care professionals],” she says, noting that in the 1960s and 1970s it was common for white doctors to secretly sterilize Native American women who had come to them for routine operations, such as appendectomies.

Colleen Palacios, RN, SANE-A, a forensic nurse who works at Yukon Kuskokwim Health Corp. in Bethel, Alaska, says she has been able to bridge cultural differences with her Alaska Native patients. She sees about 100 rape victims a year, most of them flown in from remote rural villages.

“There was a big learning curve when I first got here,” says Palacios, who is originally from San Antonio, Texas. “I didn’t understand what life was like in the villages. You have to build the trust and you have to understand that life in the village is all about survival. Culturally, I need to keep in mind that I must meet the patient’s needs, such as having a safe place [to stay].”

Emerging Opportunities

Now that SANEs have shown they can improve collection and documentation of evidence in rape cases, the next logical step would be for the judicial system to make greater use of forensic nurses’ expertise in other types of crime cases, such as domestic violence, elder abuse and murder investigations. But while more of these opportunities may open up at some point down the road, there is currently very little funding in these areas and few nursing positions exist for them.

Of course, stabbings, shootings and murders are meticulously documented, but this is traditionally the work of police crime scene technicians who are not nurses. Many forensic nurses, however, think their profession gives them a competitive advantage for performing these jobs, because of their clinical background. At a death scene, for example, “a nurse would think of opening the medicine cabinet to look for digoxin [or other prescription drugs that could provide clues to the cause of death],” Carroll says.

Another emerging opportunity for forensic nurses, especially SANEs, is starting their own consulting businesses. This option is best suited to experienced, entrepreneurial SANEs who are very self-directed.

After working in three hospital-based SANE programs in the Los Angeles area, Cari Caruso, RN, SANE-A, decided to contract her services directly to law enforcement agencies. She spent an initial investment of $9,000 to purchase equipment so that she could examine rape victims in her own office, away from the hospitals. She believes the hospital setting is usually unnecessary because only 2% of rape victims have serious injuries.

Today her business, Forensic Nurse Professionals, based in Pasadena, Calif., is thriving. Caruso has signed up with three police departments, including the one in Pasadena, to do SANE work for them. Still, she says she earns better money teaching SANE courses at a community college and working as a legal consultant for law firms representing defendants in rape cases.

Education and Certification

Despite the scarcity of job possibilities, forensic nursing education programs are flourishing. The IAFN Web site lists 36 graduate and certificate programs in the specialty, including those offered by Johns Hopkins University School of Nursing, Vanderbilt University School of Nursing, Duquesne University School of Nursing and the University of Washington School of Nursing, to name just a few. There are also online forensic nursing certificate programs, such as those offered by Kaplan University and Fitchburg State College.

Nurses do not learn forensics in their basic education, says Barbara Simmons, PhD, RN, a clinical assistant professor at the University of Illinois at Chicago College of Nursing. She teaches an advanced practice forensic nursing certificate course to students at the graduate level.

Of the 20 students currently taking her course, about a quarter of them are nurses of color. Minority nurses are “a good fit” in forensics, she says, because “they can understand many cultural nuances that others wouldn’t.”

Forensic nursing is “a very promising field, but the job opportunities are not there yet,” Simmons warns. However, she adds, earning a certificate in forensics can provide immediate benefits for experienced nurses who want to enhance their skills in their current jobs. For example, emergency nurses who have learned how to do evidence collection can provide additional value to the EDs that employ them.

Compared with forensic nursing master’s degree or certificate programs, sexual assault nurse examiner training is relatively short, typically a five-day, 40-contact-hour didactic course. Classroom and online SANE training programs are offered throughout the country by a variety of organizations, including nursing schools, community colleges, hospitals, and even state and local law enforcement agencies. After completing the academic course, nurses must also complete a clinical preceptorship in which they gain experience by working on several cases under the supervision of an experienced SANE.

Although SANEs do not have to be board-certified to practice their specialty, earning national certification can definitely boost their marketability. The IAFN, through its Forensic Nursing Certification Board, offers Sexual Assault Nurse Examiner-Adult/Adolescent (SANE-A) and Sexual Assault Nurse Examiner-Pediatric (SANE-P) certification exams twice a year at numerous locations around the country.

Just the Facts, Ma’am

While forensic nurses need to be culturally sensitive, they must also be scrupulously impartial. This became a key issue in the racially charged Duke University lacrosse team case in 2006. A young African American woman, hired to be a stripper at a party hosted by the team, claimed she had been gang-raped by three white members of the team.

The SANE who examined the woman wrote a report which found “diffuse edema of the vaginal walls,” but no abrasions, tearing, bleeding or DNA evidence. However, when questioned by a police detective a week later, the nurse said she found evidence of “blunt force trauma.” This became a key factor in the decision to prosecute for rape.

It turned out the case was weak and eventually the charges against all three students were dropped. A 2007 report by the North Carolina attorney general found that the nurse had based her opinions not on the evidence—or lack thereof—but on the alleged victim’s demeanor and verbal statements.

When hiring forensic nurses for her sexual assault response team, Carroll says she looks for applicants who are compassionate but impartial. She also wants candidates to have at least two years of nursing experience.

Diamond, who had a master’s degree and many years of experience as a nurse when Carroll hired her, believes it is important to create an emotional bond with patients who are victims of violence. The fact that she is an African American nurse helps make it easier for black rape victims to trust and bond with her, she says. “When I come into the room and start to speak to them, you can see they become more comfortable.”

But she also strives for objectivity, which can mean not trying to judge victims or guess their motives. When police detectives are puzzled by prostitutes making rape charges, Diamond tells them: “When you say no to someone, it means no, even if you’re a prostitute.”

While Diamond does not champion the rape victims’ cause, she also does not question their claims. “My job is not to determine whether the victim was assaulted or not,” she says. “I’m there to gather evidence.”