One of the best things about nursing is that there is a rewarding job for everyone. While some professionals prefer to care for patients inside a hospital, others do their work while spending time outdoors, educating people or traveling the globe. No matter your personality or your working style, you can start an exciting career as soon as you get your registered nurse (RN) license. The following unique nursing jobs may require casual jogger scrub pants or a stylish, formal lab coat. Whatever you wear or how you like to contribute to others, one of these fresh and interesting roles is sure to suit you.
1. Forensic Nurse
If you have an investigative mind and like to advocate for your patients, forensic nursing may be right for you. These experienced RNs help to treat patients who are survivors of assault or abuse. They also collect evidence and may be asked to testify in some court cases. While it takes some training to become a forensic nurse, the field is growing. Nurses can also expect to earn between $59,000 and $89,000 per year.
Forensic nursing is always a rewarding challenge. Professionals with critical thinking skills, compassion and an understanding of the criminal justice system are encouraged to apply. While you will develop relationships with survivors, families and law enforcement, you will also make a difference in helping victims through a traumatic experience. Forensic nurses may work in hospitals, community centers and even in medical examiner offices.
Some of the biggest benefits of becoming a professional in the forensics field include a more flexible shift schedule, additional RN skills and a good salary. To become a forensic nurse, you will need at least an RN license and a BSN. Some roles will require you to obtain a certification as a sexual assault nurse examiner (SANE). There is even a SANE-P designation for caring for child and adolescent patients. Even if it is not a requirement at your current job, the SANE certification from the International Association of Forensic Nurses is invaluable to your career.
2. Occupational Nurse
Also referred to as employee health nurses, occupational nurses have a unique role outside of the hospital room. These experienced RNs work in factories, chemical plants and companies of all sizes to recognize and prevent damaging effects from hazardous exposures in the workplace. They may also be hired to treat workers’ illnesses and injuries and partner with other professionals at their company to analyze company medical benefits. Some work for private organizations, while others are hired by the government as contractors or consultants.
As an occupational nurse, you can expect to earn a higher annual salary with the more experience you have. According to PayScale, most nurses can be expected to bring in an average of $71,883 per year, while some of the highest-paid employee health nurses in the country make around $96,000. Some nurses can earn overtime pay, while others are on a fixed salary. Check with the organizations and employers in your area for specifics.
To become a nurse in this interesting field, you will need an RN license and at least two years of nursing experience. Some careers will require you to become certified as an occupational health nurse before you apply, while others will let you earn your certification in the first year on the job. The COHN or COHN-S exams take a few hours to complete. You must also submit an exam fee and recertify your license every five years. If you are committed to the effort it takes to make a difference as an occupational nurse, you will benefit the companies and employees that you work with.
3. Cruise Ship/Resort Nurse
A cruise ship nurse, resort nurse or yacht nurse gets to care for patients, all while working in relaxing or picturesque environments. Some are employed as registered nurses (RNs) in an onboard walk-in clinic, while others are authorized to provide higher-level care in a state-of-the-art medical facility. A resort nurse’s duties vary and may include everything from treating cuts and scrapes to prescribing medication.
While the nurse should have years of experience managing emergencies and triage, some common daily responsibilities include providing first aid and educating guests on how to care for medical conditions. They may also be in charge of education courses and care for onboard employees. Experienced nurses at sea could be hired to provide the company with expert information on how to deal with medical data and healthcare services.
If you would like to travel the world as a cruise ship or resort nurse, you will need an active RN license. Professionals with bachelor’s degrees or master’s degrees are even more attractive applicants for worldwide resorts, cruise lines and luxury yacht companies. Start by browsing jobs in the city or home port of your choice. Be sure to apply for your passport as you begin the interviewing process. You may be headed to a gorgeous international location before you know it.
4. Nurse Informaticist
Nursing informatics is a field of study that combines the fields of information science, communication and computer science. By gathering and analyzing data, nurse informaticists help hospitals and clinic administrators improve the flow of communication and information within their facilities. Other job responsibilities include interpreting and communicating data that will help to increase a clinic’s efficiency, promote excellent patient care and cut unnecessary costs.
To become a nurse informaticist, you will need an RN license, experience with patients and a BSN. Experienced RNs may find a job if they have an additional bachelor’s degree in healthcare or information technology. To be successful in this role, you should be analytical, with robust technical skills and an interest in solving problems. If you are willing to study and earn additional degrees or certifications, nursing informatics is sure to interest you and challenge you throughout your career.
This recent survey of nurse informaticists revealed that over half of them have a postgraduate degree. With all of the experience and specialty skills that nurse informaticists have, it is no surprise that they make a good living. According to the salary professionals at ZipRecruiter, this type of nurse makes an average of over $102,000 per year. While you will love what you do, you will also know you are contributing to the improvement of your hospital and the enhancement of patient care. This is what makes being a nurse informaticist so rewarding.
5. Travel Nurse
Well, travel nursing can’t really be described as “unusual” now, but have you thought about it? Do you thrive on fresh experiences? Going to new places and meeting new people? Does the idea of being an ad hoc nurse while “living out of a suitcase” sound… sort of exciting? If this sounds like you, travel nursing is both a fulfilling and lucrative career. The traveling nurse is in high demand, so you will need to be a well-qualified RN with years of experience caring for patients or have a Bachelor of Science in Nursing (BSN). If this sounds like you, it is time to bolster your resume and explore a new location.
You will need a minimum of 12-18 months of bedside experience in an advanced care clinic or hospital, as well as a willingness to fill staffing shortages in facilities that need you. You should also be comfortable with living in a different location every few months. Since some healthcare specialties are in more demand than others, recruiters may need you faster if you are experienced in high-demand nursing roles such as dialysis or emergency room (ER) care.
While flexibility is key, you will be able to spend your off-time exploring somewhere new. You may also be able to schedule your time in your old hometown or a favorite vacation spot. Another benefit is compensation. Travel nursing salaries are competitive and often include housing credits or travel stipends. Talk to a travel nursing recruiter about which openings are available in your area. It is also possible to search online for travel nursing jobs that are open in larger hospital systems.
Discover an Exciting Nursing Career
Once you get your RN license and gain valuable skills, there will be a variety of job roles available to you. This list of unique jobs will help you to think about which career in the nursing field will suit you. If necessary, you can also begin to obtain the necessary education and certification to land your dream job. The field of nursing is ever-changing, which means you will always have an exciting career, along with a meaningful purpose.
Sexual Assault Nurse Examiner (SANE) programs were created by nursing professionals to address the under-reporting and under-prosecution of adult sexual assaults by providing comprehensive medical care to survivors and expert forensic evidence to the legal community.
To date, there are more than 600 SANE programs in every state in the country, addressing the unique and often complex needs of sexual assault victims, according to the International Association of Forensic Nurses (IAFN). And while SANE programs are held up as the model for best practice in the case of sexual assault victims, only a handful of programs have been evaluated rigorously.
Rebecca Campbell, PhD, professor of community psychology and program evaluation at Michigan State University, says SANE programs caught on and spread quickly throughout the United States and internationally, but they did so with little evaluative data to guide implementation.
Campbell’s research focuses on sexual assault and how the legal, medical, and mental systems respond to the needs of rape survivors. She and her team conducted a series of research studies on how SANE programs impact adult sexual assault prosecution, including the following:
• By analyzing criminal case outcomes five years prior to the launch of a SANE program and during the first seven years of SANE programs, one study found that more sexual assault cases moved through the legal system and raised guilty pleas or trial convictions from 24% to 29% after the implementation of a SANE program.
• An examination of SANE program goals and philosophies and how they influenced patient care practices for sexual assault victims found that programs with a primary goal of case prosecutions lacked comprehensive victim services, including education that impacts a victim’s long-term well-being.
• A national random sampling of 110 SANE programs found consistency in forensic evidence collection, sexually transmitted infection prophylaxis, information on HIV and pregnancy risk, and referrals to community resources.
Several SANE studies have confirmed that the criminal justice system benefits from SANE programs through quality evidence collection, expert testimony, and improved communication with law enforcement. The common thread in these studies is that SANE programs lead to increased arrest rates, charges, convictions, and sentences in sexual assault cases.
These studies also noted the impact of SANE nurses is felt on many levels:
• SANE nurses attend to the medical, forensic, and psychological needs of sexual assault victims;
• SANE nurses have extensive training and experience in forensic evidence collection;
• SANE programs may increase prosecution rates in their communities by collecting forensic evidence that increases the likelihood of case referral by police;
• SANE programs contribute to the recovery gains made by victims.
But a number of studies, including a 2007 study from the University of Kentucky, pointed out that only a small number of programs had a formal reporting system in place that communicates case outcomes, including arrests, prosecutions, and convictions. Knowledge of case outcomes, study authors noted, provides a learning experience by identifying strengths and weaknesses at both the law enforcement and medical community levels.
At the first national SANE Coordinator Symposium in 2009, the group called for additional research in several areas, including developing best practice for SANE programs and compiling SANE models used nationally.
Campbell and her team used a competitive grant from the National Institute of Justice to develop a practitioner toolkit for evaluating the work of SANE programs. The toolkit offers three evaluation designs:
• Pre-SANE/post-SANE evaluation—compares how far cases progress through the criminal justice system before and after the implementation of the SANE program;
• Post-SANE-only evaluation—compares how far cases progress through the system after launching a SANE program;
• Ongoing evaluation—charts prosecution outcomes from this point forward.
The toolkit walks users through a six-step evaluative process and offers ideas for using those findings to improve best practices, as well as reporting, investigation, and prosecution of sexual assault cases. The goal of the toolkit is to assist SANE program staff in evaluating how their program affects the progression of sexual assault cases through the criminal justice system.
The four main sections of the toolkit include a basic overview for conducting a program evaluation, an introduction of how SANE programs create change in communities, a step-by-step explanation of the three types of evaluations a program can use, and an illustration of how to create community action by determining what works and what needs to be improved in a particular SANE program.
The pilot program evaluated six SANE sites—two rural, two mid-sized, and two urban programs. The pilot found that most sexual assaults reported to law enforcement (80% to 89%) were never referred by police to prosecutors, or there were no charges filed by the prosecutor’s office. None of the programs had a statistically significant increase in prosecution rates pre-SANE to post-SANE, but cases processed post-SANE were 80% more likely to achieve convictions or guilty pleas.
Campbell said the evaluative results of the six programs are representative of SANE programs nationwide. “Nationally, this is very typical,” she says. “We’ve seen a lot of studies where most sexual assaults reported with forensic exam do not end up in successful prosecution. That’s what the six programs in this study highlights.
“This continues to be an issue, a problem.”
Campbell says the toolkit did what her team hoped it would do—it got people talking and looking at data to see what’s really happening in their communities, in regard to sexual assault cases. She says the toolkit resulted in communities applying for new grants to form new programs or to revitalize existing sexual assault response teams.
The toolkit and materials are available for public distribution through the National Criminal Justice Reference Service, and other SANE programs are starting to use it, according to Campbell. She says she hopes to secure additional grant funding to create a more interactive, web-based version of the toolkit.
“There is only so much one organization—one discipline—can do in terms of trying to address the problem of under-prosecution of sexual assault,” Campbell says. “Nursing programs focused on patient care and forensic work should continue to focus on good patient health outcomes, because it’s a crapshoot on what happens in the legal system.”
Creating a SANE Program
Diane Daiber, RN, SANE-A, a forensic nursing services coordinator at the Cleveland Clinic in Ohio, was working as a staff RN and case manager in the emergency department setting for 19 years when she realized there was a disconnect between health care and patients touched by violence.
“Many nurses will describe taking care of a patient who has experienced sexual assault and not having the understanding or knowledge about sexual violence to provide optimal care,” says Daiber, adding that most nurses have no training in assessment of sexual assault or in the collection of evidence. “I cannot think of any other diagnosis that is handled that way. I knew there must be a better way of caring for patients who have experienced violence, and took the SANE training.”
She took her initial SANE class in 2001 with two other nurses and was granted the opportunity by her employer to develop a SANE program at Hillcrest Hospital in the Cleveland Clinic system. Today, the SANE program employs four SANE-A (adolescent/adult), two of whom have dual certification in SANE-P (pediatric).
Daiber says once the program was developed, the benefits became clear. The Cleveland Clinic SANE practice evolved to forensic nursing, with SANEs responding to domestic violence and other forms of maltreatment and trauma, as well as sexual assaults.
“As nurses, our priority is the health and welfare of our patient. We provide one-on-one, holistic, patient-centered care,” says Daiber. “Sexual assault has short- and long-term health consequences. We understand the neurobiological effects of trauma.
“Our goal is to decrease the effects of that trauma and begin the healing process from the moment we meet this patient and their family or significant others.”
The Cleveland Clinic’s SANE practice is hospital-based, with most patients seen in the emergency department. But SANEs will travel to other nursing floors for consultation, and forensic teams travel to other hospitals in the Cleveland Clinic system if the patient’s medical condition prohibits her or his transport to a SANE.
Daiber says there is great interest in the field, but the on-call structure of most departments makes it challenging for nurses to maintain a commitment. She explains that expanding the patient population to include domestic and teen dating violence, child and elder maltreatment, liability-related issues, and trauma patients will ensure the most comprehensive use of the clinical skills of the forensic nurse.
“The key is that forensic nurses have trauma-informed care skills to provide care to patients that have experienced all forms of trauma and abuse,” says Daiber.
Preparing Tomorrow’s Forensic Nurses
More and more schools of nursing are adding forensic nursing certificate and degree programs to address the increased interest.
“There is no specific path to getting into the field,” says IAFN President Polly Campbell, RN, BS, BA. “Some nurses seek out the forensic nursing role through their workplace; others discover the role through reading, webinars/educational sessions, or colleagues; others pursue it through higher education.”
Educational opportunities in forensic nursing have increased significantly in the last 10 years, says Jennifer R. Campbell, program coordinator and assistant director of the University of California, Riverside Extension, which offers a Forensic Nursing Certificate through an online degree program that focuses on victim advocacy and investigative sciences.
Mary Kozub, PhD, RN, assistant professor and forensics advisor at Xavier University School of Nursing in Cincinnati, Ohio, says television and media are driving a societal and cultural fascination with forensic sciences. She jokes about writing a letter to the crime drama CSI to suggest adding a forensic nurse to the team to educate the public about their work.
Xavier offers an MSN forensic nursing concentration, in addition to a dual degree option with the Criminal Justice Department. As a nurse at Cincinnati Children’s Hospital Medical Center for six years, Holly Shively saw everything from trauma to gunshot wounds in the operating room. When she was looking for advanced educational opportunities, she found the forensic nursing program at Xavier University and refocused her career goal on working in homicide and, potentially, a coroner’s office.
“I would like to do evidence collection and expert witness testimony in the court system,” says Shively, adding that she worked with the local police homicide unit and the coroner’s office through the Xavier program. “I was able to do anything they were doing at any of the crime scenes, including collecting evidence, taking pictures, interviewing suspects and witnesses. I actually went into the crime lab and learned to do fingerprinting. They taught me their skills.”
Susan M. Schmidt, PhD, BSN, MSN, CNS, COHN-S, CNL, director and professor/epidemiologist in the Xavier University School of Nursing, says she worked with the Criminal Justice Department at the university on the dual degree option because health care workers do not understand crime scenes and the importance of protecting evidence, as well as how to treat a criminal and a victim with respect and dignity.
“A nurse could bring a lot to that crime scene,” says Schmidt. “We’re moving as a nation into a whole new area of the Affordable Care Act. With that, we’re moving into population health and away from taking care of sick people, trying to take care of well people and keep them from getting sick.
“Forensic nursing will help one of the leading causes of ill health in our nation turn around.”
While SANE programs—and the forensic nurses behind them—are making an impact and interest in the field is growing among nursing professionals, finding a job in this relatively new and still evolving field can be a challenge.
In the United States, most forensic nurses practice in hospitals, but they can also work in child advocacy centers, universities, community anti-violence programs, coroners’ and medical examiners’ offices, corrections institutions, and psychiatric hospitals. They also may be called in on mass disasters or to help out during community crisis situations.
According to the US Bureau of Labor Statistics, there were 2.7 million registered nurses in the United States in 2010. Job growth for RNs is expected to grow by 26% through 2020.
The IAFN’s goal is to have a forensic nurse in every hospital and venue where her or his skills are needed. But because it is a relatively new specialty in nursing, there aren’t many jobs out there. Typically, a forensic nurse creates a job that is then recognized in the work setting. But Polly Campbell says there is a growing value and recognition of the skills forensic nurses bring to the table, and she is confident opportunities will grow with time.
“As is often the case, a forensic nurse must often pioneer her first position in a hospital or community since there is so little awareness of the role and what the specialty has to offer,” says Polly Campbell. “Changes in attitudes and beliefs, federal and state laws, and caring health care providers have all contributed to an improved standard of care for victims and perpetrators of violence. Forensic nurses are change agents, leading the way for all practitioners.”
Kimberly Bonvissuto is a freelance writer based in Cleveland, Ohio.
Why is it that black women are more likely to be victims of rape or other forms of sexual assault than white women, yet they are often more reluctant to report the crime? One reason, suggests a new study conducted by researchers at the University of Pennsylvania School of Nursing, is that rape victims with dark skin are less likely to have their physical injuries detected, treated and documented as evidence by the sexual assault nurse examiners (SANEs) or other health care professionals who examine them.
The study, published in the November 2008 issue of The American Journal of Emergency Medicine, was based on a sample of 120 black and white female volunteers who underwent a forensic examination after having consensual sex. More than half (55%) of the women suffered at least one post-sex injury to their external genitalia, such as a tear, abrasion, swelling or redness. However, the examiners were able to identify such injuries 68% of the time in white women but only 43% of the time in black women.
According to the National Crime Victimization Survey, one of the main reasons why women do not report sexual victimization is “lack of (physical) proof” that an incident occurred.
Because this proof is so often undetected in dark-skinned victims, these women end up disadvantaged in both the health care and criminal justice systems, the Penn study concludes.
“The findings from this study have clinical ramifications for those performing forensic sexual assault exams,” emphasizes Penn Nursing professor Marilyn Sommers, PhD, RN, the study’s principal investigator. “Practitioners need to increase their vigilance when examining individuals with dark skin to ensure all injuries are identified, treated and documented.”
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.
Where to Gather More Evidence about Forensic Nursing International Association of Forensic Nurses
www.forensicnurse.org American Forensic Nurses
www.amrn.com The Forensic Nurse
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].”
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.”
Although she didn’t know it then, a personal trauma in 1994 changed the course of Karen Coleman’s professional career. Coleman, an emergency room RN at the time, was raped by her then-husband, who had been barred from her home by an order of protection. “When I went to the hospital after the assault, I had a physician perform the evidence collection kit and he didn’t have any idea what he was doing. He had no clue,” she recalls. “He wasn’t sure about the process. He wasn’t familiar with collecting evidence. I had to show him how to do my own rape kit.”
Today, Coleman, who is African American, is the Sexual Assault Nurse Examiner (SANE) coordinator for Victims Assistant Services in Elmsford, N.Y. It was by chance, Coleman says, that she learned about the field of forensic nursing. Three years after surviving her assault, she came across an article about nurses being specially trained to do forensic examinations of rape victims, and she learned that a SANE program was being considered in her county.
Coleman attended several meetings about the new program, which she then was asked to coordinate. “I thought it was ideal, because I felt nurses could do these exams,” she says. “Having been a victim myself and receiving a less than optimal exam, I made it my mission in life to make sure no one else would ever have to go through that.”
Coleman is now responsible for the recruitment, hiring and retention of SANE nurses for her program, which operates in 11 of the 14 hospitals in Westchester County. Her position is full time but the nurses hired into the program work on call.
“Forensic nurses ensure that evidence is collected appropriately and can be used in a court of law,” Coleman notes. “It’s important that crime victims know about us. All you hear about are the horror stories of waiting in the hospital and having physicians like the one I had who don’t know what they’re doing, who are less than compassionate and who tend to judge the victim.”
I’ll See You in Court
Forensic nursing is a relatively new field that combines the health care profession with the judicial system. In 1995 the American Nurses Association officially recognized it as a specialty of nursing. In April 2002, the International Association of Forensic Nurses (IAFN) held the first international certification exam. The 71 nurses who passed the exam earned the international designation SANE-A (Sexual Assault Nurse Examiner-Adult and Adolescent).
Coleman plans to take the exam when it is offered again in October, following IAFN’s Tenth Annual Scientific Assembly in Minneapolis. In addition, five states–Kentucky, Maryland, New Jersey, South Carolina and Texas–have their own certification exams for sexual assault nurse examiners. Texas and Maryland offer separate certifications for adult and pediatric cases. While certification is not mandatory in order to work as a forensic nurse, Coleman believes it gives added credibility. This is important because one of the key parts of the forensic nurse’s role, in addition to performing the comprehensive exam in the hospital, is to give testimony in court.
“The legal system is beginning to recognize the expertise of forensic nurse examiners and we are beginning to be qualified as experts,” Coleman explains. “If you can say when you are giving your credentials that you have taken a state-approved training, that you have taken a state-approved or nationally approved certification exam and you passed it, then at least you are able to say that you have met the standards for this profession of nurses and that you can be considered an expert with more knowledge than the average person in the field of sexual assault.”
When testifying in court, forensic nurses can be qualified as either an expert witness, who is allowed to give his or her opinion, or a fact witness (who, as the name implies, can only state the facts). This ruling is made by the judge.
“The prosecutor will present you, knowing you will discuss your background, the number of cases you have performed, what you do and what your job is,” says Jean Epps, RN, BSN, coordinator of the Sexual Assault Nurse Examiner Program at Howard University Hospital in Washington, D.C. Epps, who is African American, is a CFNE (a forensic nurse examiner certified by the state of Maryland).
When testifying at trials, forensic nurses are there to present information in an objective way. “Even though the prosecution may call you, you are not there to speak for or against the victim or the defendant. You are just there to present the facts of the examination,” states Epps, who also plans to take the IAFN SANE–A examination in October.
What Minority SANEs Bring to the Table
Because forensic nursing is such a new and rapidly growing specialty, it offers tremendous opportunities for both recent graduates and experienced RNs looking for a career change. Moreover, there is also a strong need for better minority representation in the field.
According to Coleman, “there are just not that many of us [nurses of color] working in this area. However, approximately 50% of the victims we treat are African American. You can probably add another 20% who are Latina.”
If minority women knew that there were more forensic examiners who were also people of color, they would be even more likely to seek medical assistance, Coleman believes. “During their experience of being a victim, they are going to be coming into contact with law enforcement people who, chances are, will not look like them,” she says. “I just think it adds a level of comfort. I am not saying, however, that because I am African American I am any better able to take care of a rape victim. I just think it is helpful to see someone that kind of looks like you among all the people you are gong to have to deal with.”
This victims’ advocacy role is important to Coleman, who has become a vocal supporter of her chosen field. She often gives talks about forensic nursing and is interviewed by the media. She appeared in the Lifetime television documentary “Fear No More,” which told the stories of five women who were victims of violence. “Rape is a conspiracy of silence, and those who are able to talk about it should do so,” she insists. “There is no shame in being a victim.”
Tools, Techniques and Teams
Certifiably SANE: How to Get Certified as a Sexual Assault Nurse ExaminerThe International Association of Forensic Nurses (IAFN) celebrated its tenth anniversary this summer. With more than 2,400 members in the U.S. and abroad, the association encompasses a diverse body of nursing professionals who specialize in the forensic aspects of health care–literally, nursing as it pertains to the law. The Sexual Assault Nurse Examiner-Adult and Adolescent (SANE-A) designation offered by IAFN is the only national certification of its kind. To earn the designation, nurses must pass a certification exam consisting of 170 multiple choice items written within the framework of the nursing process. The exam takes approximately four hours to complete. To be eligible to sit for the examination, nurses must:
hold a current, unrestricted license as a registered nurse (RN) and have a minimum of two years full-time equivalent practice as an RN;
have completed an adult/adolescent SANE education program that includes either a minimum of 40 contact hours of instruction or three semester hours of classroom instruction in an accredited school of nursing; and
have had clinical supervision until able to demonstrate competency in SANE practice.
The SANE-A designation is one of the newest specialty certifications in nursing. IAFN held the exam for the first time in April 2002, at 41 sites around the country. It will be offered again in October, and more offerings are planned for multiple sites and dates in the future. Although the exam is initially being offered only in the United States, IAFN is working to make it available in other countries as well. Certification as a SANE-A is valid for a period of three years and re-certification will be available by examination or by continuing education. The current cost of sitting for the initial certification exam is $225 for IAFN members and $350 for non-members. During the certification program’s first three years (2002-2004), nurses who are currently practicing as SANEs but do not meet the established criteria can ask the IAFN certification board for special consideration to take the exam. For information about dates and locations of SANE-A exams to be held in 2003, or to learn more about forensic nursing in general, visit the IAFN Web site at http://www.forensicnurse.org/ or contact Kimberly Marrero, IAFN executive secretary, at (856) 256-2425, email [email protected].
What kind of background, skills and experience are necessary for a career in forensic nursing? To become a potential SANE-A, a nurse must be at least an RN and must complete specialized training to meet the standards IAFN outlines for forensic nurses. Epps says the national standards include 40 hours of didactics and 40 hours of clinical work. Nurses are trained in handling and collecting evidence, such as hairs, fibers and swabs of fluids collected for DNA testing. Additional forensic training is required to work with children.
There are also a number of tools forensic nurses must master in order to help document a victim’s injuries for court cases. This equipment can range from easy-to-use items, like a digital camera for photographing visible injuries, to such complex devices as an Omnichrome–which can detect bruising beneath the skin’s surface–and a colposcope (a large microscope with a camera attached that enables examiners to take photographs of genital injuries in sexual assault cases). Operating this high-tech equipment and making sure all the documentation is done correctly is one of the challenges of the job, according to Sun Borden, RN, BSN, a SANE preceptor in Monmouth County, N.J.
The Discovery Channel show “New Detectives” sparked Borden’s interest in forensic science, she says. In March, she took the first step toward becoming a forensic examiner by completing a 42-hour course on forensic nursing at Rutgers University. Before she can begin working independently, she must work three cases as a preceptor. She has already observed one case and has worked another case in conjunction with a SANE nurse.
Borden, who is of Korean descent, reports that the experience has been a good one. “I like how the SANE nurses work with [assault] survivors,” she says. “It is a very positive experience.”
Borden also takes satisfaction in knowing that nurses are playing such an important role in forensic science. “I think it is a step ahead for nurses. It used to be that the physicians did the exams and the nurses’ role was to assist them,” she points out. Historically, she adds, the victim could be in the emergency room for hours waiting to be seen, which can prolong or add to a survivor’s trauma. “Now, with the SANE nurses, it is different. When the SANE team is activated, we go to the site right away and we handle the case and the interview as soon as possible, so there is no waiting time.”
The examination and interview take place in a private area, away from the emergency room. “We try to give the victims as much privacy as possible,” Borden explains. “Assault survivors do not want to sit in an ER waiting room, because [they feel] someone they know might come in and recognize them.”
Borden also enjoys the experience of working on a team, which can typically include law enforcement officers and the victim’s advocate as well as the nurse. “We all sit down as a group and we start doing the interview,” she says. “You have everyone looking at a different aspect of it, but we are all there for one person–the survivor. Any questions the survivor has we can answer from three different perspectives. We get the whole story, so we can do the examination appropriately.”
The entire process can take a significant amount of time, Borden continues. “From the beginning of the exam to the end takes about three or four hours. Traditionally, the doctors in the emergency room were so busy with all the other cases they had to look at that they didn’t have much time to spend with the victim. But with the nurses, we are there the whole time with them.”
The SANE program Epps directs at Howard University Hospital opened in October 2000. “Prior to that,” she says, “the sexual assault exams were performed by personnel who were in the ER, usually physicians.” Like Borden, Epps sees the progression to a nurse-focused program as very positive: “You have nurses who are specifically trained in how to collect forensic evidence, to listen to the victims and to hear was it is that maybe they’re not saying.”
Helping More Than Just Rape Victims
While much of the focus of forensic nursing is on the sub-specialty of sexual assault, forensic nurses are not limited to working on these types of cases. Many forensic nurses work with victims of other types of interpersonal abuse, including domestic violence, child and elder abuse/neglect and physiological/psychological abuse. Forensic nurses can examine victims of near-fatal or fatal traumas, such as shootings or stabbings. Some even work as death investigators.
Lucretia Braxton, RN, sees a wide range of patients in her role as a forensic nurse examiner in the emergency room at the Medical College of Virginia at Virginia Commonwealth University. Braxton, who is African American, trained at the Virginia State Police Academy in Fredericksburg, first as a SANE and then as a Forensic Nurse Examiner (FNE). She earned state certificates in both areas at the academy, but Virginia doesn’t certify nurses in these areas.
The emergency department where Braxton works is the leading trauma center for the state of Virginia. In a typical month, Braxton estimates that the department’s forensic nurses handle 20 sexual assault victims and ten homicide victims. The murder victims eventually go to the medical examiner’s office, but while the ER team is working to try to save the person’s life, the forensic nurse collects evidence. The nurse may even follow the victim up the operating room to complete the evidence collection. The center also sees quite a few domestic violence victims. “These victims don’t always report it, so it is hard to quantify how many there are,” she adds.
Objectivity is a key part of being a forensic nurse, Braxton believes. “You have to know when to draw the line between being an empathetic nurse and being there just to collect your evidence,” she explains.
In cases of stabbings or shootings, forensic nurses collect such things as bullets and any debris that is on the body, such as leaves that may have clung to the body from the crime scene. They are also in charge of removing the bloody clothes the victim was wearing and putting them in a special wrapping. These nurses also photograph and measure wounds. If the victim dies, the forensic nurse examiner will often collaborate with the medical examiner on the case, answering any questions he or she may have regarding what the nurse saw.
Braxton says a background in emergency nursing is helpful for nurses who want to move into the forensic field. “It gives you the experience you need in how to work with trauma victims,” she explains. “When the victims are brought into the ER, you see the very initial trauma right there. If you are trained and experienced in emergency nursing, you know how to react to what you are seeing, what you need to do, what the doctor needs, what he is going to call for.” As a forensic nurse, she adds, you are also trained to know what things not to touch, so that evidence is not accidentally destroyed.
A Ground-Floor Opportunity
Not only is forensic nursing an exciting and rewarding career, there is also a growing demand for nurses with these specialized skills. “Forensic nursing is expanding, more so than it used to be,” Braxton reports. “Forensic nurses are being incorporated into the emergency room setting now. In the past, hospitals felt that if evidence needed to be collected, any nurse could do that. Today we are finding out that the more expertise a nurse has in knowing exactly what should be collected, the better the evidence turned over to the detectives will be. And that can help lead to a better outcome in catching the perpetrator.”
Nursing schools are starting to recognize this trend as well. In September, Johns Hopkins University School of Nursing in Baltimore began offering an MSN–Clinical Nurse Specialist, Forensic Nursing Focus program. The school tapped Daniel Sheridan, RN, PhD, a forensic clinical nurse specialist at Johns Hopkins Hospital Department of Emergency Medicine, to create the new program.
“I convinced them that there was a need for it,” says Sheridan. “I have been a forensic nurse for many years, and Hopkins School of Nursing realized there is a growing need and a growing interest in this whole area.” Since the field is in its infancy, he adds, forensic nurses often have the advantage of helping to create their own positions, and even whole forensic nursing departments.
Prior to joining Johns Hopkins, Sheridan worked as a full-time employee for the state of Oregon, investigating abuse of institutionalized people who were mentally and cognitively impaired. He was the only member of the team who was a nurse. “This is a brand new area and people are still carving out new and innovative roles for the forensic nurse,” he emphasizes. “You have to really go out and be able to market yourself, to explain that you have specialized experience and training that are going to help an institution. This field really is at the ground level.”
Karen Coleman agrees, adding that the satisfaction her job brings her is amazing. People often ask her how she can work in such a difficult and traumatic field. “But once you get into this work, you know that everything you do is going to help a victimized person, and hopefully lead to a conviction in a court case,” she says.
Coleman adds, however, that helping to convict criminals is not her primary goal. “My focus is to help that victim get through that medical experience,” she maintains. “I hope that as we get better at taking care of victims, collecting evidence, providing support and linking them up with services, more victims will come forward and cooperate with law enforcement and there will be better outcomes in court.”
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