SANE Coordinator Karen Coleman, RN, at her deskSANE Coordinator Karen Coleman, RN, at her desk

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.”

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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).

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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

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 (top row, far right), and her forensic nursing teamLucretia Braxton, RN (top row, far right), and her forensic nursing team

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.

SANE Preceptor Sun Borden, RN, BSNSANE Preceptor Sun Borden, RN, BSN

“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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