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Multidisciplinary and Collaborative Approaches:

Multidisciplinary and Collaborative Approaches:. Bringing it All Together Working as a Team Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor, Johns Hopkins University School of Nursing Forensic Clinical Nurse Specialist. 4N6 RN. Forensic Nurse

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Multidisciplinary and Collaborative Approaches:

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  1. Multidisciplinary and Collaborative Approaches: Bringing it All Together Working as a Team Daniel J. Sheridan, PhD, RN, FNE-A, SANE-A, FAAN Associate Professor, Johns Hopkins University School of Nursing Forensic Clinical Nurse Specialist

  2. 4N6 RN • Forensic Nurse • Forensic = Pertaining to the Law • International Association of Forensic Nursing • www.iafn.org • 1-410-626-7805

  3. UNDERSTANDING THE PROFESSION • Nurse’s Aide – continuing education course and/or on the job training • MA’s Medical assistants (report to MDs) • One to two months of training (HS-GED) • CNA’s Certified nursing assistants (report to LPN/LVN/RN) • Licensed by Board of Nursing • One or two months training

  4. UNDERSTANDING THE PROFESSIONVocational-Practical Nurse • LVN’s Licensed vocational nurse • Licensed by the Board of Nursing • One year professional school • Must work under supervision of a RN or medical provider • LPN’s Licensed practical nurse • One-year professional school • Licensed by the Board of Nursing • Must work under supervision of a RN or medical provider

  5. Staff Nurse • Experience varies • Few clinics or physician offices employ Registered Nurses – too expensive

  6. UNDERSTANDING THE PROFESSION – Registered Nurse • RN Registered nurse • Diploma • Two-year associates degree (AD) • Bachelors degree (BSN) traditional/accelerated • Generic entry Master’s degree in Nursing • must have a previous degree + pre-reqs (Clinical Nurse Leader) (knowledge of a new graduate) • All must take NCLEX exam – • Licensed by the Board of Nursing

  7. UNDERSTANDING THE PROFESSIONAdvanced Practice Registered Nurses • NPs Nurse practitioner (independent v MD) • Prescriptive privileges • CNS Clinical nurse specialist (hospital) • CRNA Certified registered nurse anesthetist • Master’s prepared clinicians • (two years post bachelors) but by 2015 must have clinical doctoral preparation • DNP Doctorate of Nursing Practice • (practice three years post bachelors) • PhD Doctorate of Philosophy • (research – average 5 years post master’s)

  8. Clinical Nurse Specialist versus Nurse Practitioner • NP can prescribe medications. CNS cannot (CNS) • NP can diagnose and treat illness. • CNS serves as an expert resource to everybody

  9. CNS Role • Expert in clinical area(s) • Educator • Consultant • Patient, family, staff, administrators, APS, surveyors, ombudsman, police

  10. Legal Nurse Consultant • LNC = Legal nurse consultant (certified versus trained • Can be any level of registered nurse • May or may not have any real expertise • Clinical competencies • Plus education • Plus experiences

  11. UNDERSTANDING THE PROFESSIONPhysician’s Assistant • PA’s Physician’s Assistant • Most Master’s prepared clinicians • Military trained • Supervised by a physician

  12. UNDERSTANDING THE PROFESSION Physicians • Bachelor’s degree • Medical School – four years • Residency – minimum 3 years • Fellowship – minimum 1 year

  13. What is Nursing?Be able to discuss the Nursing Process • A - assessment • D – nursing diagnosis • P - plan • I - intervention • E - evaluation

  14. Forensic Nursing It’s the collision between the law and medicine • It’s a lot more than Quincy or Diagnosis Murder! • It’s not as dramatic as CSI • Coroner versus Medical Examiner ???

  15. What is Forensic Nursing • Forensic nursing is the application of the nursing process to public or legal proceedings: the application of the forensic aspects of health care to the scientific investigation of trauma. • (IAFN Website)

  16. Clinical Forensic Nursing • The application of clinical nursing practice to trauma survivors or to those whose death is pronounced in the clinical environs, involving the identification of unrecognized, unidentified injuries and the proper processing of forensic evidence.(IAFN Website)

  17. Common Patient/Client Groups • Treatment of patients (victims) (survivors) of • abuse • violence • criminal activity • Vehicle crashes

  18. History of Forensic Nursing • 1975 - John C. Butt, MD Alberta Canada • Hired and trained RNs as medical examiner investigators • Know medical terminology/pharmacology • Empathy/public relations • Over 60% of death investigator cases involve natural death • Fostered better police/health care roles • Based on England’s Police Surgeon Concept

  19. Early Nursing Leaders • Mid-1970’s Ann Burgess, DNSc, RN • Rape Trauma Syndrome • Mid - 1970s Rape Victim Advocates - RVA • Forensic Sexual Assault Exams - • nurses training MDs, retrain, retrain…. • Late 1970’s - 1980’s Domestic violence • Barbara Parker, PhD, RN - 1977 • Ginnie Drake, PhD, RN - 1982 • Jackie Campell, PhD, RN - 1979

  20. Early Nursing Leaders • 1981 - Domestic Violence Homicides – Ohio, New York • Jackie Campbell, PhD, RN • 1986 -Family Violence Program, RPSLMC, Chicago • Daniel J. Sheridan, MS, RN • 1987 - Death Investigations • Virginia Lynch, MS, RN, Georgia

  21. International Association of Forensic Nurses • 1992 - 74 nurses, mostly SANE formed IAFN • 1993 - First Annual Scientific Assembly in Sacramento, CA 160 members • (My Member # 251) • 1995 - Formally recognized by the ANA as a specialty of nursing • 2009 - Over 3,000 members with next conference in Atlanta

  22. Forensic Nurse Provides • Consultation services to: • Nursing, medical, law-related agencies • Expert court testimony: • regarding interpersonal violence, trauma, death investigations, unexplained injuries • Adequacy of health services • “Translation” or background information on routine medical care

  23. Can you read this? Need a translator?? • 85 y/o w/female w/h/o HTN, IDDM, CAD, PVD, MI x 2, multiple TIAs • s/p TAH-BSO, CABG x 2, R-AKA • MMSE 15/30 • Presents with +LOC, 0 x 1

  24. Or do you want a nurse to translate to this…….. • 85 year old white female with a history of hypertension (high blood pressure), insulin dependent diabetes mellitus, coronary artery disease, peripheral vascular disease, and multiple transient ischemic attacks • Status post (History of) total abdominal hysterectomy and bilateral salpingo-oophorectomy (removal of her uterus, tubes and ovaries), coronary artery bypass grafts x 2 and a right above the knee amputation • Mini- Mental status test indicate possible dementia 15/30 • Presents with + loss of consciousness, is oriented only to her name

  25. Types of Forensic Nurses • SANE/SAFE/FNE/SART • Interpersonal Violence • CA/CN • DV/FV • EA & DD Abuse Investigator • Stranger to Stranger • Death Investigators -Deputy Medical Examiners - Coroners • Correctional Nursing - Prisons/Jails • Psychiatric Forensic Nursing - Criminally Insane, Malingerers in Workman’s Comp.

  26. Today’s USA Today p. 3A

  27. Types of Forensic Nurses • Crime Labs • Criminalists - Scene Investigators • Expert Witnesses • RN to Police Officer • RN to FBI Academy • RN to JD to Assistant Attorney General Medicaid Fraud Prosecution Unit in DC

  28. Role Differences – Forensic RN v LNC • Topic Forensic RN LNC • Wound ID + - ? • Bed sores + + • Standards of care + + • Translation + + • Neglect of care + + • Capacity - -

  29. Role Differences - 2 • Topic Forensic RN LNC • Photo document + - ? • Evidence collection + - ? • Family violence + - • DV Grown older + - • Sex Assault issues + - • SANE + -

  30. Working with medical personnel • So how can we work together? • Physician’s who “get it” are rare. • If you have one, nurture that role • Develop a cadre of nurse experts

  31. Working with medical personnel • What kind of information does the APS case worker need? • Who can give that information • How can this information be obtained

  32. Information needed • DO NOT ASK FOR A “CAPACITY ASSESSMENT” OF YOUR CLIENT • In most cases you will not get it

  33. Information needed • What are the medical issues • Ex. high blood pressure, diabetes • Are they controlled? • If not, why not? • Ex. unable to afford medications, unknown • Is the client compliant with the medical plan • If not: why not ? • Ex. memory problems, no transportation, unknown

  34. Complete copy of records from the most recent hospitalization(s) including: • EMS-EMT-Paramedic transport forms • ED physician and nurses notes hand-written and typed • Any photographs taken by hospital staff/wound specialists/surgeons • Admission History and Physical • All progress notes including RN & social work notes

  35. All dictated consultant notes • All radiology reports & summaries • Actual x-rays/scans may be needed later • All laboratory results • Medication Administration Records • Discharge summaries

  36. Information needed • Does the client have to take medication for his medical issues? • If yes, which ones ? • Ex. lisinopril for high blood pressure • If not, why not? • Ex. diabetes controlled with diet • Is the client able to obtain the medication(s) • If not, why not? • Ex. unable to afford medication, unknown

  37. Information needed • Does the client keep clinic appointments • If not, why not? • Ex. forgetful, no transportation, unknown • What is the date of the last visit? • Ex. 10 month ago • Does the clinician have any concerns? • If yes, explain: • Ex. noticed disheveled appearance at the last visit

  38. Who can give the information • Can be obtained from: • Secretary • Office assistant • Nurse • Clinician (MD, NP, PA) • HIPAA: • Health Insurance Portability and Accountability Act of 1996

  39. Get a signed release of information from: • The client/patient/victim • Medical power of attorney • Guardian • Court order – subpoena

  40. How to get the information • Call the office and ask for: • the fax number • name of the nurse/MA/CNA • Fax your request • Ask for permission to talk with the nurse

  41. How to get the information • Leave a number where you can be reached at all times (you might only get 1 phone call) • Cell phone number • Best time to call: • Early morning

  42. “Court” is Part of the Role • Levels of Proof • Preponderance • > 50.1% • Clear and Convincing • > 75.1% • Beyond Reasonable Doubt • > 99%

  43. Discuss my neck tie…….

  44. Documentation Pearls If you did not chart it……… You did not do it!!!!! Avoid personal opinion Avoid charting arguments with co-workers Avoid derogatory remarks about client, family, or other providers Write legibly, legibly, legibly, legibly

  45. Forensic Documentation As verbatim as possible Do not sanitize Do not “medicalize” Avoid pejorative documentation Document excited utterances Document medical exceptions to hearsay

  46. Avoid pejorative documentation Stop charting “refused” Stop charting “uncooperative” Stop charting “non-compliant” Stop charting “alleged” and “allegedly” Stop charting your feelings Stop charting your anger

  47. An Oregon case… • The importance of documentation!!

  48. Decubitus Ulcers Are they a sign of neglect?

  49. Decubitus Ulcer • Bedsores • Decubiti (plural) • Decubitus ulcer • Pressure sore – ulceration of tissue deprived of adequate blood supply by prolonged pressure.

  50. Bedsores, Decubitus ulcers, Decubiti, Pressure ulcers, & Pressure sores • Caused by ischemia due to pressure, shearing, and friction, from contact between the patient and an underlying surface.

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