Forensic Nursing Chronicles

Perhaps it’s considered a dirty little secret in many families, but the fact that according to Curry, Perrin and Wall’s 1998 article “Effects of abuse on maternal complications and birth weight in adult and adolescent women.” in Obstetrics and Gynecology 92, 530-534, an estimated 1 in 6 pregnant women experience abuse from an intimate partner needs to be considered and assessed for during prenatal visits.
In assessing a pregnant woman, there are certain behaviors that should be considered as risk factors for abuse, such as those identified in the study by Berenson, AB, Stiglich NJ, Wilkinson, GS and Anderseon GD published in the American Journal of Obstetrics and Gynecology, 1991, June; 164, pp 1491-6 titled, “Drug abuse and other risk factors for physical abuse in pregnancy among white, non-Hispanic, black and Hispanic women”. They determined that abused women were “more likely to be divorced, admit to illicit drug use, use alcohol and smoke compared to nonabused females in their study.” In the study 501 pregnant women attending a public clinic were interviewed, 20% of the women reported physical abuse. Another study cited in the text by Huth-Bocks, Levendosky and Bogat in 2002 titled, “The effects of domestic violence during pregnancy on maternal and infant health” in Violence and Victims, 17, pp 169-183 found that “abused women were more likely to have public insurance, be single, have less than a high school education, and to have medical or obstetrical complications.” Another “risk factor” identified for the pregnant woman “frequent alcohol abuse by the male partner has been found to be associated with the likelihood of violence in the home” (Wilt,S & Olson,S, “Prevalence of Domestic Violence in the US”, JAMWA, Vol. 51, No. 3; pp 77-82, May/July 1996.) In JAMI, Vol. 267, No. 23, June 17, 1992, McFarlane,J., Parker,B., Soeker,K. and Bullock,L.’s “Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care” the conclusion was that “a simple clinical assessment screen completed by the health care provider in a private setting and with the male partner absent is effective in identifying abused women.”
Once the potentially abused pregnant woman is identified, there are certain interventions that have been proven to be most effective in helping to reduce the incidence of continued abuse to the woman. McFariane,J., Soeker,K. and Wiist,W.’s study published in Public Health Nursing Vol. 17, Issue 6, pp. 443 in November / December 2000 titled, “An Evaluation of Interventions to Decrease Intimate Partner Violence to Pregnant Women” found that “violence scores at 2 months post-delivery were significantly lower for Outreach groups compared to counseling only, but not significantly lower than the Brief intervention group.” Another study that McFarlane,J., Parker,B. Soeker,K., Silva,C., and Reed,S. did was published in Res Nurs Health 22, pp 59-66 in 1999 titled, “Testing an intervention to prevent further abuse to pregnant women” 132 pregnant women received 3 counseling sessions designed to decrease further abuse. A comparison group of 67 abused women were given a wallet-sized card listing community resources for abuse. Using repeated MANCOVA with entry scores as a covariate they were followed at 6 months and 12 months post delivery. The study found that “significantly less violence was reported by the women in the intervention group than the women in the comparison group.”
As startling as the statistic is, “1 in 6 women are abused during pregnancy”, it is incumbent upon those medical professionals providing care for pregnant women to have an effective screening tool to identify those women at risk for abuse, to do a comprehensive assessment of the woman without her partner present, and to have an appropriate referral base for intervention that will help to reduce the incidence of abuse in the woman’s life.

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This post is about the O.J. Simpson book called “If I Did It.” Some are considering this book, to be a blatant confession. Apparently in this book describes if he did kill Nicole Simpson and Ronald Goldman how he would have done it. This book does not come out to stores for a few more weeks, however it is already causing uproar with friends, family, and the media. O.J. Simpson is to have am interviews with Fox Television on November 27 and November 29, a two part interview. Regan books is publishing this book, in comments as to they feel this is his actual confession. Still victims’ family members and friends are still mad about the fact that this would even be published. Honestly why would anyone write a book, after they have been accused of murder, write a book and tell society this is how I would of done it. Now I would think that a lot of the book would focus on factors that were of course identified in the courtroom, when he went to trial. O.J. Simpson continue to owe Ron Goldman’s family over 33.5 million dollars from the civil judgment. According to Yale Galanter, O.J. Simpson’s attorney this is his comment: He said there is “only one chapter that deals with their deaths and that chapter, in my understanding, has a disclaimer that it’s complete fiction.” Which was published in today’s news. Announcing this book was a shock to most of society, who has followed the case from 1995, or who are friends, family, or ongoing watchers of the case. The announcement of this book has generated tons of publicity for the lawyer, media, author, just about anyone involved. Some people believe its just his way of confession, and maybe this all will come to an end, and maybe get some relief to those who need it.

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forensic nursing chronicles
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Responding to the September 9 article “The importance of forensic nursing”

Patient interviews can be healing in and of themselves as well as providing legal documentation for the client/victim. Based on the placebo effect, findings show that a warm respectful interview with health care personnel can begin the healing process, allowing the client to release stress and negative emotions. This is especially important for the client who has been subjected to violence. A healing therapeutic relationship triggers the body’s natural healing mechanisms for both emotional and physical healing. (For more on the placebo effect see http://www.fda.gov/fdac/features/2000/100_heal.html or http://www.bcx.net/hypnosis/placebo.htm)

The therapeutic approach to a patient that optimizes the confidence of the patient and reassures her that she will be helped and respected is paramount. As a hypnotherapist and red cross first responder I am trained to begin interaction with a patient (conscious or unconscious) by gently laying a hand on the patient’s (uninjured) hand or forearm and saying clearly and gently, “My name is ………., I’m trained in …… and I’m going to help you.” This simple statement can relieve the patient of fear and anxiety and begins the process of building trust and rapport. Patients who are recovering from surgery and still under the effects of anesthesia can benefit greatly from hearing, “ Every thing went just fine. You’ll recover very quickly and easily.” Since the power of suggestion is heightened both in a state of anxiety or semi-consciousness it is very important that the patient hear positive suggestions for health and recovery.

Respect and support can also be communicated through touch and eye contact. Throughout the interview gazing warmly at the patient, giving her proper attention adds the healing relationship. One should avoid glancing at clocks or allowing the eyes to dart away while the patient is talking. If the client becomes emotional gently squeezing her hand, patting a forearm or shoulder or even offering a box of tissue encourages release and not only fosters a trusting relationship but often reduces the patient’s need for extended catharsis.

While performing the physical exam one can avoid triggering the patient emotionally by preparing him for your touch. A simple phrase like, “This is my touch” or “I’m going to need to touch your face now.” is effective. Introducing the touch to injured or sensitive areas by first touching a non-sensitive area (i.e. touching the thigh, saying, “Here’s my touch” before contact with the perineum) is also important. Keeping touch firm, gentle, and brief helps communicate respect and confidence as well.

One should avoid correcting the patient even if the information she shares is known or suspected to be false. A patient in this vulnerable state may shut down or become defensive if she feels she is being contradicted. The same holds true for using statements intended to encourage when they contradict the patient’s present state or words. Such statements as, “You’re okay!’”, “Don’t cry.”, or “You’re just upset.” can feel like abandonment or even attack to a victim in the midst of catharsis. Allowing the patient to feel and express deep feelings, however briefly is part of the healing process. More effective and supportive statements are, “Are you okay?”, “Go ahead and let it out.”, or “I’m sure you’re upset.” as such statements do not imply judgment or contradiction.

The healing power of patient-healthcare professional interaction is often underestimated and frequently more harm than good is done by ignoring such simple attention to communication details. Even if you are the only professional the victim encounters who gives her confidence, respect and warmth those few moments of interaction can make the difference between quick recovery and a long painful ordeal. Regardless of the legal outcome the healing triggered by such a positive therapeutic relationship will make a great deal of difference in each life you touch.

Responding to the September 9 article “The importance of forensic nursing”

Patient interviews can be healing in and of themselves as well as providing legal documentation for the client/victim. Based on the placebo effect, findings show that a warm respectful interview with health care personnel can begin the healing process, allowing the client to release stress and negative emotions. This is especially important for the client who has been subjected to violence. A healing therapeutic relationship triggers the body’s natural healing mechanisms for both emotional and physical healing. (For more on the placebo effect see http://www.fda.gov/fdac/features/2000/100_heal.html or http://www.bcx.net/hypnosis/placebo.htm)

The therapeutic approach to a patient that optimizes the confidence of the patient and reassures her that she will be helped and respected is paramount. As a hypnotherapist and red cross first responder I am trained to begin interaction with a patient (conscious or unconscious) by gently laying a hand on the patient’s (uninjured) hand or forearm and saying clearly and gently, “My name is ………., I’m trained in …… and I’m going to help you.” This simple statement can relieve the patient of fear and anxiety and begins the process of building trust and rapport. Patients who are recovering from surgery and still under the effects of anesthesia can benefit greatly from hearing, “ Every thing went just fine. You’ll recover very quickly and easily.” Since the power of suggestion is heightened both in a state of anxiety or semi-consciousness it is very important that the patient hear positive suggestions for health and recovery.

Respect and support can also be communicated through touch and eye contact. Throughout the interview gazing warmly at the patient, giving her proper attention adds the healing relationship. One should avoid glancing at clocks or allowing the eyes to dart away while the patient is talking. If the client becomes emotional gently squeezing her hand, patting a forearm or shoulder or even offering a box of tissue encourages release and not only fosters a trusting relationship but often reduces the patient’s need for extended catharsis.

While performing the physical exam one can avoid triggering the patient emotionally by preparing him for your touch. A simple phrase like, “This is my touch” or “I’m going to need to touch your face now.” is effective. Introducing the touch to injured or sensitive areas by first touching a non-sensitive area (i.e. touching the thigh, saying, “Here’s my touch” before contact with the perineum) is also important. Keeping touch firm, gentle, and brief helps communicate respect and confidence as well.

One should avoid correcting the patient even if the information she shares is known or suspected to be false. A patient in this vulnerable state may shut down or become defensive if she feels she is being contradicted. The same holds true for using statements intended to encourage when they contradict the patient’s present state or words. Such statements as, “You’re okay!’”, “Don’t cry.”, or “You’re just upset.” can feel like abandonment or even attack to a victim in the midst of catharsis. Allowing the patient to feel and express deep feelings, however briefly is part of the healing process. More effective and supportive statements are, “Are you okay?”, “Go ahead and let it out.”, or “I’m sure you’re upset.” as such statements do not imply judgment or contradiction.

The healing power of patient-healthcare professional interaction is often underestimated and frequently more harm than good is done by ignoring such simple attention to communication details. Even if you are the only professional the victim encounters who gives her confidence, respect and warmth those few moments of interaction can make the difference between quick recovery and a long painful ordeal. Regardless of the legal outcome the healing triggered by such a positive therapeutic relationship will make a great deal of difference in each life you touch.

When human fallibility leads a nurse to perform a medication error that results in a patient death some states are eager to take the nurse to criminal court with a charge of criminally negligent homicide. People who know standards of practice for nurses make the argument that licensing boards made up of nurse peers allows a fair review. Advocates that say boards are in a better position to trend like mistakes and promote methods to decrease the mistakes in the future protecting the public further leverage the argument.

The American Nurse Credentialing (ANA) follow this thought process by indicating they have a sharp focus to help protect the public. Another argument I feel is the strongest for not taking these cases to criminal court is the lack of “intent”. I firmly believe the nurse will feel extremely guilty and depressed over a med error she committed that resulted in patient injury or death. The majority of cases would not be able to find intent by nurse. The court systems are very slow to bring cases to court where the board of nursing moves more swiftly toward resolution. So it does seem reasonable that a board of their peers in my opinion review nurses.

A second argument for have the nursing board review cases is their knowledge of the Nurse Practice Act which clarifies the scope of nursing practice for specific states. This document is not entirely consistent in content or interpretation through out the United States. A board of nursing that is familiar with the document would allow more efficient and consistent application of the nurse practice act. If a board of nursing found the nurse has over stepped the scope of practice it would be their duty to have the case reviewed by the state Attorney General’s office. The review by the nursing board would help clarify the nurse actions in relation to nursing standards and decrease the burden on the court system.

More and more liability is being place on nursing assessments when cases are brought to court and unfortunately, more and more often the nurse is being blamed for the medical mishap.

It is incredible to think the surgical scrub nurses would be liable in the court of law when a physician removed the wrong limb. Today, it is the responsibility of all health care entities to take an active role in assessment of patients prior to any procedure. Did I say health care entities or did I mean to say nurses. As nurses, it is vital that we take our assessment skills seriously and use then at every opportunity in no matter where we work whether in a surgical suite or primary care office.

This brings up the topic of nurses knowing what to assess when caring for their patients. For example when a nurse is caring for the Emphysema patient and the physician orders O2 at 10L via nasal cannula. Using your nursing assessment skills, one might question the appropriateness of such a high flow via the nasal cannula. On the other hand, the patient who has CHF and is receiving 80 mg. of lasix every 6 hours IV for diuresis but potassium replacement has not been ordered nor are post lasix labs ordered and through your nursing assessment, the patient is complaining of feeling strange. Will your nursing assessment skills bring these issues to the attention of the physician and prevent a potential fall, which could end up causing the patient to fracture their hip thus causing a thrombosis, which could potentially cause death in any patient.

Another good example would be the potential for medication errors committed by either nurses or physicians. Many forensic medical cases are related to some sort of health care entity error. Having good assessment skills along with good nursing knowledge has prevented many deaths while caring for patients. But then again having good nursing assessment skills can reassure a nurse that she/he has done the very best in caring for the patient.

This reminds me of a situation that happened back in the mid-nineties when I floated to a dialysis in-patient unit. I was assigned to care for four patients. All of the patients on this unit were on cardiac monitors. One of my patients was a young woman in her early fifties. She had just been diagnosed with renal failure and had received her first dialysis treatment via IV cannula that day. This patient was also an employee at this very hospital. Early in the evening, the patient complained of anxiety and it was noted that she had valium ordered for anxiety, so after a thorough assessment of the situation the patient was given the valium. Later that evening around 10 pm, the patient complained that she was still feeling anxious and was not able to sleep. According to the physician order, the valium could be repeated if needed. After again a thorough nursing assessment and consultation with the charge nurse, the second valium was given to the patient. As the early morning was approaching and the lab technicians were doing their morning lab draws and the nurses were at the nursing station closing their patients charts, one of the cardiac monitors went off indicating abnormal heart rhythm- it was my patient. We called the code blue and ran to the patient’s room with the crash cart. The lab technician stated that the patient was talking normal with no complaints to her and all of a sudden, she stopped talking and fell back into the bed. Within a couple of minutes the room was swarming with it seem everyone trying to resuscitate this patient. After an hour of resuscitation attempts, the ER physician called the code. We were all in shock and no one could figure out what happened. Personally, I quickly reviewed all my assessments of this patient trying to look for anything I might have missed. It wasn’t until a month later I found out that via an autopsy that the patient had had a massive heard attack and there that no way anyone could have know this was going to happen on that very morning. Oh, yes the valium had no relevance in this patient’s death.

Again, good nursing assessment skills are vital in the care of our patients. Someday, this could mean that your precious nursing license may be on the line as well. Doing the best nursing assessment at all times is vital in the life of every patient we have been entrusted to care for and should be utilized at every opportunity in the attempt of providing the best care possible for the good of all.