maria nittis - division of medicine, nsw health - future training of forensic nurse examiners in...
DESCRIPTION
Dr Maria Nittis, Department Head Forensic Medical Units, Division of Medicine, NSW Health presented this at the 2nd Annual Forensic Nursing Conference. This is the only national even of its kind promoting research and leadership for Australia's Forensic Nursing Community. The program addresses future training of forensic nursing examiners, forensic mental health consmers, homicide and its aftermath, ethical dilemmas in clinical forensic medicine, child sexual abuse, providing health care to indigenous patients in the forensic arena and more. To find out more about this conference, please visit http://www.healthcareconferences.com.au/forensicnursingTRANSCRIPT
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SANE OR INSANE
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BACKGROUND FOR THE SANE PROJECT
• Labor’s Public Safety Plan: Stage 5 for DV and SA announced
changes to enable nurses to perform forensic examinations
and appear as expert witnesses. (?2003)
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BACKGROUND FOR THE SANE PROJECT
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BACKGROUND FOR THE SANE PROJECT
• Background work for the project was undertaken by MoH
– based on a report produced by Churchill Fellow and
scholarship recipient - Jo Spangaro – 2004
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REGIONAL HEALTH DISTRICTS
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REGIONAL EXAMINATION SITES
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BACKGROUND FOR THE SANE PROJECT
• Background work for the project was undertaken by MoH
– based on a report produced by Churchill Fellow and
scholarship recipient - Jo Spangaro – 2004
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BACKGROUND FOR THE SANE PROJECT
• The Health Minister’s Office asked Primary Health and
Community Partnerships Branch to develop a funding
proposal for SANE in 2003. Department of Health provided
costings for 20 new positions across the state: $1.9
million
• Deputy Director-General operations committed seed
funding $200,000 in January 2003.
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DoH ADVERTISEMENT FOR SANE
• See those aged 14 and above.
• Assess injury
• Objectively document health history and history of the
crime
• Collect forensic data
• Prevent psychological and physical health risks
• Facilitate client control over assault issues
• Facilitate healthy reorganisation and readaptation
following sexual assault.
Written by
policy
maker or
counsellor
or clinician
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ESSENTIAL SELECTION CRITERIA - 2003
• 5 yrs or more experience clinical nursing
• Willingness to attend one week training in Sydney and if
necessary, an additional week placement
• Ability to be flexible and be placed on 24 hr on-call roster
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DESIRABLE SELECTION CRITERIA
• Extensive experience in conducting pelvic examinations
on women
• Training in Midwifery, Sexual Health, Family Planning or
Women’s Health
• Experience of taking, handling and documenting
pathology samples
• An interest in working in the area of sexual assault.
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TRAINING
• August 2005, 27 nurses commenced their SANE training
• One week of face to face training conducted by VIFM in
Sydney
• Requirement to observe 5 sexual assault examinations
and perform 5 supervised sexual assault examinations.
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OUTCOME
26%
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DAL (FASS) Results – Since Dec. 2010
Area Health Service Result
Sydney West 1 58
Sydney West 2 Never practised as Forensic Nurse Examiner
Sydney West 3 Never practised as Forensic Nurse Examiner
Sydney West 4 Never practised as Forensic Nurse Examiner
Taree 5 16
Newcastle 6 2
Newcastle 7 4
Newcastle 8 1
ACT 9 1
Nowra / Wollongong 10 5
Nowra / Wollongong 11 Never practised as Forensic Nurse Examiner
Nowra 12 Never practised as Forensic Nurse Examiner
Nowra / Wollongong 13 Never practised as Forensic Nurse Examiner
Albury 14 SANE - resigned
Tamworth 15 Never practised as Forensic Nurse Examiner
Bathurst 16 SANE - resigned
Broken Hill 17 Never practised as Forensic Nurse Examiner
Armidale 18 Never practised as Forensic Nurse Examiner
Port Macquarie 19 Never practised as Forensic Nurse Examiner
Greater West 20 Never practised as Forensic Nurse Examiner
Greater West 21 SANE - resigned
Cowra 22 Never practised as Forensic Nurse Examiner
Hunter New England 23 Never practised as Forensic Nurse Examiner
Greater South 24 SANE - resigned
Greater South 25 Never practised as Forensic Nurse Examiner
Lithgow 26 Never practised as Forensic Nurse Examiner
Wagga 27 SANE - resigned
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WHAT WAS MISSING FROM CHURCHILL REPORT
2008
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FUNDAMENTAL FLAWS
1500 km
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LESSONS LEARNT FROM SANE
NSW
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FUNDAMENTAL FLAWS
No forensic medical infrastructure:
i. No support
ii. No mentoring
iii. No review of Examination records or Certificates
iv. No training or supervision
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FUNDAMENTAL FLAWS
No positions created:
i. No guaranteed award
ii. Did not necessarily have Health Services support
iii. Extensive delays because working another job
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FUNDAMENTAL FLAWS – ESSENTIAL CRITERIA
Incorrect Selection Criteria:
• 5 yrs or more experience clinical nursing
• Willingness to attend one week training in Sydney
• and if necessary, an additional week placement
• Ability to be flexible and be placed on 24 hr on-call roster
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SANE certification
• If you are asked to witness 5 examinations and do 5 examinations
• In a Unit that sees 40 adult examination per year
• And 70% of those patients presented after hours
• A Trainee Forensic Nurse Examiner would have to be placed at a unit
for 10 months – full time (if no on-call work)
OR
• On call for 4.25 months 24/7 – if only done in the after hours period.
OR
• Working 3 months permanently and on-call 24/7
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SANE certification
• There are 50 Sexual Assault Units in NSW
• There are an average of 800 kits submitted to the forensic laboratory
for analysis per year
• Ratio of 2: 1 – exams performed for results returned
• Assumption: Each unit, on average, has 32 patients per year
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FUNDAMENTAL FLAWS – DESIRABLE CRITERIA
• Extensive experience in conducting pelvic
examinations on women
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FUNDAMENTAL FLAWS – DESIRABLE CRITERIA
• Extensive experience in conducting pelvic
examinations on women
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FUNDAMENTAL FLAWS – DESIRABLE CRITERIA
• Extensive experience in conducting pelvic
examinations on women
• Training in Midwifery, Sexual Health, Family
Planning or Women’s Health
or ED or GP or Drug Alcohol or Mental Health
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FUNDAMENTAL FLAWS – DESIRABLE CRITERIA
• Extensive experience in conducting pelvic
examinations on women
• Training in Midwifery, Sexual Health, Family
Planning or Women’s Health or ED or GP or Drug
Alcohol or Mental Health
• Experience of taking, handling and documenting
pathology samples
Immunisation Certificate or Venepuncture
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FUNDAMENTAL FLAWS – DESIRABLE CRITERIA
• Extensive experience in conducting pelvic
examinations on women
• Training in Midwifery, Sexual Health, Family
Planning or Women’s Health or ED or GP or Drug
Alcohol or Mental Health
• Experience of taking, handling and documenting
pathology samples Immunisation Certificate or
Venepuncture
• An interest in working in the area of sexual assault.
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FUNDAMENTAL FLAWS – DESIRABLE CRITERIA
• Extensive experience in conducting pelvic examinations on
women
“I think that stuff is over-rated” Dr. Christine Bassindale Perth SARC
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THE WSLHD EXPERIENCE
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Forensic Nurse Training from 2008
• We have trained three nurses and two more are in training or about
to be trained since 2008
1. Worked at Unit
since 2008; FTE
0.8; 2nd busiest
examiner in the
state; ED and SH
background; Grad
Cert Forensic
Nursing / SANE
2. Worked at Unit since 2012; FTE
0.4; 30 yrs nursing experience; ED
and Research background; Worked
independently with haemodialysis
patients
3. Worked at Unit for 9
months; FTE 0.4; Defence
force background; 2 yrs in
HDU. ICU. CCU -
Resigned
4. Worked at Unit since
January; FTE 0.4;
Extensive ED background
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Know what the Nurse will be Required to Do
• See victims of sexual assault aged 14 or more;
• Assist with paediatric sexual assault examinations;
• See victims of domestic violence aged 16 or more.
• Consents
• Gather forensic and medical history
• Documentation of injuries including photography
• Collection forensic evidence
• Prophylactic meds e.g. HIV PEP, MAP, Hep B
• Expert Certificates with opinions
• Expert witness at Court
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Our Selection Criteria
• Registered Nurse with APHRA and postgraduate qualifications in
forensic nursing or willingness to obtain same
• High level interpersonal skills, both verbal and written and
demonstrated ability to work independently
• Must be a NSW accredited vaccinator or willingness to obtain same
• Computer competency (including Microsoft Word, Power Point and
Email) and reasonable typing speed)
Job is for a
forensic nurse
Presenting
Expert Opinions
in Oral and
Written forms
Hepatitis B
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Our Selection Criteria
• Current driver’s license and willingness to use same for work
• Demonstrated clinical experience with assessing immediate health
care needs of patients and the ability to determine need for referral
if appropriate
• Demonstrated ability in effective time management
• Experience with female genital examinations including speculum or
willingness to learn.
34km between
both units
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Our Interview
• Typing test where we observe speed and ability to correct spelling
and grammer.
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Our Interview
• Typing test where we observe speed and ability to correct spelling
and grammar.
• Observe their fluency skills and confidence levels – someone who is
easily flustered in an interview is likely to be easily flustered in court
• We get them to fill out, on a weekly chart, which evenings and days
they are free and which evenings and days they have commitments
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If successful
We paid for the Family Planning Course – learn about female genital examinations,
speculum examinations, STIs and Contraception - $2,300
• Replacing this with a tailor made course for nurses where they are taught
speculum examinations and practice on a paid volunteer: $130
• Looking at in house teaching at the hospital gynaecology clinics
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If successful
We paid for a unit of study at Sydney University in Sexual Assault - $3132.37
• Impact of sexual assault on health and community
• Anatomy of men and women
• Basic forensic science including DNA and Toxicology
• History and Examination
• Follow Up
• Counselling
• Medico Legal Issues: consent, chain of evidence and court reports
In Australia other courses include Flinders University new online course (in
association with John Hopkins): Fundamentals of Forensic Health Care available for
health care practitioners including nurses and paramedics:$1100
• Covers topics such as Legal Overview, When injuries speak, Sexual Assault, Details,
Documentations and Decisions, Evidence Collection
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If successful
We paid for the Expert Witness Training Course - $1000
• ACLM runs Basic Law Intensive – 2 days - $880 or $680 if member
• ACLM runs Expert Witness programme – 2 days - $1175 or $950
• Unisearch run course with Hugh Selby – 1 day - $650
TRAINING COST: $6,432.37
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In House training
• Provide Reference Material for Everything
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In House training
• Provide Reference Material for Everything
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In House training
• Provide Reference Material for Everything
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FNE Competencies
• Drew up a list of competencies
• Stops the learning process from appearing overwhelming
Where to look Web address
AAFP www.forensicphysicians.org
National Occupational Standards http://www.colinwrightassociates.co.uk/pr
ojects/national-occupational-standards-
nos
IAFN www.iafn.org
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In House training
Decontamination
Procedure
Consent
History Decide what
samples to collect
Speculum
examinations
Collect Samples
Injury
Interpretation
Injury
Documentation
Photography STI prophylaxis
Toxicology
Collections
Pack Up
Generate Expert
Certificate
How to Provide an
Opinion
• We broke examinations up into sections and as they became competent they would
complete that part of the examination.
• Learn nothing from observations after the first case if you are a pure observer
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In House training
• If you are asked to do 5 examinations or 5 Expert Certificates with the
feedback at the end
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WHAT SKILLS DOES A FORENSIC
NURSE EXAMINER TRAINEE
REQUIRE AT YOUR UNIT
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Way Forward - Skills
• Need solid clinical judgement and knowledge of when to refer
• Emotional toughness and confidence
• Need to be able to collect blood and provide immunisations
• They need to be able to type quickly and ability to learn to use new software
systems
• Ability to participate in after hours’ roster – flexibility and a car
• Need to be able to perform genital examinations including speculum
• Need to have good verbal and written communication skills
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Way Forward - Training
• Post Graduate Training
• Skill Fill e.g. imaging, vaccinations, speculum examinations etc – need a list of skill
fill opportunities
• In house training where trainee is involved in the examination from an early point and
made responsible (Placement in busy unit for a 6 month term)
• Training of nurses does not end once they are working independently – need a way of doing
this e.g. review case notes, expert certificates and images (e.g. photos of injury etc.) /
provision of training and updates / “phone a friend”
• Every now and then, once training completed, assist a graduate trainee in an examination ( 2
examples).
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Backdrops:
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Templates for use anywhere!
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