Texas Nursing Forensics

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In the United States, sexual assault was historically considered a judicial problem; however, it is now considered a major public health concern because of the health and psychological effects on individuals. The problem most notably emerged in the public eye in the 1960s with the women’s liberation movement.  In recent times the #METOO movement has increased awareness of the problem, and many organizations have surfaced to assist the assaulted. This program will focus on the problem in rural areas in the state of Texas and how nurses working in Texas Nursing Forensics with these emergency departments can best assist sexually assaulted patients. 

Introduction to Texas Nursing Forensics

In the United States, sexual assault was historically considered a judicial problem; however, it is now considered a major public health concern in Texas Nursing Forensics because of the health and psychological effects on individuals. The problem most notably emerged in the public eye in the 1960s with the women‘s liberation movement.  In recent times the #METOO movement has increased awareness of the problem, and many organizations have surfaced to assist the assaulted. This program will focus on the problem in rural areas in the state of Texas and how nurses working in Texas Nursing Forensics with these emergency departments can best assist sexually assaulted patients. 

According to the Rape Abuse and Incest National Network (RAINN) (1), in less than every 80 seconds, a person is sexually assaulted. In 2015 the Texas Statewide Sexual Assault Prevalence Study found that 33.2% of adult Texans or 413,000 individuals reported having been sexually assaulted at some point during their lives. (2)  

Assault can be the product of domestic abuse, gang violence, date rape, and incest.  Assault can be inflicted on any age or gender and often occurs by someone who is related to or knows the assaulted.  Sexual abuse, as described by the American Psychological Association (APA) “is unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent“. (3). Statistics show that more women and children are sexually assaulted than men or boys and girls under 18 years of age are at the highest risk. According to RAINN (1), men and boys, especially college–age, are also at risk with transgender students at the highest risk of this group.  Today many organizations deal with this issue and offer hope and assistance to those affected.  

Not only does the impact of sexual assault affect the emotional and physical health of victims, but there are also major associated costs. These costs are incurred from:  

• Emergency department visits 
• Law enforcement time and wages 
• Evidence collection and testing 
• Court fees, including civil and federal lawsuits 
• Loss of wages and health care costs of the affected.   

In 1996 the national cost of this problem was approximately $450 billion per year.  (4) National Institute of Justice. Those numbers have jumped into the trillions of dollars in the last two decades.  In Texas alone, the costs exceed $26,000,000 annually. (2) 

In many parts of the United States, Sexual Assault Nurse Examiners (SANE), nurses who are expertly trained in performing forensic examinations and collection of evidence, are utilized (5). Since there is a lack of SANE nurses in rural Texas, registered nurses working in these emergency departments must learn the SANE process to perform the forensics exams and evidence collection by completing a 2–hour educational program.

The Nurse’s Role in Texas Nursing Forensics

Sexual assault is an extremely traumatic experience. Those affected can have a wide range of issues, emotionally, spiritually, physically, and psychologically.  While we may not address all of these issues in the initial visit to the emergency department, we must consider these concerns while the patient is in our care since we are often the first responders.   

Compassion, empathy, and privacy are a hallmark of excellent practice in these situations.  Many patients will experience shock and disbelief. “Why me?  Will I be ok?“ or “it‘s no big deal, I‘m fine“.  (6). There may be “fear of responses from friends, family, colleagues the public and criminal justice providers.“ (7) Rape victims may also have concerns about pregnancy, STDs, and HIV/AIDS.  These patients may feel their world has turned upside down and fear if others know they may be scorned, told it was deserved, and fear their names could be made public (7).  Texas nursing forensics patients may not want to talk about the assault, as reliving it could bring out unwanted emotions. 

Active listening, believing what the patient tells you, validating their feelings, maintaining confidentiality, and honoring their decisions around what to do about the assault are a few of the methods the interviewing nurse should use.  Since nurses are taught to treat the whole person rather than the “problem“ alone, this skill is vital in caring for this group of patients.   Repeating information back to the patient will help to elicit more precise information.  It will also help in validating what the patient is telling you so an atmosphere of trust can be obtained.   

Working with all personnel in the emergency department is also essential.  From the paramedics, law enforcement officers, family, or anyone accompanying the patient to the physicians, social workers, and forensic medical examiners, each professional has a specific skill set and role in the patient‘s care.  Teamwork among these groups of individuals will provide for the best possible outcomes for the patient.  In order to provide excellent care, all gender identities must be taken into consideration, as well as age and sexual orientation.  No bias or judgment should ever be displayed to the patient.  Customs, beliefs, religious and spiritual needs should also be considered during the visit.   

If the Texas nursing forensics patient arrives alone, the nurse should inquire if the patient wants a companion or an advocate to be present.  An advocate could be a family member, a friend, a member of the clergy or a social worker. It will always be the patient‘s choice.  However, care must be taken for the patient to feel comfortable as recalling the events and having a family member or friend who is also emotionally involved, or even the assaulter, may deter the patient from complete openness and honesty.   An interpreter should also be arranged if needed with the patient‘s consent.  If the patient has not alerted the local police, the nurse should inquire if they wish to report the assault and if so, the police should then be called. If available, a sexual assault response team or SART should be immediately contacted. It is of the utmost importance to remember that it is always the patient‘s choice and consent in all situations surrounding the case.   

Admitting the patient to a private room in a quiet area of the emergency department lessens interruptions from outside sources.  When performing the initial assessment and gathering information, documentation must include a very detailed and complete history, including any physical trauma to the person‘s body.  The history should include any bruises, lacerations, or other visual injuries and how and when they occurred.  The nurse should perform the interview slowly, giving the patient time to process and answer each question.  The patient may or may not want to identify the person who assaulted them and should not be coerced into doing so. 

A complete medical, surgical, and gynecologic history, in the case of a female patient, and any new symptoms occurring after the assault should be asked.  Drug allergies, medications, and any alcohol or illegal drugs used at the time of the event are also documented. A compassionate and empathic tone should always be used to allow the patient to feel safe and understand there is no judgment of them from any person in the emergency department.  Patients should be given the opportunity and encouraged to grieve and react during this time. They will need to feel comfortable enough to ask and answer questions throughout the interview.  

 In Texas nursing forensics, it is a law that the nurse obtain written consent from the patient.  During the complete physical exam, the nurse will be charged with taking care that any physical evidence of the assault from clothing or body fluids is not disturbed. Also, during this time, suicidality and emotional supports should be assessed.   Providing expert treatment for sexually assaulted patients is of utmost importance.  When available, a SANE nurse will perform the forensic examination.  This examination is vital to collect and preserve physical evidence from the patient while also assessing life and limb injuries.  If a SANE nurse is unavailable, as in Texas’s rural areas, a “medical forensic examiner“ will perform the examination.  

During the physical assessment, the patient should be advised of every step before each part of the exam and be made aware that they have total control of what is happening.  It is important that the nurse help the patient understand he or she always has the right to refuse any and all of the steps in the examination.  When documenting the case, the nurse should use open–ended questions to elicit the patient’s best and clearest responses. Documentation must be complete and exact, including every stage of the assault with times, dates, and descriptions considering the patient‘s emotional state and ability to recall. Using motivational interviewing and repeating back what the patient has stated is very helpful.   

In the case of a minor, a parent will give the consent, and if no parent is available or is the assaulter, the child will be turned over to the appropriate child and family services in the state.  If the assaulted patient has dementia or is an elder with cognitive issues and is therefore unable to consent, adult protective services should be contacted. (8)There are also rules governing military sexual offenses. Remember when documenting these cases, whether using handwritten or electronic medical records any and all information is subject to HIPPA.

Forensic Law and Collection Process in Texas Nursing Forensics

The Texas government code 420.031 (9) describes the protocol that must be taken to develop and protect evidence collection in a sexual assault case.  Since a major part of Texas is rural, the code was enacted to protect and care for patients and the evidence in those areas where a SANE nurse is not available.  In those cases, a medical forensic examiner may perform the exam and evidence collection for Texas nursing forensics.   

A medical forensic examiner is described as any practitioner MD, Registered Nurse, Nurse Practitioner, or Physician‘s Assistant who has undergone a minimum of 2 hours of training in forensic evidence collection.  The law outlines requirements in the collection and preservation of evidence.  In 2019 the code was amended to require written informed consent from the patient or guardian for release of the evidence and must be gained prior to the history and physical.  Obtaining consent also carries important psychological implications after a sexual assault since the patient‘s right to consent was violated by the assaulter. Sexual assault examination teams should always be involved as early as possible.   

In Texas, there is no statute of limitations on reporting sexual abuse of a child.  For an adult (over 17 years of age) that statute ends ten years after the crime.  However, during the investigation of the offense, if “biological matter“ is collected and the matter:  

• Has not yet been subjected to forensic DNA testing; 
  
• Has been subjected to forensic DNA testing and the testing results show that the matter does not match the victim or any other person whose identity is readily ascertained;  
• Probable cause exists to believe that the defendant has committed the same or a similar sex offense against five more victims“ there is no statute of limitations. (9) Sexual assault evidence can be found in several areas, including the crime scene, the patient’s body, skin, hair, nails and clothing, and other items belonging to the patient (11).  There is a specific kit used to collect this evidence.  As described by RAINN, the kit is best known as a RAPE or Sexual Assault Evidence Kit (SAEK) and is inclusive of the items listed below: 
  -“Bags and paper sheets to put on the floor and collect clothing or other evidence that may fall off of the patient while undressing, 
  –A comb to collect evidence from hair, 
  –Forms for documentation,  
  –Envelopes and containers for the evidence 
  –Instructions on use of the kit, documenting guidelines 
  –Blood sampling materials and swabs.“ (11) 

Types of evidence collected in Texas nursing forensics are usually skin samples, scrapings from fingernails, and oral, genital, and anal swabbing internal and external.  Directions on how to collect this evidence is included in the kit.  The forensic examiner can also use special types of photography to document internal injuries. (11) Personal cameras should never be used.  Remember, it is the law that the patient consent to each part of the exam. 

As described by RAINN, prior to the Texas nursing forensics exam, it is best if the patient has not changed clothes, combed their hair, brushed their teeth, tried to clean the area, showered or bathed, or used a restroom. If needing to use the restroom, a urine sample should be collected, educating the patient not to cleanse the perianal area.  In the event that they have already showered or bathed and have not arrived after the acute assault, emergency personnel needs to educate the patient to keep the clothes they were wearing and any other belongings they had with them at the time of the assault in a paper bag in order to preserve the evidence. (11)  If the patient comes to the emergency department up to 7 days after being sexually assaulted, the exam can still be performed.  After the 7 days, it is at the forensic examiner’s discretion whether the exam should be performed. Collection and protecting forensic evidence is a legal, moral and professional responsibility (12) 

Any medical witness who testifies in court is held in the highest regard and as experts in sexual assault. (5)  Courts will closely scrutinize the chain of custody, and if broken, it can cause a conflict in the case and question of validity.  Cases may be heard in criminal, civil, juvenile, military courts, or grand juries.  If a forensics examiner is called to be a “fact“ witness, no opinions on the case will be heard. Only the procedures that were performed on the patient will be admitted, and if the testifier is not the professional who performed the examination, they may be questioned regarding SANE protocols.  If called upon to be an expert witness, the SANE nurse not only has knowledge of protocols but can educate and give opinions to the court.   In either case, the necessity for excellent knowledge of SANE protocols is important.  Nurses must be comfortable testifying in court as it is a rigorous and stress–provoking experience.  Working with your organization‘s lawyers and prosecutors as well as reviewing the case extensively will prepare the nurse to testify in a case. (5) 

Chain of Custody

In order to protect the patient and evidence for the courts, a chain of custody of the evidence must be followed precisely.  Failure to comply does not mean the evidence is not admissible in the courts; however, the more complete the evidence, the better chance of conviction of the assaulter.  Texas A&M‘s nursing program offers a chain of evidence handbook outlining each step in the collection of evidence.  The information below highlights the collection process from that handbook (8):

“Precise chain of custody must be maintained and well documented through the entire patient assessment and evidence collection process. Chain of custody documents includes the dates and times of each individual who handles every piece of evidence, from the time it is collected to the legal proceedings.“

Evidence must also be labeled with the patient‘s name, date of birth, a unique identifier number from the institution, the examiner‘s initials, date, and time.  

Chain-of-custody documentation must include:  

1. Receipt of evidence
2. Storage of the evidence 
3. Transfer of the evidence, 
4. Date and time of each transfer
5. The printed name and signature of each person in possession of the evidence 
6. Signatures of all persons transferring or receiving the evidence. 
7. Swab and evidence collection.  

There should be two swabs used from each site. (8) 

Evidence must be kept in sight of the staff person collecting it at all times. After collected,  the evidence must be dried and contained in the SAEK kit and sealed per kit instructions until it can be handed over to the appropriate law enforcement official and opened only by crime lab personnel.  Each emergency department should have a locked storage space to provide temporary custody of collected evidence until it can be transferred to the appropriate persons or lab.  If a patient is transferred to another facility, the chain of custody again must be documented according to the law. 

The law in Texas nursing forensics allows an adult to choose whether to report the assault to law enforcement.  If the choice is to not report, evidence will still be collected and preserved for up to 5 years post–assault.  In the case of child sexual assault, elder abuse (over 65), or disabled persons, all medical personnel must report the case to law enforcement as mandatory reporters.  Texas caregivers are also required to give patients an information sheet describing where to find appropriate services for the sexually assaulted.  This document can be found on the Texas consumer protection website.   

Physical and Emotional Issues Post Assault  

After a sexual assault, patients can experience anxiety and depression, PTSD and turn to alcohol and/or substance abuse.  There may be feelings of fear, denial, guilt, shame, loss of self, loss of control, and anger. (8) Their world has been turned upside down, and they feel life has stopped, and they cannot move forward.  They may feel ashamed and wonder if, in some way, they were responsible.  They may not feel safe in their own space and may lack trust.   

In domestic cases, the patient may be concerned about their attacker.  They may worry that their attacker will be prosecuted and sent away.   Daily life can be disrupted to the point of self-isolation and loss of the patient‘s job, family, and social life.  A patient may become disabled to the point of homelessness and poverty.  Many will feel the attack is transparent and that others can tell they‘ve been assaulted just by looking at them.  Flashbacks can occur at any time, and they may experience nightmares of being chased or attacked. They may also have constant thoughts of the abuse, causing insomnia and intense anxiety.   

Sexually assaulted patients are more likely to contemplate and attempt suicide than those of other assaults.  These issues can extend into long periods of time, with unknown triggers bringing flashbacks or repeated negative feelings.  Patients need to be educated to understand that all of their feelings are normal to the trauma and understand that these feelings are temporary. Each person heals in different ways and in different timeframes.  Ongoing support and therapy will assist the patient in recovery as well as self-help and group programs.  There are many online, telephone, and in–person programs for victims as well as organizations to assist with ongoing issues.  For example, the RAINN program can be helpful in advocating for patients and guiding them on their journey to recovery.  

 Many psychologists and therapists deal explicitly with sexual assault patients.  The attorney general of the state of Texas website has information and resources for all crime victims.   Having a trained sexual assault counselor at the emergency visit time can be of great assistance with the initial contact and subsequent referrals to professionals.  Compassionate, empathic, and supportive care by emergency nurses at the initial contact can positively impact the patient‘s road to a safe and healthy recovery.   

Physical injuries must also be considered using clinical assessment, radiology, MRIs, and CT scans when necessary.  Laboratory collection for STDs (sexually transmitted diseases), pregnancy in females, possible HIV, and other illness exposures are also a consideration during the physical exam and history taking.  Follow–up care for these injuries with subsequent laboratory tests and appointments made with appropriate specialists should be made.   

Ideally, the Texas nursing forensics professional could schedule a telephone call with the patient in 2-3 days to assess how they are doing and for continued support and referrals.  At that time, the patient may have more questions or concerns that the nurse can help with and provide for follow–up care and resources.   A list of educational programs and therapists who specialize in sexual assault and support groups should be supplied to the patient at the time of the visit and subsequent phone calls. There is no handbook on how to recover from trauma; it is an individual journey that is experienced solely by each person; however, there are many resources to assist a sexually assaulted patient at the time of the event and long after.  

Conclusion

Sexual assault has become a major and costly health problem in the United States. The state of Texas has implemented a code of laws to identify, protect and collect evidence from patients who have experienced this crisis.  The utilization of SANE nurses is common in major metropolitan area hospitals, but many rural areas in that state are not equipped with the program.  To properly care for these patients and collect and protect evidence appropriately, Texas has mandated education for those emergency department nurses not served by SANE personnel.   

It is imperative that emergency department nurses and other Texas nursing forensics professionals become educated in the use of SAEK kits for evidence collection and chain of evidence protocols. The utilization of the SANE method allows for standardized care that is safe and protective of the patient and the patient‘s rights.  It protects evidence for investigation while helping to keep costs down.  

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