Consequences of Presence of Forensic Nurses in Health Care System: A Qualitative Study.

BACKGROUND: Nursing is a vital element in providing safe and effective care. Forensic nursing is one of the specialties in this discipline which, in addition to creating more satisfaction in nurses, is considered essential in holistic, quality, and safe care. This study aimed to describe the consequences of the presence of forensic nurses in the health system.
MATERIALS AND METHODS: This qualitative study was conducted between 2017 and 2018 in Iran. Semi-structured interviews were performed with 18 participant experts in the field of health and law. The interviews were analyzed using the inductive content analysis approach proposed by Graneheim and Lundman.
RESULTS: The consequences of the presence of nurses in the health system were summarized into two categories: positive and negative consequences. The positive consequences consisted of improved performance, better legality of nurses, the calmness of nurses, prevention of patients' rights violations, advancement comparable with developed countries, reduced costs, increased accuracy and speed in dealing with forensic cases, improved performance of Iranian Legal Medicine Organization and increased employment. On the other hand, the negative consequences were role conflict with other involved professionals and nursing shortage. Participants included nurses (with different specialties), nurse lawyers, forensic medicines, forensic midwives, a judge, and a medical lawyer.
CONCLUSIONS: If planners and policymakers have a positive attitude toward the presence of forensic nurses, we can anticipate better forensic services for clients through the development of systematic educational programs, the formation of forensic teams, and the expertise of this profession can provide many benefits. Copyright:

Introduction

Nursing is essential for safe, effective, and humane care.[1] The nursing profession is basically a humane performance focused on physical, psychological, and spiritual needs.[2] Nurses should increase their knowledge to meet the multiple needs of their patients because their duties are different from the past.[3] Today, nursing has changed from a passive state to an independent, decision-maker profession.[4] Role development in nurses has beneficial effects on nursing care and enables them to better perform their duties for patients.[3] To play advanced nursing roles, in addition to professional concepts, nurses should be familiar with legal concepts not only to provide quality care in multidisciplinary teams[5] but also to defend their rights in appropriate situations.[6]

In the health care system, nurses often meet clients, families, and populations victimized by accidental or deliberate injuries, exploitation or ill-treatment but are not prepared to deal with them.[7] Many organizations including the World Health Organization (WHO) and International Association of Forensic Nurses (IAFN) have stipulated that legal contents and concepts should be taught to undergraduate students as well as nursing alumni.[8]

Forensic nursing is a specialty in the nursing discipline, which brings the concepts as well as principles of both law and nursing sciences together.[9] This creative and evolving specialty seeks to meet the needs of the health care system with legal problems. The advancement of forensic nursing in the last decade has developed a new and better image of the nursing profession and provided services to living and dead people.[10] This discipline provides a new perspective on the approach of holistic care for patients at hospitals or community centers involved in legal issues. Today, applying legal sciences in nursing has formed wider roles in clinical research related to crime and legal processes to promote public health and safety.[11]

Forensic nurses work in multidisciplinary teams to provide the best possible care for all clients involved in legal issues including victims of sexual assault, child abuse, fraud, suspected death, medical errors, or false accusations regarding these errors and prisoners.[12] A significant difference has been found between forensic nurses and physicians in providing care for victims which may be due to the high skill of nurses in caregiving and more time spent at the bedside.[13] In addition, with forensic nurses, the possibility of being examined by the same sex is increased.[14]

Despite all the benefits of forensic nursing in the international community, few activities have been undertaken in Iran for its establishment. Studies in Iran indicate that most nurses are not aware of many legal concepts.[1516] In Iran, the law is also based on social conditions, culture, religion, and sharia. According to the judicial system of the country, particularly after the Islamic revolution, which was formed according to jurisprudence as well as Islamic rules and the Islamic Penal Code or the Civil Law deeply influenced by religious and cultural regulations, forensic nursing should be inevitably modified. In the judicial system of Iran, laws related to social harms, injuries, violations, natural or man-made disasters, and protection of nurses in case of lawsuits are also different, which shows why it is important to deal with this topic in Iran. Therefore, understanding legal concepts and forming forensic nursing in the country are essential.[17] This study was performed as part of a larger study to explore the experiences and perceptions of professionals about the consequences of the presence of forensic nurses in the health care system of Iran.

Materials and Methods

This qualitative study was conducted between 2017 and 2018 in Iran using conventional content analysis with Graneheim and Lundman method.[18] Participants were 18 specialists in the field of health and law, selected via a purposive sampling method. The inclusive criterion was familiarity with legal issues and with clients. After calling the specialists to introduce the research team and explain the purpose of the study, the interviewer (one of the researchers) took their informed consent to participate in the study and made an appointment with each of them for an interview. The place of the study was any location according to the preference of the participants. They included Iranian Nursing Organization, health care centers, emergency stations, colleges of nursing and midwifery, workplaces, addiction centers, dormitories, and parks.

Semi-structured interviews with open questions were conducted for data collection. At the beginning of each interview, some warm-up questions were asked from the interviewee. Then, the main subject was mentioned with a general question “What do you know about forensic nursing?” After this, with some questions such as “Considering your field, do you think that forensic nursing is necessary?” or “What are the present outcomes of forensic nurses?”, the interview continued. Probing questions such as “Please explain more” or “Give an example, please,” were occasionally asked. In conclusion, an open question such as, “If there is anything you would like to add, please do so” was asked. Additional data regarding nonverbal responses of the interviewees were written during each interview.

The duration of the interviews was between 18 and 126 min with an average of 72. As soon as each interview was completed, the recorded file was first listened to carefully and then, transcribed verbatim. The entire text was carefully read to understand the overall sense of the text. After reading the text several times and immersing in the data, the units of the analysis were characterized and the key meanings were extracted and the initial codes were formed. These codes were then organized based on similarities and differences found in subcategories and categories. Afterward, the similar codes were placed in one subcategory and similar subcategories formed the categories.[18] The data were analyzed by MAXQDA 10 software.

In order to ensure the accuracy of the findings, the four criteria of Lincoln and Guba were applied.[19] To provide credibility, the researchers reviewed all the steps from data collection and transcription to analysis via member as well as peer checks with colleagues, research teams, and observers outside the group. Probing questions, data immersion, and sampling with maximum variation were considered. The researchers recorded and reported all the steps and decisions accurately for confirmability to enable others to follow-up the research if needed. For trustworthiness, all stages of the study were explicitly described from the beginning to the end to provide audition for an external supervisor. For transferability, the authors attempted to describe the method section of the study in detail, including the selection of the participants, data collection, and data analysis to enable the readers to evaluate the application of data in other researches.

Ethical considerations

To conduct the research, the registration code of ethics was obtained (IR.SBMU.PHNM.1395.676) from Shahid Beheshti University of Medical Sciences and all ethical codes were observed. The interviews were audio-recorded with participants' permission. The researchers assured all participants regarding the confidentiality of the information and the safe retention of all documents.

Results

Table 1 presents the demographic characteristics of the participants. During the analysis of the transcripts, two categories and 12 subcategories were obtained from the extracted codes. The two categories were positive and negative consequences of the presence of forensic nursing, which are described in detail [Table 2].

Table 1

Demographic characteristics of participants

Participants	Sex	Spatiality	Educational level
1	Female	Nurse	Master of Science
2	Female	Nurse	Ph.D. Degree
3	Male	Medical lawyer	Master of Science Student
4	Male	Nurse	Bachelor of Science
5	Male	Nurse lawyer	Master of Science
6	Male	Physician	Specialist in Forensic Medicine
7	Female	Nurse	Ph.D. Student
8	Male	Judge	Ph.D. Degree
9	Male	Nurse lawyer	Master of Science
10	Female	Nurse	Ph.D. Degree
11	Female	Forensic Midwife	Ph.D. Degree
12	Female	Forensic Midwife	Ph.D. Degree
13	Female	Nurse	Bachelor of Science
14	Female	Nurse	Ph.D. Degree
15	Male	Nurse	Ph.D. Student
16	Male	Nurse	Bachelor of Science
17	Male	Nurse	Bachelor of Science
18	Male	Physician	Specialist in Forensic Medicine

Table 2

Categories, subcategories, codes and quotations of the study

Categories	Subcategories	Example of codes	Example of quotations
Positive consequences	Improving performance of nursesBetter legality of nursesCalmness of nursesProtection of the patient’s rightsGrowth comparable with developed countries Cost-effectiveness of forensic nurses rather than forensic medicinesHigher accuracy in handling casesHigher speed in handling cases	Provision of legal adviceTracking offensesCrime preventionProfessional testimonyIncreased awareness of professional and organizational lawsPreventing colleagues from running responsibilitiesTracking error eventsForensic nurses supporting nurses’ rightsError reductionProviding patients with legal informationError preventionProtection of patients’ rights after deathGrowth of large universitiesImprovement of health system comparable to other parts of the worldLower wage of forensic nurses than forensic medicineLack of budget in the health system to train forensic medicineBusy job of forensic medicineLosing important information about records Presence of forensic nurses at hospitals around the clockIncreased access to a legal agent for clientsProcessing of legal files by a forensic nurse	“If a nurse is aware of legal issues, she/he becomes less engaged with legal authorities and she/he does her/his job, better and more consciously.” (P17, male, a prison nurse)“One of the problems is the battery of patients and the personnel are so nervous they can hardly tolerate them. When it happens, they hide it. In such cases, a forensic nurse can prevent the problems since she/he is the one who represents discipline, prohibits wrong acts and follows up these things.” (P15, male, a psychiatric nurse)“Legal issues, perhaps if we were taught these things, as a nurse, we could perform our job with more comfort and less concern. For example, a nurse knows that what she/he is writing in patient’s record would be useful someday and can protect her/him.” (P7, female, emergency nurse)“In our hospitals, whether public or private, people’s trust has been diminished. In fact, a forensic nurse can make patients aware of their rights and increase their confidence.”(P10, female, a Pediatric Nurse)“Forensic nurse has been training in advanced countries for many years and if we want to be like them, one way is having a forensic nurse.” (P14, female, a community health nurse)“A forensic nurse cooperates and has less salary. There are a lot of jobs that can be performed by her/him. Her/his wage is much lower and accessibility to her/him is much easier and more.” (P2, female, a med-surg nurse).“Forensic cases are likely to go to the courts, prolonging examinations may, in some cases, diminish the accuracy required. A number of examinations can be performed by a forensic nurse and the accuracy can be improved.’’(P18, male, forensic medicine).“Forensic nurse must be in hospitals around the clock. She/he can examine patients immediately. In this way, she/he can increase the speed of handling cases.” (P9, male, a nurse lawyer)
Negative consequences	Higher performance of Legal Medicine Organization Higher rate of employment for nursesConflict Nurses shortage	Increased awareness of legal authoritiesSupplying manpower in the shortage of forensic medicineIncreased speed in file processingIncreased accuracy in file processingNurses’ problems for a livingWandering graduates Forensic nursing parallel to forensic medicineMidwifery opposition Separation of nurses from bedsideShift of forensic nurses toward regulatory agenciesImmigration of forensic nurses	“Nurses are the first-line members who visit clients. Forensic nurses in forensic emergencies such as rape and abuses, in diagnosis, treatment and reporting to the judicial system can help in and then lead to better performance of the Legal Medicine Organization.” (P6, male, forensic medicine)“You have nurses, now, with insufficient income and if you view it from the point of employment, nurses can work in this field and we have created jobs for them.” (P8, male, a judge)“How can a nurse with no experience in speculum insertion or enough knowledge about genitalia diagnose vaginal, cervical, or external genitalia traumatization?” (P11, female, a forensic midwife)“Now we have a shortage of nurses in our country, whatever foreigners do, we should not repeat, because they have different conditions and maybe, they do not have as many forensic medicines as we have.” (P1, female, a med-surg nurse)

Positive consequences

Forensic nursing is a dynamic and evolving specialty and nurses' lack of familiarity with the nature of the field may serve as a barrier to provide specialized care. The community, health care providers, and patients should be familiar with the benefits of the presence of the forensic nurse in the healthcare system. The category consisted of 10 subcategories: improved performance, better legality of nurses, the calmness of nurses, prevention of patients' rights violation, advancement comparable with developed countries, reduced costs, increased accuracy and speed in dealing with forensic cases, improved performance of Iranian Legal Medicine Organization, and increased employment.

Negative consequences

This category of the study entailed two subcategories: role conflict with other disciplines and nursing shortage. Conflict in organizations among groups occurs when people disagree with regards to goals or methods of work. Negative consequences of the presence of forensic nurses may occur if forensic nursing cannot find its proper position in relation to other legal professions such as forensic medicine or midwifery, leading to role conflict. Another negative consequence is the nursing shortage. The nursing shortage is a global problem and the reasons for the shortage of nurses are varied and complex.

Discussion

This study was designed to explain the implications of the presence of forensic nurses in the health system of Iran from the perspective of specialists. The derived consequences from the data included some positive ones: improving performance of nurses, better legality of nurses, calmness of nurses, protection of the patient's rights, growth comparable with developed countries, cost-effectiveness of forensic nurses rather than forensic medicines, higher accuracy in handling cases, higher speed in handling cases, higher performance of Legal Medicine Organization, as well as higher rate of employment for nurses. The negative consequences included role conflict with other disciplines and nursing shortage.

Several studies have highlighted the benefits of the presence of forensic nurses in health care systems, namely empathy, support, and strengthening the sense of control and empowerment of most patients by forensic nurses.[20] In addition to the abovementioned benefits, improved practice of nurses is achieved through better patient care, increased patient safety, and accessibility to services, decreased load of healthcare system, increased self-confidence, increased patient satisfaction,[21] elevated professional skills, increased credibility as well as accountability,[14] and increased prosecution of criminals.[22]

Among the benefits mentioned is the calmness of nurses. Lack of knowledge leading to legal violations in the profession with increased nursing errors and the resultant complaints result in increased costs, reduced occupational credibility, stress, anger, disappointment, guilt, and legal prosecution.[4] Involvement in legal cases related to patients' lawsuits is a painful and disabling experience for nurses, which negatively influences their practice and causes boredom with the job and mental as well as practical obsessions at work, desertion, and then frustration, fear, anxiety, physical and emotional exhaustion, embarrassment, and lowered self-esteem.[23] The presence of forensic nurses as instructors/counselors can help to prevent legal problems and avoid the abovementioned issues.

The presence of a forensic nurse leads to better legality of nurses. Since they are involved in many problems related to law such as negligence, malpractice, etc., knowing the legal issues can prevent them from a large extent.[16] Forensic nurses can defend their own rights with the necessary skills and knowledge they have and, if necessary, collect information to resolve legal issues.[6] At the same time, the presence of them as legal agents can lead to more legality of staff.

Due to their training, experiences, and professional duties, forensic nurses act better in death investigations, evidence gathering, record preservation, media management, public rights protection, privacy assurance, and support as well as having empathy with victims' families.[9] In addition, when forensic nurses are present, direct observation of care provided by other nurses would become possible and such acts as intentional torts (misconduct, scaring the patients, hurting, incorrect restriction) and quasi-intentional torts (slander, violation of territoriality, disclosure of patients' confidential information) are prevented.[24] Additionally, prosecution of criminals may increase[22] and, thereby, violation of the patients' rights is prevented.

One of the benefits of this presence is the growth compared with developed countries. In today's world, changes are inevitable. Professions that would not change according to the developments of health and justice would fail to upgrade their skills and services.[25] This also applies in our country, Iran; therefore, nursing needs to be changed to grow along with developed countries. In addition to the need for change, the costs of the health care system should be considered with great importance. At present, health systems are facing expanding needs and financial restraints[26] and having forensic nurses is a way to decrease these costs.[927]

Increased precision in handling cases through better documentation, detecting as well as collecting proper evidence, preparing for testimony in court,[28] and preventing the lengthiness of trials are other benefits of having a forensic presence. Having forensic nurses in each shift can reduce unnecessary delays and loss of life as well as evidence. A forensic nurse can provide immediate legal feedback and reduce many harmful delays by detection of suspicious cases, professional interviews with the victims, direct questions regarding the condition of the injury, accurate collection and documentation of evidence, coordination with the police and, if necessary, testimony.[25]

The higher performance of the Legal Medicine Organization is another benefit. In 1980, American pathologists and physicians found that forensic medicine organizations could not meet the needs of patients and nurses' collaboration was demanded.[10] In health care settings, victims must often wait for a visit to a forensic medicine. Meanwhile, it is not implausible that a life is lost. Thus, the presence of a forensic nurse in each shift can reduce this delay, loss of life, and destruction of evidence.[25] This fact becomes much more urgent when, according to the President of the Medical Council, the number of forensic medicines in Iran is one-third of the standard.[29] Thus, the presence of forensic nurses can partly offset this shortcoming.

The researchers believe that the establishment of new disciplines is critical to conform to the new needs of society.[30] In the health care system including the nursing profession, role development is a global trend, which is observed in recent decades.[31] Having forensic nurses leads to role development[22] and, consequently, higher employment in the profession. In contrast to all benefits mentioned above, role conflict with other forensic disciplines especially forensic midwifery was highlighted in the interviews. This is not solely for forensic nursing and the nursing profession. Forensic nursing combines nursing science, legal sciences, public health principles, and legal systems. These different origins innately cause role as well as duty conflicts.[32]

Nurses often find themselves in situations where role conflict occurs because of competition in healthcare settings and interaction with patients, families, physicians, and other colleagues who are in charge of patients and decide for them.[33] In Iran, according to the participants, no role conflict exists between forensic doctors and nurses but it seems that forensic midwives do not accept the role of forensic nurses as examiners of sexual abuse and consider other roles for forensic nurses. However, the victims of rape that occurs throughout the world may have to wait for a long time to receive medical services for their usually unseen traumas. In order to collect samples and evidence, they are not allowed to drink, eat, or use the toilet. Their waiting time may take up to 12 h until forensic examinations are performed.[34] This time would decrease to less than 60 min with the presence of a forensic nurse and the performance of the examinations.[35]

In addition, health care personnel do not often have the necessary experiences and skills to perform clinical examinations. In fact, the examinations of rape victims take 3–4 h on average and they usually dislike doing them and, at the same time, they are not qualified for testimony in the court.[34] This situation is exacerbated due to unprofessional conduct when the victims are blamed for being raped.[3637] The presence of trained forensic nurses provides victims with medical, psychological, and legal services at the community level or in health care settings.[38]

Another negative consequence is the nursing shortage. Based on the perceptions of participants in this study, forensic nurse training results in nurses not providing bedside care and aggravates the nursing shortage. However, forensic nurses use the nursing process to perform the assessment, provide and document care, educate patients, and collaborate with health care professionals for all clients involved in legal issues.[39]

The limitations of the current study were the social situation, specific religious, and cultural features of the context.

Conclusion

The findings of this study showed positive and negative consequences of the presence of forensic nurses in the health care system of Iran. In addition to improved performance of nurses and the cost-effectiveness of services, forensic nurses can prevent and resolve the legal problems of their colleagues as well as patients. However, role conflicts with other forensic professionals and shortage of workforce have been stated as negative aspects of their presence in the health system of Iran. If planners and policymakers have a positive attitude toward this presence, it can be hoped that by developing an integrated educational program for this discipline, a forensic nurse would better recognize the legal needs of clients and the required services and professionals. In such a suitable context, better forensic services can be delivered by forming forensic teams including forensic nurses, defining job descriptions, and providing necessary facilities. Obviously, with respect to the critical roles of nurses in providing care, it is obligatory to include educational programs of forensic nursing as a priority in continuing education programs and in curriculums of nursing at different academic levels.

Financial support and sponsorship

Shahid Beheshti University of Medical Sciences

Conflicts of interest

Nothing to declare.