"Oh! What a tangled web we weave, When first we practice to deceive."  Sir Walter Scott


 

Meliss Vessier-Batchen, RN, MSN, is an assistant professor with Charity School of Nursing/Delgado Community College. She is a doctoral student at Louisiana State University Health Sciences Center in New Orleans; her focus is forensic nursing with a concentration in death investigation. She is also a death investigator with the St. Tammany Coroner's Office.

Direct correspondence to Meliss Vessier-Batchen or to editor@lifeloom.com.


Forensic Nurse Death Investigators

Introduction

             There is no standard definition of a death investigator, making it extremely difficult to delineate differences between Forensic Nurse Death Investigators (FNDI) (Allert & Becker, 2003; Courson, 2000; Lynch, 2001) and Non-Nursing Death Investigators (NNDI). Literature provides very limited descriptions of the death investigator’s role. The lack of research on the death investigator role has resulted in an inability to link skills and knowledge used in death investigation with those used in nursing.

             A composite definition states that the death investigator’s role is to represent and advocate for the deceased (Allert & Becker, 2003; Fulton, 2003, James & Nordby, 2003; McPeck, 2002). The investigator should possess scientific and experiential knowledge in order to make professional and accurate judgments on manner of death based on pre-death symptomology, history, post-mortem appearance, toxicology, and other diagnostic studies. In addition, the current literature suggests a death investigator must be able to recognize and integrate other evidence, such as patterned injuries and patterns of injury, revealed during the investigation (Allert & Becker, 2003; Fulton, 2003, James & Nordby, 2003; McPeck, 2002).

Forensic Nurse Death Investigators (FNDI) and Non-Nursing Death Investigators (NNDI)

             According to Lynch (1993), 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, and/or death related medicolegal issues. For the purpose of this paper, a Forensic Nurse Death Investigation is identified as a specialization in forensic nursing and conducted by a registered nurses function in an FNDI role. A Non-Nursing Death Investigator (NNDI) is anyone that performs the duties of the death investigator whose education and/or training background is other than nursing. NNDI’s include investigators with education backgrounds ranging from high school diplomas or General Equivalency Diplomas (GED) and on-the-job training by other investigators to degrees in forensic science or other related sciences other than nursing.

Application of the Nursing Process by Forensic Nurse Death Investigators

             As nursing roles shift from the more traditional roles to the non-traditional role of death investigator, the major components of the nursing process must be re-conceptualized in order to clarify how nurses operate in the forensic environment. The components of the nursing process are the client, the environment, the definition of health, and the definition of the nurse’s role.

             Concepts and theories used as a foundation for forensic nursing interventions include victimization, violence, manipulation, custody, and human rights. Understanding these concepts may clarify the FNDI’s understanding of the client, survivors, environment, and the non-traditional nurse’s role (Hufft & Peternelj-Taylor, 2000). Placing nursing in the DI context, the object of nursing care, the client, can be thought of in terms of the decedent, the families or next-of-kin, the witnesses or discovery person to the event, the other agency officials, and/or the community (neighbors, neighborhood, subdivision, area of the city, the city, etc.).

             The environment or context for practice for the FNDI may include any location where a decedent has been found or a death has occurred, including an acute care or long-term care facility. In many jurisdictions, a death that occurs within twenty-four (24) hours of entrance into an acute care facility automatically classifies that death as a coroner’s or medical examiner’s case. The decedent may only be released by the coroner/medical examiner or a designated representative – usually a death investigator. In long term care facilities, any death not expected or classified as a hospice case automatically becomes an investigative case. Again, the coroner/medical examiner or a designated representative determines release of the decedent.

             The concept of health and health promotion, as the goal of nursing, is a challenge to reconstruct for the FNDI role. However, the physical, emotional, and spiritual elements of the health of the client, although in a non-traditional sense, must be addressed. For the individual client, the decedent, health is not a traditionally applicable term. Health is taken into consideration, however, when assessing events or factors preceding death. The health history of the client is extremely important as is the knowledge of medical procedures, treatments, surgeries, etc. in identifying possible links to a client’s demise.

             Clients may also include the survivors of the death (family, discovery person, etc.). For these clients, holistic care is still very much applicable. Health is defined as the state of optimal coping achieved by a survivor in order to emotionally handle the events concerning the decedent. When you consider community or society as client, the health of the community can be defined within the scope of violence or emotional well-being, social order and/or stability. The FNDI works within the criminal justice system to assist in the discovery of data to resolve the manner and cause of death and that resolution is a contributing factor to community well-being and social health.

             Ethics in nursing, as defined by Rumbold (1999), are people-oriented and focus on helping people toward holistic living. Whether applying ethics to the living or deceased client, the nurse’s actions should be guided by determining what is the right thing to do. The treatment of the decedent should be no less than what is expected for any living client, although the focus may be different. The concept of grief resolution may be applied to survivors of the decedent and to the agency personnel at the scene. Nurses are there for patients, families, and colleagues in traditional settings. Forensic Nurse Death Investigators maintain their nursing knowledge and skills when moving to these non-traditional roles.

             Nurses are working as DI’s across the United States, in New Jersey, St. Louis, Missouri, in some counties in Texas. A particularly innovative and interesting program exists and is in high demand in Charleston County, South Carolina. The coroner, Susan Chewning, RN, operates her office with 2 of her 3 investigators being registered nurses. This office runs an intern program that orients interested nurses to the rigors of death investigation including taking 24 hour call with a full-time investigator and being called out on every call. The interns have the opportunity to attend scenes, including traffic fatalities, homicides and suicides, with the death investigator. There are classroom sessions that provide a training outline and expectations for the role. There are currently waiting lists for program sessions.

General skills and Knowledge

             Nurses considering the DI role must possess specific skills and knowledge necessary to conduct an effective and thorough death investigation. Excellent written and verbal communication skills are essential. This includes, but is not limited to, the ability to communicate with families and agency officials with varying levels of education and communication skills. Emotional reactions of survivors may hinder effective communication during notification of a death. Investigators must be able to work with clients who are distraught with grief and guilt, and sometimes with the intention of deception. The FNDI must be prepared to use deductive and inductive reasoning skills to quickly and accurately assess the situation, estimate safety factors, and operate within any limitations set by the situation.

             The FNDI must have a working knowledge of the jurisdictional laws as well as state and federal laws governing the responsibilities of the death investigator. In Louisiana, as in other jurisdictions, death investigators may function, more accurately, as deputy coroners, issuing orders for protective custody in psychiatric cases. A strong knowledge base in physical and mental assessment, anatomy & physiology, medical treatment modalities, and pharmacology, will assist in formulating an accurate health history of the client.

             Although no descriptions of the characteristics of a successful death investigator are available, one can make logical assumptions regarding needed attributes of a person functioning in the FNDI role. Helpful attributes include a curious nature, an eye for detail, the ability to discriminate and document crucial and pertinent information in an objective manner, a strong stomach, good coping skills, mechanisms, and techniques, education, training, inductive and deductive reasoning skills, an analytical, logical nature, extensive clinical experience, intuition, an ability to compartmentalize feelings, and social maturity.

             It is interesting to contemplate whether nurses in the FNDI role perform differently than NNDI’s. As more nurses enter the realm of death investigation, research must be conducted to describe what nurses do, if and how FNDI’s perform differently than NNDI’s, and whether the unique characteristics and education background of nursing brings anything unique and special to the DI role. One of the most important considerations for FNDI’s is the benefits, or lack thereof, of nurses as death investigators. Although currently unmeasured, FNDI’s must examine the effects of their presence in the role on those identified individuals in the investigation. The knowledge of medical conditions and understanding of history, procedures, treatments, and pharmacology are major contributing factors in determining the direction of a scene. The nurses’ ability to analyze and assimilate health histories, the importance of writing reports and summaries in an objective format, making relevant observations and communications in a non-judgmental way, and use of interpersonal and interrelation skills should enhance sometimes difficult interview. The FNDI’s understanding of the social environment as part of the community, and an holistic view of client care, caring, and understanding the patient (decedent) as part of the community, in combination with the value of touch and voice, and an investigative nature in interviewing and working with the survivors of the decedent bring the nurse’s practice experience into a new arena (Personal communication, Dr. K. Wren, LSUHSC, 2003).

             The nurse’s supportive role may include dealing with extremely emotional, distraught, and, possibly, aggressive survivors. In many cases, opportunities for survivors to achieve closure in the relationship with the decedent are nonexistent. The survivors may also have witnessed a traumatic death, lost a loved one to homicide, or been the discovery person of an unexpected death or suicide. As death investigators, forensic nurses are on the scene prepared to investigate the death and render care to the survivors, maximizing time, care, and information.

Nurses and Death Investigation

             The most frequently asked question this author has encountered at any one time (besides “Do you watch CSI?”) is “Why would a nurse want to be a death investigator?” If some thought is given to this question, why would a nurse want to “see dead people, on purpose”? This answer may be different for each nurse. For the author, it has been the feeling that nursing knowledge and experience can be used in finding out what happened to a decedent, why it happened, and, in applicable cases, if it could have been prevented. Nursing knowledge may fuel a quest to put the pieces together, using the analysis and assessment skills of nursing. It can direct the questions asked by the investigator, ultimately assisting the forensic pathologist in finding out why this person died. Finally, FNDI’s may aid survivors of the event in accepting and expressing grief relating to their loss.

             The American Academy of Forensic Sciences (AAFS) and the American College of Forensic Examiners (ACFE) offer professional support and networking opportunities for those in a forensic role. Each offers a slightly different advantage with membership and each should be investigated thoroughly by perspective members to understand what each organization has to offer and how membership will enhance role and knowledge development for that individual.

             First and foremost for forensic nurses is membership in the International Association of Forensic Nurses (IAFN). Their website is www.iafn.org. This is an organization that provides information on forensic nursing roles and networking opportunities. Additionally, the IAFN is dedicated to the development of standards and certification for forensic nurses.

             Credentialing is important as it demonstrates of a standard of knowledge required to competently perform the duties of a death investigator in an ethical and consistent manner. For death investigators - nursing and non-nursing – the American Board of Medicolegal Death Investigators (ABMDI) currently offers two levels of credentialing; registration and certification. Everyone must start with registry which, when passed, makes the registered death investigator a diplomat in ABMDI. The exam is divided into sections addressing interaction with agencies, communication, interacting with families, investigating deaths, identifying and preserving evidence, maintaining ethical and legal responsibilities, demonstrating scientific knowledge, and coping with job-related stress. All sections must be passed. There is also a list of skill requirements that the death investigator must fulfill. Certification level is available but the exam cannot be taken until more stringent qualifications and requirements are met by the examinee. The person must have a minimum of 4800 hours logged as a full-time investigator, at least six (6) years experience as an investigator and registry through ABMDI. For nurses, IAFN is currently forming a committee which will develop a certification exam for death investigators.

             Currently, there are no required standards for credentialing or education of death investigators in the United States. Individual jurisdictions may specify minimum requirements including registry, college degrees, experience, or formal training through a certificate program. This varies greatly from place to place and may depend on the system within the jurisdiction (coroner, medical examiner, or combination). The senior investigator for Jefferson Parish in southern Louisiana requires his investigators to have a bachelor’s degree in forensic science or other related science.

             If you are interested in learning more about the role of the death investigator, consider contacting your local coroner’s or medical examiner’s office. There may be voluntary or contract positions that would allow further exploration of the field. Until you’ve experienced the varied and sometimes grizzly scenes you cannot be absolutely sure this role is for you. But when you are on a scene and your investigative juices begin to flow, your compassion and caring nature works in harmony with you deductive and inductive reasoning, you will know you’re in the right place doing the right thing with your nursing.

References

             Allert, L.J. & Becker, M. (2003). Death investigation: Nursing on the cutting edge. Forensic Nurse. Retrieved January 30, 2003 from http://www.forensicnursemag.com/articles2811lifedeath.html

             Courson, S. (2000). The investigative specialty of forensic nursing. Pennsylvania State Nurses Association Career Series. Retrieved January 17, 2003 from http://www.psna.org/Career/forensic.htm

             Fulton, M. (2003). Forensic nurses as coroner and death investigators. Forensic Nurse. Retrieved January 19, 2003 from http://www.forensicnursemag.com/articles011lifedeath.html

             Hufft, A.G. & Peternelj-Taylor, C. (2000). Forensic nursing : An emerging specialty. In J.T. Catalano (Ed.), Nursing now: Today’s issues, tomorrow’s trends (pp. 427-448). Philadelphia: F.A. Davis

             James, S.H. & Nordby, J.J. (Eds.) (2003). Forensic science: An introduction to scientific and investigative techniques. Boca Raton: CPC Press.

             Lynch, V. (1993). Forensic nursing: Diversity in education and practice. Journal of Psychosocial Nursing, 31(11), 7-14.

             Lynch, V. (1995). Clinical forensic Nursing: A new perspective in the management of crime victims from trauma to trial. Critical Care Nursing Clinics of North America, 7(3), 489-507.

             McEwen, M. & Wills, E.M., (2002). Theoretical basis for nursing. Philadelphia: Lippincott, Williams, & Wilkins.

             McPeck, P. (2002). Crimefighting RN. Nurseweek.com. Retrieved January 17, 2003 from http://www.nurseweek.com/news/features/02-09/chabert_web.asp

             Standing Bear, Z.G. (1995). Forensic nursing and death investigation: Will the vision be co-opted? Journal of Psychosocial Nursing, 33(9), 59-64.

Copyright 2003 by Meliss Vessier-Batchen


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