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Giving Thanks, 2016

This Thursday is Thanksgiving here in the US. And with all the complicated history that holiday holds, it remains a time to take a hard look at the life I lead and express some real gratitude for what I have. I won’t lie–2016 has been kind of awful in many ways: I lost one of my very best friends this year; we had to put down our beloved husky earlier this fall (after we discovered in some of life’s most terrible irony that she had essentially the same kind of cancer as my dear friend); and of course, the US election. Decidedly not good. So this exercise is more important than ever–my short, but heartfelt list of gratitude:

  1. FHO Readers: Let’s face it–you guys are pretty terrific. I’ve heard from you a lot this year. You’ve sent countless emails to me (and even posted a few comments) extending your love and support in the wake of tough times, and providing encouragement with the unveiling of the new site. And I have met *so many* of you at conferences and trainings–I really value these interactions, both virtual and IRL. People ask how I have the energy to devote to this site, but the truth is, I get so much more out of it than you may realize, both in community and in lessons I learn from you as you reach out with questions and concerns. I really heart my readers.
  2. Family: One of the reasons I love this holiday is that it’s the one time of year I am immersed in family. The rest of the year we are pulled in a million directions, but for this one week, we are all together, and it is pretty glorious. In part because we’re serious about food and cooking, in part because the makeup of our table is diverse and welcoming, and fitting for the season. Participants will range in age from 4 to 92. One third of the table won’t speak English as their 1st language. And heaven help us, my teen age girl child’s boyfriend will be there, as well. So there it is.
  3. Work: I love what I do, it’s never the same 2 days in a row, I get to work with my friends a lot (as well as many I admire), and I meet interesting people along the way. It’s awesome and I am so very thankful I can make a living this way.
  4. DC: For all the turmoil I feel about politics right now, DC is a thrilling place to live and I am lucky to be in the middle of it. I hope I can always live there, in my lovely, progressive neighborhood full of restaurants, kids, gay folks and dogs. I wouldn’t want to be anywhere else (or be here with anyone else).
  5. This guy: His name is Hamilton, and he’s coming home with us Sunday.

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Happy Thanksgiving to all who celebrate. I’m out for the rest of the week. See you back here Monday.

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Since Last We Spoke, Thanksgiving 2016 Edition

This may be one of my favorite weeks of the year–my family is serious about cooking, so we are hard core about our Thanksgiving meal. Invariably my parents’ table includes an assortment of medical students, residents and/or attendings who had nowhere to go for the evening. This year, aside from my little brother and his family, my girl-child and spouse, there will also be an Israeli doc and his family who are relatively new to the whole Thanksgiving circus. It’s absolutely the best.

I was in trial last week and had company over the weekend, so I stayed off the computer for as much as I could. Still, a few things caught my eye since last we spoke:

Well, this is appalling

46,000 donations already

Interesting take on social media

May be the only thing to get me through the next 4 years

Quick, get that IUD!

Moving essay in honor of Transgender Remembrance Day

Conquering your fear of public speaking

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Elder Abuse/Neglect

Health Care Providers’ Role in Identifying and Responding to Older Victims of Abuse

NCALL has a webinar coming up: Health Care Providers’ Role in Identifying and Responding to Older Victims of Abuse. The session will be held 8 December at 11am ET. From the site:

Health care providers are in a unique position to identify and respond to elder abuse. Dr. Veronica LoFaso, a geriatrician at Weill-Cornell Medical College in New York City, will discuss signs of elder abuse and neglect and how health care providers can identify and respond to potential older victims. Dr. LoFaso will also describe how victim service providers and other professionals can engage health care providers to work collaboratively with them. In addition, she will describe the important role health care providers can play on multidisciplinary case coordination teams.

Register here.

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DV/IPV

Non-Fatal Strangulation Documentation Toolkit

Here’s a project to get excited about: IAFN just released the non-fatal strangulation documentation toolkit, available for free download (PDF). As noted in the preface, the toolkit “provides the forensic nurse with detailed guidance on assessment techniques, documentation, and evidence collection for this patient population. This toolkit also provides documents such as discharge instructions and sample policies that can be adjusted to best suit your institution and your forensic practice.” I encourage you to share widely, particularly with your ED physician and nursing colleagues (you’ll notice there is emergency medicine representation on the task force that developed this document).

We’ve been pretty hungry for guidance like this, so my hunch is this will be a popular post 🙂

{see also: Strangulation Position Paper, strangulation case review (fee)}

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The Urgency of Intersectionality

We do not spend a whole lot of time in forensic nursing talking about intersectionality, of which I was reminded when I received notice of this new TED talk today. That in and of itself is an issue. But the current realities here in the US being what they are makes this both timely and necessary. So I’m just going to leave this right here:

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Since Last We Spoke, 11-14-16

I’m in Norfolk, VA this week with the Navy, and my schedule will be a bit unpredictable, so please bear with me as I try to get posts up. Some weeks I”m better at planning ahead than others–what can I say.

I had a really fantastic workshop on Friday with the Indiana IAFN chapter and it got me thinking quite a bit about how spiritually fulfilling it is to come together as a likeminded group and just get to talk about this work we love. I really needed that, so thanks to all of you who brought me to Indianapolis, and who made the day so lively and thought provoking.

Yesterday was a travel and work day for me, so I haven’t spent much time online (not to mention I find my feeds to be depressing and scary right now with the US election). But here’s a little of what’s caught my eye since last we spoke:

Productive conversations during difficult times

A new app to report assaults

Ah, the office control freak

Feel like you need to contribute (more) in the wake of the election? Here are some charities helping to ensure everyone’s safety and equality. (I just set up a small monthly to donation myself.) Or try this list.

Interesting look at the impact of electing Trump on business leadership

A (tiny) bright spot in the election

New approach to families of suspects killed by police

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This Forensic Nurses Week, A Look Ahead

To wrap up Forensic Nurses Week, let’s talk about what the future holds for the profession…

We’re at this point in our profession where we can really enumerate some incredible collective accomplishments, including multiple national protocols, a significant body of research, evaluation tools–we’re young, but we’ve got quite a bit to show for our relatively brief existence. So what’s next for us? What I submit are less predictions and more considerations for your time and attention. If we make them happen, so much the better for us and our patients. My big three:

  1. Diversify funding. We have to move away from solely being funded by criminal justice resources and look at ways to cultivate healthcare dollars for our programs. To be clear, I love how supported we have been by the criminal justices agencies that have funded many of our programs and projects. But there’s a lot more we could do if we had broader support from healthcare agencies. Expanded practice; more research around healthcare outcomes for our patients; funded clinical preceptorships and even residencies.
  2. Attack attrition. The sheer number of nurses who never complete their clinical training, or join our programs but leave within the first year, is staggering. As things stand, we are not getting great return on our investment writ large. We need to evaluate the very specific reasons people bail and identify concrete solutions to minimize their impact. I’m pretty certain there’s a project here.
  3. Focus post-baccalaureate forensic nursing programs. Yes, I’m down with education for education’s sake. But most people don’t have the kind of expendable funds to simply go back to school because learning is awesome (although it is, and I would go get an MBA if it was free). There’s this enormous push to get forensic nurses to go back to school, but if you look at the curricula for many of the graduate forensic nursing programs (at least here in the US), I can’t identify the specific job people are being educated for. First off, we haven’t developed enough full-time roles for forensic nurses to allow people a legitimate chance to make a living in the field. And the bulk of the jobs specifically for forensic nurses out there don’t generally require a forensic nursing graduate degree. A practitioner degree, or an MPH or even an MBA? Sure. But not a masters in forensic nursing. So I think we need to look at a long-range plan for expanded forensic nursing roles at all levels of health care. And simultaneously, we need to rethink forensic nursing graduate curricula so that we are educating forensic nurses with greater purpose (and yes, I have some pretty specific ideas about this, so call me, schools of nursing–I will come consult for you).

I would love to hear where you think we’re headed in the next 5-10 years, so chat me up online, here on the site (or knowing you guys), via email. My point of view is obviously a very specific one.

Happy Forensic Nurses Week, everyone. Know that I really honor the diverse contributions you make to the field, the collegiality I so enjoy because of my interactions with you on FHO and in actual life, and the sheer determination you display in getting programs up and running and keeping them afloat–all in the name of providing great care to victims (and perpetrators) of violence. Kudos to all y’all.

 

 

Categories
Testimony

Be Better: Implement a Quality Improvement Process

This Forensic Nurses Week, we’re talking about ways to make our practices better. The last couple days have focused on individual performance. Today, let’s talk about program performance…

The expert at trial should never be the first person to review our record of the patient encounter.

But that’s exactly what happens when a forensic nursing program has no formalized quality improvement process in place. And that’s a problem–because it means the program has set no benchmarks for what constitutes optimal performance. If there are no benchmarks for quality, how can a forensic nurse know if they’re doing a good job? How can they grow in their clinical capacity? How can the program hope to effectively (and sustainably) expand their program to other patients?

As we wrote for the SANE Sustainability project:

Every SANE program should have a process for regularly reviewing patient care and clinician performance. Having such a process means that the program has set specific and achievable benchmarks for quality. Programs that have a plan in place often center that plan on quality assurance initiatives, which are an appropriate initial step. But programs should strive to incorporate a quality improvement process for sustainability. Quality assurance focuses on the individual and addresses a problem or deficiency that has already occurred; quality improvement is systems-focused and is proactive, done with the intention of making changes to prevent future issues from occurring. Some aspects of a quality process can serve a dual role: chart review, for example, allows for both quality assurance (e.g. making sure that documentation is complete for every patient seen in the program) and quality improvement (e.g. noting that multiple clinicians appear to have issues obtaining clear photos at close-range). Peer review also can serve both functions, bringing to light issues with individual documentation or interpretation of findings, but also serving as an educational opportunity that informs the clinical knowledge of all participants.

You can read the full piece on the NSVRC website. It’s full of resources and suggestions for implementation. (And if you still haven’t downloaded the app, get it here).

This should not be an optional program component. I have never talked about creating a defensible practice (one that can withstand vigorous scrutiny on cross examination) and not discussed the importance of a quality process. Program managers should fight for paid time in their schedules to implement and conduct quality improvement activities. Forensic nurses in programs without quality improvement processes should strenuously advocate for them. Medical Directors should step up and participate, as well–your voices are needed as one aspect of an effective quality process. And if you already have a process in place, talk about how it’s working with other program managers who are struggling to make this happen. Quality improvement processes benefit professional growth, efficacy of witness testimony, and most importantly, patient care.

Tomorrow, we wrap up the discussion of improving our profession with a look ahead. What’s next for us?

Categories
Testimony

Strive for Better Documentation

Because it’s Forensic Nurses Week, we’re focusing on ways to improve practice. Today, let’s talk about documentation.

Want to know my one wish for better medical-forensic documentation? Three words: review of systems (ROS). Seriously–hear me out on this.

In order to improve documentation, it’s critical to consider its purpose. We don’t document our encounters in anticipation of trial. We document because it’s the standard of practice for any healthcare encounter, forensic or not. We document because we aren’t going to be the last person to care for this patient. Everyone benefits from picking up where the last guy left off rather than starting from scratch each time (an argument for why medical-forensic records should be available to other healthcare providers, but that’s another post).

So why am I so enamored with ROS? Because it forces us to think about the entire patient, not just the most likely sites of injury or the areas that get swabbed; because it allows us to consider concomitant health issues with which our patients present, ones we can address while they’re with us.* And since we were talking about differential diagnoses yesterday, let’s keep in mind that completing a ROS with every patient often allows us to better identify the most likely causes for the patients’ findings.

Why do I like to see it in records I review before trial? Because it’s harder to argue that the treating clinician is just a forensic technician or arm of the investigation when there is this type of comprehensive exam documented. It demonstrates a commitment to caring for the whole patient and not just focusing on where potential evidence may be found. I have no hard science to back this up, but my anecdotal experience is that programs that don’t conduct (and document) ROS with their patients are more likely to have other gaps in their exam process and documentation: missing vitals, health history, allergy information, suicide assessment, danger assessment, follow-up recommendations. Conducting a ROS means clinicians are more likely to subscribe to the notion that experiencing violence is a healthcare crisis, not just a crime.

Tomorrow, let’s talk about the one process program managers can implement to move our practices forward.

*Many of my patients don’t regularly access healthcare services, so it’s a shame to waste the opportunity to provide as much care as I am able to, simply from a public health perspective.

Categories
Testimony

This Forensic Nurses Week, Ask Yourself: How Do We Do Better?

This week, because it’s Forensic Nurses Week, I’d like to talk about how we can keep getting better. First up: one way to generally improve our value to patients and the justice system simultaneously.

There’s a lot to really celebrate about the work we do in forensic nursing. But we still have areas upon which to improve. Often times our field is preoccupied with the legal aspects of the work, sometimes to the detriment of good patient care. There is an abundance of research that underscores just how extensively violence impacts health in both the short- and long-term. And yet so much focus is on evidence collection and the patient as “crime scene” (a completely unfortunate designation).

The best thing we could do to be better at this work, both in the exam room and in the courtroom would be to do everything in our power to improve our assessment skills. Participate in as many educational sessions as we can find on injury evaluation and general physical assessment; spend time with more experienced clinicians crafting comprehensive differential diagnoses for the injuries and infections we see. Not only will it mean better care for each patient who sees us (and appropriate anticipatory guidance prior to discharge), it will also mean that if we take the stand we can speak extensively to the clinical care of our patients, including what else could have caused the issues the patient had (and why we ruled out many of them). Why is that important? Because we are licensed nurses and our role is to provide healthcare, not investigate crime. Want to have the opportunity to tell a jury what the patient said about the assault? It’s a lot less likely to happen if our exam process sounds more like an extension of the investigation rather than a comprehensive healthcare encounter. Want to be the most credible witness possible? Make sure there is little room to attack testimony as biased.

On a related note, I don’t think it’s necessary to be an advanced practice clinician to be a good forensic nurse, but because of the autonomous nature of this work, we do have to develop some of those skills to be particularly proficient. That comes from flexing our assessment muscles (and the documentation muscles that go with it). Comprehensive patient assessments (with corresponding comprehensive documentation of those encounters) increase our efficacy in court. Because our job in court is to teach–not to get the “bad guy” and not to make the prosecution’s case.

I would submit that if we concentrate on enhancing our clinical capacity, patients will also benefit in the courtroom, but the inverse is definitely not true. If we focus on what could happen in the courtroom, patients’ healthcare will suffer. I see it over and over again when I review records and listen to clinicians testify.

Tomorrow, let’s discuss documentation– specifically the one thing that could universally improve medical-forensic record completeness.

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It’s Forensic Nurses Week! (And a Few Other Things)

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Happy Forensic Nurses Week to all of my colleagues around the world. Here’s to everyone who is doing this important work with the myriad populations we serve every day. If you haven’t seen the packet of information IAFN has for recognizing this week, wander over to their dedicated page and download your own press release or get some ideas for celebrating your team/staff. I’d love to hear if you’re doing anything special this week–I’ll be spending part of it in Indianapolis with the Indiana IAFN Chapter at their conference, so come say hello if you’ll be attending.

Obviously here in the US we have an election tomorrow–please for the love of all that is holy, go vote. Still not sure where to go? Google’s latest doodle will help you find your polling place. (#ImWithHer)

Lastly, Friday is Veterans Day (for my non-US readers, here’s a little about the history of this day). Please don’t forget to recognize all the veterans in your life.

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DV/IPV Sexual Assault

Criminal Victimization, 2015

Brand new statistics (PDF) on criminal victimization out from the US Department of Justice’s Bureau of Justice Statistics. Particularly for those of you seeking support for your programs or engaging in educational endeavors, here’s what we know about crime last year, including violent crimes like sexual assault and intimate partner violence…

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Uncategorized

Since Last We Spoke (and a Giveaway Winner!)

Greetings to you all, and a good Monday morning–my hometown baseball team is up in the World Series 3-2 and we are a mere 9 days from this election being over, one way or another. Here’s hoping you had a lovely weekend, wherever you spent it. A continued trial means I am unexpectedly at home this week with nothing scheduled (but plenty to do), so I’m looking forward to that. Also, congratulations to Christianna Peterson, the winner of the latest giveaway.

Here’s what I’ve been reading since last we spoke:

It’s like we’ve just discovered contraceptives have side effects that can be unpleasant

Somewhat related

Life skills no one taught you

Be a leader people want to follow

I have seriously mixed feelings on this

News from Baylor just keeps getting worse and worse

In other football news…

We’ll end this list on a positive note:

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Testimony

Evaluating the Treating Clinician’s Testimony: A Defense Expert Perspective

Don’t forget we have a giveaway going on this week. See all the details here.

I taught a new session at IAFN this year, Evaluating the Treating Clinician’s Testimony: A Defense Expert Perspective. It was one of ten that was recorded, and it’s now available for purchase on the IAFN site. For $25 ($40 for non-IAFN members) you can check out the talk– 1.5 CEs are included in the fee. Find this, and all of the other recorded sessions here.

 

Categories
Child Abuse DV/IPV Sexual Assault

Childhood Trauma: Changing Minds

Don’t forget we have a giveaway going on this week. See all the details here.

Have you seen the new multimedia presentation on childhood trauma from Futures Without Violence? If not I encourage you to take a look–some terrific information about how trauma impacts kids’ brains and what we can do to help.

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Categories
Sexual Assault

The Intersection Between Prostitution, Human Trafficking, and Victimization Among Justice Involved Women

Don’t forget we have a giveaway going on this week. See all the details here.

The National Resource Center on Justice Involved Women has a webinar coming up next week: The Intersection Between Prostitution, Human Trafficking, and Victimization Among Justice Involved Women. The session will be held November 1st from 2-3:30pm ET.

From the site:

It is estimated that 90% percent of justice involved women have experienced some form of victimization in their lifetime. As a result of this trauma, women may engage in behaviors that are criminalized, such as drug use or prostitution, and may be less commonly seen as “victims” by the justice system. What’s more, their vulnerability may expose them to further victimization, trauma, and exploitation — such as human trafficking.

The NRCJIW, in partnership with the Center for Court Innovation, will conduct a webinar on November 1 to explore the nexus between prostitution, human trafficking, and victimization among justice involved women. The webinar will discuss strategies that justice system stakeholders can take to identify women who may be victims of exploitation and human trafficking, address their needs, and improve their response to these women.

Register now for this informative webinar to take place on Tuesday, November 1 from 2:00 – 3:30 pm Eastern.

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Uncategorized

Welcome to the New FHO!

Welcome to the new, improved Forensic Healthcare Online! As we approach FHO’s 8th birthday, I thought it was time to spruce things up a bit. Here’s what you’ll find on the redesigned site:

  • More focused content: FHO readers have their favorite areas and now it’s easier than ever to find what you’re looking for, whether it’s DV/IPV, sexual assault, child abuse, elder abuse or court testimony.
  • More organization: the popular stuff leads, but nothing should be tough to find with clear categories and a pleasing lay out. All regular blog posts can now be found under Articles.
  • More consistent clinical guides: on the old site, clinical guides were all over the map, design-wise, making it harder to find what you needed. Now all clinical guides have one format, for a streamlined look that’s easier to read.
  • More responsiveness: check out how FHO looks on phones and tablets. Nice, right? Now you won’t miss out on content or functionality when you visit FHO on a mobile device.
  • More content: coming soon to FHO—an online store with resources that take your practice to the next level, whether in the exam room or the courtroom. Peer-reviewed, available for download to computers or mobile devices, and regularly updated. All of the things you’ve come to expect from FHO, just more of it.

To celebrate the launch of the new FHO site, let’s give something away, shall we? Leave a comment with feedback about the new look, and on Friday, 28 October one reader’s comment will be chosen at random to win either a copy of the Forensic Nursing Core Curriculum or a $50 Amazon gift card. THIS GIVEAWAY IS NOW CLOSED. THANKS ALL WHO ENTERED. I encourage you to take some time to really poke around the site—I’ll be fine-tuning as we identify issues in this next week, so by all means, let me know if you spot a problem. (I’ve spotted one of the 1st ones—the bulk of comments from the old site haven’t yet transferred to the new one).

Finally, I would be remiss if I didn’t take a moment to thank my spouse, Sasha Rutizer, JD, and my father, Alan Markowitz, MD, who have supported my work on this site since its inception. Both have been unwavering in their encouragement and provided terrific suggestions about next steps and ways to get there. And a special thank you to my merry crew (you know who you are) who have weighed in on logo choices and other design elements, cheered on the evolution of FHO and just generally make me a better clinician, educator and writer. I have had the great, good fortune to have wonderful collaborators, mentors and friends in my twenty plus years in this field.

Categories
DV/IPV

Since Last We Spoke, 10-17-16

I’m really pretty well consumed with the election coverage, or at least my Twitter feed is (and my FB feed, and my Instagram feed). I fear until the election is over, this weekly feature will be a little sad. Sure, there are other things happening in the world, but I have no idea what. So here’s what little I’ve been reading since last we spoke:

 A familiar story

This hurt me on so many levels

A lovely tribute

As someone with chronic pain I feel all of this

The magnitude of stalking

One paper’s response to threats

A long, but fascinating, read

The sexism of the likability trap

Categories
Child Abuse

Consent for Kids

I’m just going to go ahead and leave this here (although feel free to share with some of our politicians…)

{By @BlueSeatStudios; h/t NSVRC}

Categories
Child Abuse

Trauma Informed Care of Immigrant and Refugee Children

The National Health Collaborative on Violence and Abuse has a webinar coming up next month: Trauma Informed Care of Immigrant and Refugee Children. The session will be held November 16th from 1-2:30 pm ET. CMEs will be available for physicians (sadly, with all of the nursing representation in this organization, they still aren’t offering CEUs for us, but a girl can hope). Click through for available details:

From the email (no session description available):

Learning Objectives:

  1. Examine the effects of trauma on immigrant children
  2. Discuss mental health screening of immigrant children
  3. Discuss strengths based approaches to build resilience and heal trauma
  4. Learn how to utilize the medical home/care coordination models to more effectively meet the unique needs of immigrant children and families.

Featured Speakers:

Andrea Green, MD, Director of the Pediatric New American Clinic at UVM Children’s Hospital

Cathleen Kelley, MSW, LCSW, Pediatric New American Clinic at UVM Children’s Hospital

Register here.