Nurses' performance of trace preservation in sexual violence against women: an integrative review

ABSTRACT

Objective

to analyze the challenges for nurses' performance of trace preservation in cases of sexual violence against women discussed in the literature.

Method

this is an integrative review carried out in the SCOPUS, Cochrane, LILACS, MEDLINE and CINAHL databases and in Google Scholar in January 2021. The descriptors Sex Offenses and Forensic Nursing were used, combined with the Boolean operator AND. A total of 207 articles was found and 15 were selected.

Results

The identified challenges were: lack of human resources and training in forensic nursing; training of nurses to collect traces; limited performance of trace preservation procedures; conflicts between the nurse's role in care provision and in the collection of traces; absence of protocols or standardization of the existing ones; underreporting of sexual assault cases; lack of time and fear of liability or reprisal; absence of legal instruments to regulate the nurses’ attributions and role in the chain of evidence custody.

Conclusion and implications for practice

Actions aimed at training nurses and creating protocols, with expansion and implementation of the existing public policies, are essential to strengthen the role of nurses in trace preservation in cases of sexual violence against women.

Keywords:
Sex offenses; Forensic nursing; Women; Violence Against Women; Review

RESUMO

Objetivo

Analisar os desafios da atuação do enfermeiro na preservação de vestígios nos casos de violência sexual contra a mulher, evidenciados na literatura.

Método

Trata-se de uma revisão integrativa, realizada nas bases de dados SCOPUS, Cochrane, LILACS, MEDLINE, CINAHL e no Google Acadêmico, em janeiro de 2021. Utilizaram-se os descritores Sex offenses e Forensic Nursing, combinados com o operador booleano AND. Foram encontrados 207 artigos e selecionados 15.

Resultados

Os desafios identificados foram: carência de recursos humanos e de formação em enfermagem forense; formação de enfermeiros para coleta de vestígios; execução limitada de procedimentos para a preservação de vestígios; conflitos entre o papel do enfermeiro no cuidado e na coleta de vestígios; ausência de protocolos ou padronização dos já existentes; subnotificação dos casos de agressão; falta de tempo e medo da responsabilidade legal ou represália; ausência de instrumentos legais que regulamentem as atribuições do enfermeiro e seu papel na cadeia de custódia das provas.

Conclusão e implicações para a prática

Ações que visem capacitar os enfermeiros. A criação de protocolos, de forma a ampliar e implementar políticas públicas já existentes, são imprescindíveis para o fortalecimento da atuação do enfermeiro na preservação de vestígios nos casos de violência sexual contra a mulher.

Palavras-chave:
Delitos sexuais; Enfermagem forense; Mulheres; Violência contra a Mulher; Revisão

RESUMEN

Objetivo

analizar los desafíos de la práctica del enfermero en la preservación de vestigios en casos de violencia sexual contra la mujer evidenciados en la literatura.

Método

revisión integrativa, realizada en las bases de datos SCOPUS, Cochrane, LILACS, MEDLINE, CINAHL y Google Académico en enero/2021. Se utilizaron los descriptores Sex offenses y Forensic Nursing, combinados con el operador booleano AND. Encontrados 207 artículos; 15 seleccionados.

Resultados

Desafíos identificados: falta de recursos humanos y capacitación en enfermería forense; formación de enfermeros para la recogida de rastros; ejecución limitada de procedimientos de conservación de vestigios; conflictos entre el papel del enfermero en el cuidado y en la recolección de huellas; ausencia de protocolos o estandarización de los existentes; subregistro de casos de agresión; falta de tiempo y temor de responsabilidad legal o represalias; ausencia de instrumentos legales que regulen las atribuciones de los enfermeros y su papel en la cadena de custodia probatoria.

Conclusión e implicaciones para la práctica

Acciones dirigidas a la formación de enfermeros y elaboración de protocolos con ampliación e implementación de las políticas públicas existentes son fundamentales para fortalecer el papel de los enfermeros en la preservación de vestigios en casos de violencia sexual contra la mujer.

Palabras clave:
Delitos sexuales; Enfermería forense; Mujeres; Violencia contra la Mujer; Revisión

INTRODUCTION

The International Association of Forensic Nurses (IAFN) recognizes forensic nursing as a specialty that uses nursing science for the benefit of the population and of justice. Its main objective is to offer support for investigations of cases involving victims of different types of violence - physical, sexual, psychological, economic and domestic – and traumatic accidents, and also in the occurrence of deaths, trauma treatment of aggressors and victims, human trafficking, among other situations^1,2.

Recognized in the international scenario, the forensic specialty encompasses different areas of competency, having a paramount importance in the comprehensive healthcare provided for victims of violence, survivors of mass disasters, and people in deprivation of liberty included in the prison system, in mental health services and related sectors. In Brazil, this specialty has been recognized by the Federal Council of Nursing since 2011. However, it is necessary to disseminate and concretize the profession in the country, as it is a need of the current society³.

Violence is a serious social problem with increasing proportions. It challenges international agencies to search for solutions to mitigate the occurrences and their consequences. Countries like the United States and Canada have started to make and promulgate governmental policies and to improve the application of forensic science, qualifying and refining the collection of traces with the objective of preserving people’s lives and holding the perpetrators liable⁴.

Concerning sex offenses, the forensic nurse, supported by technical-scientific knowledge and by skills that run through a humanistic education, can collaborate with the judicial branch, contributing to investigations and to combat this type of crime, which shows their relevance to forensic science. They establish an important link between the health sector and the Judiciary⁵. In Brazil, Directive No. 204/2016 of the Ministry of Health and Resolution No. 564/2017 of the Federal Council of Nursing (COFEN) provide for the nurse’s duty when assisting cases of violence against women. Article 52 sets forth that any episodes involving violence must be reported^6-9.

It is consensual knowledge that, during assistance, traces are vital for a successful investigation, as they can contribute to the discovery of a solution that will lead to the resolution of the crime. The criminal investigation searches for the truth, aiming at the criminal prosecution of the perpetrators. Thus, the analysis of traces is crucial to prove the guilt or innocence of a suspect¹⁰.

Situations involving violent crime and traumas produce consequences in which interdisciplinary action is necessary. The main objective of nurses is to provide healthcare for victims of violence against women, and they must adequately identify and preserve biological and non-biological traces found on the body of the victim/aggressor or at the place where the crime was committed, as such traces might, later on, be used as expert evidence in court, with forensic relevance¹¹.

In this context, it is imperative that the clinical practice of the forensic nurse be incorporated into the daily routine of the professionals who assist people exposed to violence - a scenario that has been increasingly present in the health services. Our study was guided by the following question: “What is the evidence of the challenges for the nurse’s performance of trace preservation in cases of sexual violence against women?”. Bearing in mind that inadequate handling and/or suppression of traces preclude the investigative process, studies with this focus are important to deepen the existing knowledge about the theme, explaining the importance of the nurse’s action in these settings and contributing to enable the preservation of traces in cases of sexual violence, in order to guarantee the integrity of the criminal investigation and that the perpetrators are held liable.

Within this construct, the study aimed to analyze the challenges for the nurse’s performance of trace preservation in cases of sexual violence against women discussed in the literature.

METHOD

This is an integrative review guided by the stages proposed by Mendes et al.¹²: 1^st stage: identification of the theme and selection of the hypothesis or research question for the development of the integrative review; 2^nd stage: establishment of criteria for inclusion and exclusion of studies/ sampling or literature search; 3^rd stage: determination of the information to be extracted from the selected studies/ categorization of the studies; 4^th stage: evaluation of the studies included in the integrative review; 5^th stage: interpretation of the results; 6^th stage: presentation of the knowledge review/synthesis.

The guiding question of the review was: “What is the evidence of the challenges for the nurse’s performance of trace preservation in cases of sexual violence against women?”. This question was formulated according to the acronym P.I.Co (P = Participant, I = Phenomenon of interest, Co = Study context) ¹³. In this study, the participant is the generalist and/or forensic nurse; the phenomenon of interest is women in situation of sexual violence; the context is prehospital and hospital level.

The analysis of evidence from the scientific literature about the theme was carried out in January 2021 on the following databases, accessed by means of the Portal of CAPES (Coordination for the Improvement of Higher Education Personnel): SciVerse Scopus (SCOPUS), Cochrane Library (Cochrane), Latin American and Caribbean Health Sciences Literature (LILACS), MEDLINE via PubMed, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). A search was also performed in Google Scholar. We used the descriptors “Sex offenses” and “Forensic Nursing”, contained in DeCS (Health Sciences Descriptors) and MeSH (Medical Subject Headings), combined with the Boolean operator AND.

The inclusion criteria were original articles and texts like expert opinion, updated or theoretical texts, available in full, published in Portuguese, English or Spanish from 2011 to 2021 and which approached the theme of this research. The exclusion criteria were articles that approached other kinds of violence, news reports, and studies on development of technologies.

The articles were selected in two stages. First, we read in detail the titles and abstracts of the 207 studies found in the above-mentioned databases. After we applied the inclusion criteria and excluded 5 duplicate articles, 29 articles remained in the analysis. Subsequently, we read the texts in full, exhaustively, to analyze if they met the requirements and inclusion criteria related to the theme approached in the integrative review. Two researchers participated in these two stages in an independent way. If there was disagreement between the researchers, they talked in order to reach a consensus. The final sample was composed of 15 studies (Figure 1).

Figure 1
Description flow of the articles found, excluded and selected according to each database. Created by the authors. Fortaleza-Ceará, 2021.

The data extracted from the selected studies were analyzed in a descriptive way and composed a synoptic chart of characterization of the studies (authors, year, country where the study was carried out, participants, methods, main results and level of evidence). To classify the level of evidence, we used the hierarchy of evidence proposed by Melnyk and Fineout-Overholt¹⁴: systematic reviews and meta-analyses of randomized clinical trials, level I; randomized clinical trials, level II; non-randomized controlled trials, level III; case-control or cohort studies, level IV; systematic reviews of qualitative or descriptive studies, level V; qualitative or descriptive studies, level VI; and opinion of authorities and/or reports of expert committees, level VII. This hierarchy classifies levels I and II as strong, III to V as moderate, and VI to VII as weak.

It is important to mention that the results obtained in the integrative review were discussed based on the scientific literature about the theme, regarding the integrity of the information presented in the articles and copyright, and care was taken not to make changes in the content found for the benefit of this research.

RESULTS

The 15 selected studies were carried out in the following countries: Brazil, United States, India and England. There was a greater representativeness of studies published in the United States (n = 8) and in Brazil (n = 5). As for year of publication, it varied from 2011 to 2019, with the highest number of articles published in 2014 (n=5). Regarding type of study, all were qualitative or descriptive (n=15) and 14 had level of evidence VI. Concerning the methodological approach, there were qualitative studies (8), quantitative studies (4) and mixed methods studies (3) (Chart 1).

Chart 1
Characterization of studies concerning title, authors, year, country, objective, type of study, main results and level of evidence.

N	Title	Authors/ year	Country	Target audience/sample	Objective	Type of study	Level of evidence
1	O enfermeiro e a preservação de vestígios frente a violência sexual contra mulher	Souza et al. (2017)15	Brazil	15 generalist nurses	To investigate the preservation of traces by the nurse during provision of care for female victims of sexual violence in an emergency service of the state of Sergipe.	Analytic and descriptive, Quantitative	Level VI
2	Preservation of Forensic Evidence by Nurses in a Prehospital Emergency Care Service in Brazil	Silva et al. (2020)16	Brazil	128 generalist nurses	To evaluate the relationship between nurses’ knowledge and performance of forensic evidence procedures.	Cross-sectional quantitative study.	Level VI
3	Defining the boundaries: How sexual assault nurse examiners (SANEs) balance patient care and law enforcement collaboration	Campbell et al. (2011)17	United States	11 forensic nurses	To understand how nurses who perform forensic exams in cases of sexual assault define their work with their patients, how they collaborate with law enforcement, and how they negotiate roles differentiation.	Qualitative and Quantitative	Level V
4	Forensic nursing - Global scenario and Indian perspective	Dash et al. (2016)18	India	Sample not informed, forensic nurses	To analyze the work of Forensic Nursing with victims of sexual assault in the global scenario and its perspective in India	Qualitative	Level VI
5	Original research: Giving sexual assault survivors time to decide: an exploration of the use and effects of the nonreport option	Heffron et al. (2014)19	United States	79 forensic nurses	To examine the implementation of the option of sexual assault nonreport in Texas; explore its impact on nurses who perform forensic exams in cases of sexual assault, survivors, and the criminal justice system; and identify strengths and challenges of the nonreport process.	Quantitative and Qualitative	Level V
6	Sexual Assault Nurse Examiner Forensic Examinations for Immigrant Victims: A Case Study	Payne (2018)20	United States	Sample not informed, forensic nurses	To analyze the action of forensic nurses who perform forensic exams in sexual assault cases involving immigrant victims in the United States.	Case study	Level VI
7	The Role of the Sexual Assault Nurse Examiner in England: Nurse Experiences and Perspectives	Cowley et al. (2014)21	England	5 forensic nurses	To analyze the role of forensic nurses who perform forensic exams in sexual assault cases in England.	Qualitative	Level VI
8	Client Satisfaction With Nursing-led Sexual Assault and Domestic Violence Services in Ontario	Du Mont et al. (2014)22	United States	35 forensic nurses	To evaluate client satisfaction with nursing-led sexual assault and domestic violence services in Ontario	Quantitative and qualitative	Level V
9	The perception of role conflict in sexual assault nursing and its effects on care delivery	Downing and Mackin (2012)23	United States	14 forensic nurses	To understand the perception of role conflict in sexual assault nursing and its impact on nurses’ action and care delivery.	Qualitative	Level VI
10	When There is No Sexual Assault Nurse Examiner: Emergency Nursing Care for Female Adult Sexual Assault Patients	Delgadillo (2017)24	United States	Does not apply	To provide emergency nurses not specialized in the forensic area with a general view of the necessary skills to care for and treat victims of violence in the emergency service.	Theoretical text	Does not apply
11	The Medical/Legal Aspects of Sexual Assault Nurse Examiner (SANE) Programs in Emergency Departments	Bimber (2014)25	United States	Does not apply	To understand the importance of forensic nurses in the emergency service.	Theoretical text	Does not apply
12	Forensic Nursing: Focus on SANE	Cataruozolo (2015)26	United States	Does not apply	To describe, in a summarized way, the forensic nursing specialty, especially nurses who perform forensic exams in sexual assault cases.	Theoretical text	Does not apply
13	Conhecimento e atuação de profissionais de saúde na preservação de vestígios forenses em pacientes vítimas de violência sexual em hospital de trauma em Aracaju	Santos et al. (2019)27	Brazil	33 generalist nurses	To analyze the level of knowledge and performance of health professionals in the preservation of forensic traces when providing care for sexual assault victims at the trauma hospital of Aracaju	Analytic, descriptive and quantitative	Level VI
14	Preservação de vestígios no pré-hospitalar: papel das equipes de emergência médica em cenários forenses	Gomes (2018)28	Brazil	Not informed	To present different criminogenic situations that occur in the prehospital context and the respective traces that must be preserved.	Qualitative	Level VI
15	Preservation of forensic traces by health professionals in a hospital in Northeast Brazil29	De Oliveira Musse et al. (2020)29	Brazil	33 generalist nurses	To describe the level of knowledge of professionals who work in the emergency unit of the Sergipe Emergency Hospital (HUSE), in the state of Sergipe, Northeastern Brazil, about the preservation of traces for forensic analysis and their abilities to implement in practice the necessary processes.	Quantitative	Level VI

• Source: Created by the authors.

Box 2 presents evidence from the scientific literature about challenges for the nurse’s performance of trace preservation in cases of sexual violence against women.

Box 2
Evidence from the scientific literature about challenges for the nurse’s performance of trace preservation in female victims of sexual violence.

Evidence Synthesis	References
Lack of human resources and training in forensic nursing to assist cases of sexual violence against women	Dash et al. (2016)18, Silva et al. (2020)16, Bimber (2014)25, Souza et al. (2017)15, de Oliveira Musse et al. (2020)29
Limited training of nurses to collect traces in cases of sexual violence against women	Cowley et al. (2014)21, Du Mont et al. (2014)22, Souza et al. (2017)15, de Oliveira Musse et al. (2020)29, Santos et al. (2019)27
Limited performance of trace preservation procedures in the assistance provided for female victims of sexual violence	Bimber (2014)25, Souza et al. (2017)15
Conflicts between the nurse’s role in care provision and in the collection of traces for legal purposes	Campbell et al. (2011)17, Heffron et al. (2014)19, Cowley et al. (2014)21, Du Mont et al. (2014)22, Downing and Mackin (2012)23
Absence of protocols or lack of standardization of the existing ones for the collection of traces in cases of sexual violence against women	Silva et al. (2020)16, Cowley et al. (2014)21, Souza et al. (2017)15, de Oliveira Musse et al. (2020)29, Payne (2018)20
Underreport of sexual assault cases	Heffron et al. (2014)19, Delgadillo (2017)24, de Oliveira Musse et al. (2020)29, Dash et al. (2016)18
Lack of time and fear of liability or reprisal	Silva et al. (2020)16
Absence of legal instruments to regulate the nurse’s attributions and role in the chain of evidence custody.	de Oliveira Musse et al. (2020)29
Protection of the privacy of the violence victim	Cataruozolo (2015)26, Gomes (2018)28

• Source: Created by the authors.

DISCUSSION

Violence has become a global public health problem. The emergency services of hospitals frequently receive victims of different types of violence. Thus, health professionals, specially nurses, who usually have the first contact with the victims, play a vital role, contributing to investigations and aiding justice. Recommendations and protocols were created for the delivery of care to victims of sexual violence in 2013, and to victims of other types of violence in 2015²⁷.

This review showed that one of the challenges of the nurse’s role in this context is the lack of human resources and training in forensic nursing to assist cases of sexual violence against women. Corroborating this result, evidence has shown that the field of work of the Brazilian forensic nursing needs to be conquered, as some subspecialties like trace preservation still are traditionally performed by the criminal police²⁷.

In addition, differently from the situation in countries like England and USA, forensic nursing in Brazil is still unknown, with few specialization centers^20,21. It has started to be developed in Latin America; however, it has been recognized by the Federal Council as a specialization for the nursing professional since 2011, by means of Resolution No. 389/2011, subsequently revoked by Resolution No. 0581/2018¹⁵.

Forensic nurses have a broad field of work, as they can act in different areas involving domestic and sexual violence, child abuse/neglect, ill-treatment, prison nursing, death investigations and mass disasters. In addition, there are the areas of forensic practice, which include psychiatric nursing, expert testimony, consulting, public health and safety, trauma and emergency services, among other situations. They use exclusive skills to conduct a holistic care plan, aiming to meet the victim’s physical and psychosocial needs^26,28.

One of the aspects revealed by this review was the absence of protocols or lack of standardization of the existing ones for the collection of traces in cases of sexual violence against women, showing the need of studies focusing on the development of this type of technology. According to the literature, the forensic nurse must interview sexual assault victims in an adequate venue, aiming to provide safety, comfort and confidentiality, respecting their situation, free from any interruption or intrusion. The initial evaluation includes interview, physical examination of the entire body, identification of personal and medical history, access to relevant documentation, performance of diagnostic tests, observation and collaboration with other health professionals, as well as identification, collection and preservation of forensic traces¹⁰.

The literature indicates that the Sexual Assault Nurse Examiner (SANE) provides a more comprehensive assistance compared to other health professionals. Furthermore, their action generates cost saving and strengthens laws in favor of the victims. In addition, it is a successful care model approved by the police authorities²¹.

In Brazil, although reporting suspected and confirmed cases of violence is mandatory, another challenge is the underreport of sexual assault cases, an issue that emerged in the present review^18,19,24,29. This may be related to the professional’s fear of liability or reprisal¹⁶. Thus, nursing assistance in these cases is restricted to treating injuries, which contributes to the underdiagnosis and incorrect dimensioning of cases of violence. Our findings reveal that the assistance has positive results when it is performed by a sexual assault forensic nurse examiner, such as reduction of the time the victim waits to receive assistance; adequate recording, collection and preservation of forensic traces; and greater confidentiality of the victims. Institutional protocols guide the assistance to victims and the value of the provided care is confirmed through feedbacks and by the fact that the victims show a greater acceptance of trace collection and file police reports^20,22.

Programs of assistance for sexual assault victims conducted by certified or trained forensic nurses offer high quality and meet patients’ mental and physical health needs, encompassing evidence collection and prophylaxis of pregnancy and sexually transmitted infections, which guarantee adequate treatment and prevent future injuries²⁵.

Evidence has shown that, although forensic nurses assume a neutral attitude during the assistance, their patients feel safer to report the cases to the police authorities, as they mitigate the victims’ feelings of guilt and impotence, highlight their strong points and provide guidance during the assistance, relieving their fears¹⁷.

The health services constantly receive people affected by different situations of violence. However, the researched literature shows the presence of specialized nursing services to assist sexual assault victims in many countries, unlike Brazil, where there is little knowledge about the matter and unprepared professionals. Because they are frontline health workers, generalist nurses provide the initial care for the victims, but sometimes they are not prepared to deal with this situation¹⁵. It is important to mention that, if the traces are not collected and handled adequately, they compromise the forensic analysis and legal investigation²⁹.

As for the approach to legal competencies and the offer of qualification courses for generalist professionals in the national level, there are still gaps that hinder the delivery of assistance. This happens because, although there are rules from the Brazilian National Health System that regulate the collection of traces at healthcare units, there is not a directive that recognizes the health professional in the chain of custody and validation of traces by criminalistics institutes²⁷. This aspect was revealed by a Brazilian study that was included in the present review²⁹.

This review showed that one of the challenges experienced in practice are the conflicts between the nurse’s role in care provision and in the collection of traces for legal purposes. Due to lack of policies, economic restrictions or lack of incentives to assistance programs for sexual assault victims, sometimes the sexual assault forensic nurse examiner is not available. Thus, the generalist nurse who provides initial care needs to have knowledge and tools that facilitate the conduction of the case.²⁴

Another important challenge mentioned by the selected studies was the limited training of nurses to collect traces in cases of sexual violence against women^15,21,22,29. Although generalist nurses consider that forensic evidence procedures are important in the assistance provided for female victims of sexual violence, they do not feel technically and scientifically prepared to perform this function, which clearly shows the need of training and adherence to institutional protocols¹⁶. This limited education results in another challenge that emerged from the present review: the limited performance of trace preservation procedures in the assistance provided for female victims of sexual violence^15,25.

According to a Brazilian study carried out with a multiprofessional team at a trauma hospital, most of the professionals feel they are not prepared to perform preservation and collection of traces and do not perform the majority of the listed procedures, although they are familiarized with them. It was also found that the most performed actions are those related to documentation, compared to trace collection procedures, which were the least executed actions²⁷. Furthermore, the difficulty in protecting the victim’s privacy during assistance was another challenge mentioned by the professionals, a fact that can negatively affect the collection of crucial information to the case^26,28.

Another aspect is the need of training the teams and including the subject in undergraduate programs, a problem experienced not only in Brazil. A study carried out in India reported the same need, drawing a parallel between the nursing assistance provided for victims by qualified nurses with consolidated careers in developed countries and the reality of underdeveloped and emerging countries¹⁸. Finally, the study showed that a higher percentage of sexual assault nurse examiners develop burnout syndrome and a lower percentage present role conflicts, facts associated with workplace dissatisfaction and exhaustion²³.

CONCLUSION

We found that, although it is a natural need of the emergency services, forensic nursing is still little disseminated in Brazil. Many times, nurses are the first to provide assistance for violence victims; however, although they understand the importance of the chain of custody, they do not feel prepared to assist victims of sexual violence, and qualification is one of the most cited needs in the studies.

It is necessary to create protocols to guide the actions and conducts of the individuals involved in the assistance. In addition, it is necessary to qualify nurses and change the curricular guidelines of the nursing courses, including the theme in the curriculum. Such indispensable knowledge must be acquired during academic education, so that professionals are prepared to provide assistance for victims of sexual violence.

In addition, it is important to create laws to ensure the performance of the chain of custody by forensic nurses, practices that are currently carried out in our country by other professionals. Therefore, it is necessary to amplify and implement the existing public policies and to engage the proper entities, aiming at strategies to increase the visibility of the forensic nurse specialty in Brazil.

The study has limitations regarding the reduced number of primary studies related to challenges faced by nurses in the preservation of traces in cases of sexual violence against women. However, in spite of the scarcity of studies, they undoubtedly contributed to the construction of a cohesive dialog.

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Edited by

SCIENTIFIC EDITOR

ASSOCIATE EDITOR

Publication Dates

• Publication in this collection
  25 Oct 2021
• Date of issue
  2021

History

• Received
  05 May 2021
• Accepted
  11 Aug 2021