Forensic practices performed by nurses in emergency and urgent care for people in situations of violence: scoping reviewABSTRACT
Objective: to map the forensic practices performed by nurses in emergency and urgent care units when assisting victims of violence.
Method: This is a scoping review conducted in compliance with the Joanna Briggs Institute guidelines, following the PRISMA diagram. Documents in Portuguese, English, and Spanish were analyzed, excluding those with restricted access. Data extraction was performed by two independent researchers, with a third acting as a mediator to resolve inconsistencies.
Results: The nursing care provided to victims of violence revealed convergences among the different types of violence addressed in the 30 studies analyzed, which were published in English, Spanish, and Portuguese. The findings were systematized into three analytical categories: forensic practices performed, types of evidence collected and preserved, and challenges reported by professionals.
Conclusion: This study successfully mapped the forensic practices executed by nurses. In emergency and urgent care settings, these professionals perform crucial forensic actions, including humanized reception, detailed anamnesis, and evidence preservation. However, they face significant barriers, such as the absence of updated protocols, insufficient operational infrastructure, and a lack of specific training. Notably, even without formal forensic specialization, the practices observed demonstrate a notable alignment with the recommendations for forensic nurses.
Descriptors:
Forensic Nursing; Emergencies; Violence; Crime victims
RESUMO
Objetivo: mapear as práticas forenses desempenhadas por enfermeiros em unidades de urgência e emergência no atendimento a vítimas de violência.
Método: trata-se de uma revisão de escopo conduzida conforme as diretrizes do Instituto Joanna Briggs, seguindo o diagrama PRISMA. Foram analisados documentos em português, inglês e espanhol, excluindo-se aqueles de acesso restrito. A extração de dados foi realizada por dois pesquisadores independentes, com mediação de um terceiro para resolução de inconsistências.
Resultados: a assistência de enfermagem ofertada às vítimas de violência revelou convergências entre os diferentes tipos de violência contemplados nos 30 estudos analisados, no idioma inglês, espanhol e português. Os achados foram sistematizados em três categorias analíticas: práticas forenses realizadas, tipos de vestígios coletados e preservados, e dificuldades reportadas pelos profissionais.
Conclusão: este trabalho logrou êxito em mapear as práticas forenses executadas por enfermeiros. Em unidades de urgência e emergência, esses profissionais desempenham ações forenses essenciais, como o acolhimento humanizado, a anamnese detalhada e a preservação de vestígios. Contudo, enfrentam entraves significativos, incluindo a ausência de protocolos atualizados, a insuficiência de infraestrutura operacional e a carência de capacitação específica. Mesmo na ausência de especialização forense, as práticas observadas exibem notável alinhamento com as recomendações direcionadas a enfermeiros forenses.
Descritores:
Enfermagem forense; Emergência; Violência; Vítimas de crime
RESUMEN
Objetivo: Mapear las prácticas forenses llevadas a cabo por enfermeros en unidades de urgencias y emergencias en la atención a víctimas de violencia.
Método: Se trata de una revisión de alcance realizada conforme a las directrices del Instituto Joanna Briggs, siguiendo el diagrama PRISMA. Se analizaron documentos en portugués, inglés y español, excluyéndose aquellos con acceso restringido. La extracción de datos fue realizada por dos investigadores independientes, con la mediación de un tercero para la resolución de inconsistencias.
Resultados: La atención de enfermería brindada a las víctimas de violencia reveló convergencias entre los diferentes tipos de violencia abordados en los 30 estudios analizados, en los idiomas inglés, español y portugués. Los hallazgos se sistematizaron en tres categorías analíticas: prácticas forenses realizadas, tipos de indicios recolectados y preservados, y dificultades reportadas por los profesionales.
Conclusión: Este estudio logró mapear las prácticas forenses ejecutadas por los enfermeros. Se evidenció que, en unidades de urgencias y emergencias, estos profesionales desempeñan un papel forense esencial, incluyendo la acogida humanizada, la anamnesis detallada y la preservación de evidencias. Sin embargo, enfrentan obstáculos significativos, como la falta de protocolos actualizados, la insuficiencia de infraestructura operativa y la carencia de formación específica. Cabe destacar que, incluso sin una especialización forense, las prácticas observadas muestran un notable alineamiento con las recomendaciones dirigidas a enfermeros forenses.
Descriptores:
Enfermería forense; Urgencia; Violencia; Víctimas de delito
INTRODUCTION
Violence is a global phenomenon, multi-determined, polysemic and intrinsically complex, manifesting itself in a variety of contexts and situations, such as actions that engender fear, anguish, psychological suffering or physical harm. These events have harmful impacts on those involved and can lead to fatal outcomes. This health issue stands out as one of the main reasons that lead victims to seek emergency care services1.
Regarding statistics related to violence, research reveals that, in 2016, there were an estimated 251,000 deaths associated with the use of firearms worldwide, of which 64% were attributed to homicides, 27% to suicides and 9% to unintentional injuries (accidental). In Canada, between 2016 and 2020, there were 4,005 deaths, 3,169 hospital admissions and 2,847 emergency room visits due to gunshot wounds2.
In Brazil, 45,503 homicides were recorded in 2019, while 822,000 cases of rape were estimated in 2022. These numbers confirm the high prevalence of violence in the country and highlight the urgency of discussing effective strategies for assisting victims3. Furthermore, in 2022, approximately 18.6 million Brazilian women reported having suffered some type of violence, with a frequency of four to nine episodes of aggression throughout the year. These data reinforce the importance of deepening knowledge about the collection and preservation of forensic evidence, to ensure robust evidence in legal proceedings4.
From the 1996 World Health Assembly in Geneva, the intersection between violence and health has been officially recognized as a pressing public health issue. In response to this challenge, the World Health Organization (WHO) prepared the World Report on Violence and Health, a document that categorizes violence into different types, analyzes its impacts, and outlines intervention strategies implemented in several countries. This report highlighted the need for integrated public policies that address the social determinants of violence, prioritizing health promotion and safeguarding the most vulnerable groups1.
In addition to state initiatives aimed at combating violence, it is essential to highlight the role of healthcare professionals, especially nurses. To this end, it is essential that these professionals master the different manifestations of violence and are properly trained to make correct and timely decisions. However, specialized literature points to significant gaps in the preparation of many professionals to identify situations of violence and adopt appropriate conduct with victims1. A study conducted with 403 Portuguese nurses revealed that 40.2% of them have knowledge considered low or insufficient on the subject; paradoxically, 40.7% perform practices consistent with the principles of Forensic Nursing5. Despite frequently performing forensic procedures - such as identifying signs of violence, conducting detailed physical exams, and collecting and preserving criminal evidence -, most lack consolidated knowledge on the qualified execution of these tasks and perform them without full awareness of their forensic nature6.
Therefore, it is essential that nurses working in emergency and urgent care services be trained to recognize violence and preserve evidence in a technically appropriate manner, contributing to breaking the cycle of aggression. In this context, specialization in Forensic Nursing (FN) emerges as a transformative approach, whose knowledge and skills acquired during training enable nurses to offer welcoming and technically rigorous care, with evidence collection and preservation performed efficiently. This approach not only mitigates the negative impacts suffered by victims, but also strengthens the interface between the health field and the judicial system6.
Forensic Nursing originated in 1970 in the United States, when a group of nurses, engaged in advocating for women’s human rights, began to advocate for comprehensive care for victims of sexual violence, including the systematic collection of medico-legal evidence. The Sexual Assault Medical Forensic Exam program, implemented in the USA, was a milestone in the consolidation of this specialty and outlined the duties of the nurse as an examiner7.
In the Brazilian context, Forensic Nursing (FN) began to be cited in scientific literature in 2009, through the article entitled “Forensic Nursing: a specialty to be known”, which outlined the fields of activity of forensic nurses, covering hospital institutions, courts of justice, communities and ethics committees in healthcare services. This field of specialization was formally recognized by the Federal Nursing Council (Conselho Federal de Enfermagem - COFEN) in 2011, through Resolution 389, and its areas of competence were regulated in 2017 by Resolution 5568.
The practice of FN has as its fundamental premise the reception of victims of violence, encompassing situations of mistreatment, sexual abuse, trauma and large-scale disasters, as well as other circumstances that require interaction with the judicial system. In this regard, considering the high prevalence of patients who are victims of violent acts in emergency services, it is imperative that nursing professionals have specialized training to manage such cases, as well as to report and refer various manifestations of violence to the appropriate authorities9.
The forensic nurse working in urgent and emergency care services plays a crucial role in dealing with physical, psychological and social traumas, from the initial reception of the victim to the resolution of legal issues. To this end, it is essential that these professionals master both the scientific framework and the ethical and legal precepts, positioning themselves as a link between health sciences and the legal context10.
In this scenario, protocols based on scientific evidence are indispensable tools to guide the collection of evidence, the detailed recording of occurrences and the approach to victims in traumatic contexts associated with crimes, simultaneously ensuring the provision of qualified assistance and the resources necessary for criminal investigations. This is justified by the fact that standardization of procedures ensures the integrity of evidence, the preservation of biological traces, the exhaustive documentation of physical injuries, and attentive care for the emotional state of victims11.
Given the above, the present investigation proposes as its central question: What are the forensic practices performed by nurses in emergency and urgent care services when caring for individuals in situations of violence? The primary objective of this study is to map the forensic practices performed by nurses in this specific context, involving people who have been victims of violence. To achieve this purpose, studies from several countries were included.
METHOD
This study is a scoping review conducted in compliance with the recommendations of the Joanna Briggs Institute and structured by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. The scoping review is characterized primarily by the meticulous analysis of a multiplicity of documents, encompassing different methodologies and languages, which enables the integration and interpretation of the findings with a view to mapping the outlined objective12. A research protocol was duly registered on the Open Science Framework (OSF) platform under the identification number C10.17605/OSF.IO/KH4MA.
To formulate the guiding question, the PCC strategy was adopted, in which “P” represents Population - nurses; “C”, Concept - forensic practices; and “C”, Context - urgent and emergency care. Thus, the following question was structured: What are the forensic practices performed by nurses in urgent and emergency services?
The eligibility criteria included documents that addressed forensic practices performed by nurses in urgent and emergency care settings, without temporal or geographic delimitations, restricted to studies available in Portuguese, English and Spanish. On the other hand, the exclusion criteria included studies that were not fully accessible or that did not address the proposed theme. Additionally, paid access studies were excluded to avoid restrictions on the reproducibility of the method in future investigations. Data collection was conducted between July and October 2023, with additional refinement in February 2025 to update the results.
Initially, the keywords “Forensic nursing”, “Violence” and “Emergency” were used, extracted from the Health Sciences Descriptors (DeCS) in Portuguese and the Medical Subject Headings (MeSH) in English and Spanish, applied to the MEDLINE databases, accessed via PubMed, and CINAHL, accessed via EBSCO. At this stage, the terms present in titles, abstracts and descriptors were analyzed, seeking to identify related words.
Consequently, descriptors and keywords were selected and combined using the Boolean operators AND and OR, composing the search strategy applied to the databases MEDLINE via PubMed, CINAHL via EBSCO and the Web of Science platform: ((“Nurses” OR “Forensic nursing” OR “Nurse examiner” OR “Forensic examination” OR “Nurse’s role” OR “Nursing Role” OR “Care nurse” OR “Nursing care” OR “Forensic nurse” OR “Investigating forensic nursing” OR “Sexual assault nurse examiners”) AND (“Emergencies” OR “Emergency”) AND (“Abuse” OR “Violence” OR “Sexual violence” OR “Mistreatment” OR “Sexual assault” OR “Abused” OR “Traumatic injuries” OR “Victims of violence” OR “Domestic violence” OR “Neglect” OR “Crime victims” OR “Strangulation” OR “Exploitation” OR “Interpersonal violence” OR “Intimidation” OR “Financial abuse”)).
For the other databases and platforms, the following search strategies were implemented: Nurse Care AND Emergencies AND Abuse and ((“Nurse” OR “Forensic nursing” OR “Nursing care”) AND (“Emergency” OR “Emergencies”) AND (“Abuse” OR “Violence”)). In the databases that required specific adaptations, the Health Sciences Descriptors (DeCS) were also used, applicable to Portuguese-language databases, with the combination of the terms: Forensic nursing AND Emergency OR Urgency AND Violence.
The searches were conducted in a wide range of databases and platforms, both national and international: PubMed, CINAHL, Embase, Scopus, Virtual Health Library (VHL), JBI Database of Systematic Reviews and Implementation Reports, Cochrane (controlled clinical trials and systematic reviews), Web of Science, LILACS. In addition, sources found in the grey literature: ProQuest Theses and Dissertations, MedNar, OpenGrey, Open Thesis, Portuguese Open Access Scientific Repository (RCAAP), CAPES Theses and Dissertations Portal, National Library of Works of Australia, Online Academic Archive, DART - European E-Thesis Portal, Online Electronic Theses Service, National ETD Portal, Theses Canada and Google Scholar.
The mapping process was conducted by two independent reviewers, with the intervention of a third reviewer responsible for resolving any discrepancies. However, no inconsistencies that could be resolved were found. The extracted data were organized in a spreadsheet created in Excel software, containing the following variables: title, year of publication, language, country of origin, methodological approach and document typology.
Initially, the titles of the documents identified by applying the previously defined descriptors were read. Then, studies whose titles included the mentioned descriptors were selected. After analyzing the abstracts, those that aligned with the research objective were considered eligible for full-text reading and were subsequently categorized according to methodological approach and predominant theme. The flowchart detailing the document search and selection process is presented in Figure 1 below.
RESULTS
Regarding the typology of the publications analyzed, there was a predominance of documents written in Portuguese (n = 21; 70.0%), followed by those in English (n = 9; 30.0%). Stands out the prevalence of studies conducted using a qualitative approach (n = 20; 65.5%), followed by quantitative investigations (n = 09; 31.0%).
Regarding the geographic origin of the publications, Brazil stood out as the most represented country (60.0%), followed by the United States with (10.0%), Portugal (6.6%) and, to a lesser extent, Taiwan, Canada, South Africa, Sweden and Australia, each contributing with (3.3%) of the total. Regarding the care sector where nurses perform their duties, the scope of hospital emergencies predominated (50.1%), followed by Emergency Units (43.3%) and (6.6%) specified as healthcare services. Among the forms of violence most frequently addressed in the documents, sexual violence (20.0%) and general violence (20.0%) stood out. The metadata related to the studies are organized in Chart 1.
Forensic practices aimed at individuals victims of violence, performed by nurses worldwide, were categorized to facilitate understanding and are described in detail in Chart 2.
Regarding the preservation of evidence collected by nurses in emergency and urgent care services, three documents have outlined in detail what evidence should be obtained to ensure an effective investigation. The preservation methods are systematized in Chart 3.
In the majority of documents considered eligible for this review (n = 20; 66.6%), nurses reported significant obstacles in providing care to patients who were victims of violence. These obstacles are detailed in Chart 4.
DISCUSSION
The finding that the resources most frequently used to identify violence include subjective signs, humanized care, detailed anamnesis, thorough physical examination and institutional operational protocols is a pivotal aspect for understanding the process of assisting victims. However, the lack of a uniform and standardized description of the protocols for immediate care of these people can compromise both the effectiveness and the quality of the assistance provided((2.
In this context, a paradigmatic example is the Manual for Victims of Violence in the Healthcare Network, published in 2009 in the Federal District, which is a fundamental instrument for organizing and standardizing care. Equipped with care flowcharts, legal guidelines and notification form templates, this manual organizes and structures the actions of healthcare professionals, ensuring strict compliance with legal procedures. This approach not only improves the quality of care provided, but also significantly contributes to the appropriate conduct of subsequent legal proceedings, addressing a significant gap in victim assistance43.
Regarding the interventions most frequently reported by nurses, stands out the collection and meticulous preservation of evidence. Given these findings, there is a need for in-depth knowledge of the processes in evidence collection and preservation, since such procedures often represent the first opportunity to record material evidence. This role is crucial relevant in the potential legal outcome of cases of violence30.
According to the data obtained in this investigation, referrals are directed to a diverse range of professionals and services, including doctors from the same unit, psychologists, social workers, specialized support services and health agents responsible for the victim's area of residence. As for notification and reporting, the completion of the Compulsory Notification Form for Interpersonal/Self-Inflicted Violence is recorded, with the aim of protecting the victim, assessing each case in its specificity and deliberating on the appropriate measures. According to the Technical Standard: Humanized Care for People in Situations of Sexual Violence with Recording of Information and Collection of Evidence, published in 2015, this practice provides support to victims, encourages protective actions, prevents the repetition of violent episodes and enables the adoption of strategies that promote accountability of aggressors25.
The types of evidence collected and preserved, as outlined in the studies analyzed, are in line with the recommendations established for obtaining forensic evidence. According to Angelo24, it is essential to identify and record visible bodily injuries, as well as to collect items such as clothing, footwear, bodily fluids, hair, blood and saliva samples. Furthermore, it is recommended to collect projectiles and perform subungual scraping. These procedures are essential to support criminal investigations, as they may provide decisive evidence in various contexts.
In the reviewed publications, reports were found about the challenges inherent in care involving forensic practices. This scenario is supported by an investigation conducted in 2021, which identified difficulties like those observed in this study, particularly in the care for elderly victims of violence. Among the highlighted obstacles are the lack of organizational support, the absence of specialized training, professional insecurity, and fear of exposure44.
The lack of preparation and institutional support, manifested by the lack of well-defined protocols, specific training, and structured support, constitutes a significant obstacle to breaking the cycle of violence and providing qualified care to victims. Evidence from research suggests that the lack of adequate training among healthcare professionals compromises the effectiveness of interventions, leaving victims in a vulnerable situation. In this sense, it is imperative that society, together with management and government, recognize their shared responsibility in addressing this issue. Strengthening teams through robust resources and standardized protocols, as proposed, can optimize the quality of care and contribute to breaking the cycle of violence29.
Additionally, considering that generalist nurses often play the role of first responders in emergency situations, whether in the pre-hospital setting or in-hospital triage, it is essential that these professionals have solid knowledge of forensic aspects. The lack of this training can hinder the identification of violence cases and the preservation of crucial evidence. Therefore, specialized training in forensic procedures is essential to ensure the integrity of evidence, assisting both in investigations and the provision of effective care to victims11.
The consolidated experience of forensic nursing in the United States offers a model that can be potentially applied to Brazil, highlighting the importance of a generalist education that integrates legal competencies and practical skills. However, despite its consolidation in that country, a survey conducted with 2,493 North American nurses revealed that approximately 80.8% of the respondents admitted to lacking forensic skills to care for patients in emergency units who are victims of sexual assault45. These data emphasize the ongoing need to expand forensic education, even in contexts where the specialty is already established, aiming to train teams with resources that favor qualified care. It is therefore important to emphasize that the effective consolidation of forensic nursing in Brazil requires the implementation of continuing education programs with evidence-based practices in trauma. Such initiatives promote stronger therapeutic relationships and collaborative care, as demonstrated by a study conducted in Turkey in emergency units of three institutions, in which nurses with forensic training showed greater proficiency and effectiveness in caring for victims of violence compared to their peers without specific training46.
Furthermore, it is imperative that Brazilian forensic nursing to recognize the relevance of its role in the care provided, consolidating the mastery of specialized knowledge and expanding spaces for participation, particularly in the collection of evidence. The institutionalization of new professional specialties should be encouraged throughout academic training, through the integration of forensic content in undergraduate and graduate curricula. With access to updated information, it becomes feasible to expand the theoretical debate to the professional field, thereby enabling a larger contingent of nurses to become familiar with the theme of forensic nursing41.
Although instruments that support forensic nursing practices are available, reports of insufficient preparation for evidence collection and preservation persist. In response to this gap, in 2019, Brazil undertook planning to implement training in Sexual Assault Nurse Examiner (SANE), a subspecialty established in the United States and Canada. After the teaching material was translated and adapted into Portuguese, practical sessions with realistic simulations were conducted over five consecutive days, aimed at improving nurses’ competencies in proper evidence collection and preservation35.
As a strategy to promote professional forensic practice, the Organization of Scientific Area Committees (OSAC) in the United States, established the Forensic Nursing Subcommittee in 2021. This body aims to develop instruments that ensure the standardization and consistency of forensic practices, with evidence-based techniques, with a view to promoting high-quality nursing care. In this sense, it is considered that the standardization of tools and procedures in cases of violence constitutes a decisive step for the advancement of the profession. The committee also seeks to encourage nurses to engage in scientific discussions on the subject, contributing to the dissemination of the specialty47. The establishment of civil organizations can be seen as an effective strategy for consolidating the role of forensic nurses, as these entities raise the specialty’s visibility and represent the category in society.
Therefore, it is essential that continuing education becomes a consolidated and ongoing process, with increased encouragement for specialization in forensic nursing. This need arises from the fact that generalist and/or emergency nurses, often positioned on the front line, play a crucial role in identifying violence and preserving evidence. In this way, they contribute to interrupting the cycle of violence and facilitate the work of both forensic nurses and the judicial system6,7.
Despite the existence of a forensic nursing specialization, the results reveal that this field remains little known in Brazil, as evidenced by the predominance of generalist nurses with limited training, who end up performing roles typical of forensic nurses.
Another significant challenge is the resistance within the healthcare system and the legal community to recognize and integrate forensic nurses as essential professionals in the collection and preservation of evidence, as well as in providing humane care of victims of violence. In Brazil, this role is predominantly assigned to forensic physicians and criminal experts, which reduces the opportunities for forensic nurses to be included into relevant institutional spaces.
Structural and resource limitations in healthcare institutions are also a barrier. Many hospitals and emergency care units do not have standardized protocols for the work of forensic nurses, which compromises the effectiveness of care for victims of violence and the correct documentation of injuries.
Specialization in forensic nursing is extremely important for professionals who routinely deal with victims of violence, since it provides specific techniques for conducting physical examinations, as well as for collecting, preserving, and appropriately recording evidence. It also develops essential skills for conducting forensic interviews and interpreting subjective signs associated with violence35.
Given the above, it is proposed that Brazil adopt established models, such as those implemented in the United States, which integrate forensic nurses in the management of suspected or confirmed cases of violence. Considering that generalist and/or emergency nurses often face an overwhelming workload, the presence of a specialist can ensure that situations of violence are not neglected, promoting more integrated and effective management to such cases.
As a limitation of this study, it is worth noting that the results are based on a research strategy conducted in a single care setting, without comparisons to other nursing care contexts. Future research could expand this analysis, including different settings and approaches.
CONCLUSION
This research demonstrated that the role of nurses in providing care to victims of violence in emergency and urgent care units involves a set of practices common to generalist nursing care. However, these practices are also performed by forensic nurses, including humanized reception, detailed anamnesis and referral to a multidisciplinary approach. Regarding forensic practices, it was possible to identify activities such as photographing injuries, collecting and preserving evidence, collecting the victim's clothes and footwear, fragments, hair, seminal traces, blood samples, nail scrapings, saliva, urine, feces and secretions. It is important to emphasize that these actions are the exclusive responsibility of forensic nurses. In contrast, studies conducted in Portugal indicated the collection of bullets, cartridges, gunpowder, fingerprints and the weapon used in the crime, practices that in Brazil are performed by judiciary professionals, such as police officers and forensic experts.
Although nurses play an essential role in initial care, significant challenges were identified, such as the absence or obsolescence of institutional protocols, inadequate infrastructure for evidence collection and storage, and a lack of specialized training to manage forensic situations, factors that undermine the excellence of the care provided.
Although generalist and/or emergency nurses do not always have enhanced competencies resulting from forensic specialization, the results of this research revealed a notable convergence between the practices they reported and the techniques recommended for forensic nurses. Nevertheless, it is emphasized the essentiality of specialization in forensic nursing for professionals working in emergency care. Additionally, it is highlighted the urgency of establishing institutional policies that ensure robust structural and operational support for forensic nursing. Strengthening the role of nurses in this field can substantially contribute to improving the quality of care and the effectiveness of strategies to cope with violence, thus promoting greater safety and dignity for victims.
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