Preservation of forensic traces by Nursing in emergency services: a scoping review

Abstract Objective: to map the scientific production on the preservation of forensic traces by Nursing professionals working in emergency services. Method: a scoping review, with searches for studies carried out in six databases, in the gray literature available in Google Scholar and in the references of the studies selected. For analysis, the data reduction method was adopted. Results: 26 studies were included, organized into five categories: 1) Nursing professionals’ knowledge on the preservation of forensic traces; 2) Procedures performed by Nursing to preserve traces in the victim’s body; 3) Procedures performed by Nursing to preserve traces in the victim’s belongings/objects; 4) Procedures performed by Nursing to document traces; and 5) Actions to maintain the chain of custody performed by Nursing. Conclusion: the studies showed situations in which the emergency nurse may act in the preservation of forensic traces present in the victim’s body and in objects, as well as in the registration of traces, verifying the role of Nursing to ensure integrity of the chain of custody, especially in situations of aggression, firearm injury, sexual violence, child abuse and assistance to trauma victims.


Introduction
Emergency health services often act in the care of victims of crime situations; thus, they have in these environments a privileged opportunity to identify, collect and preserve forensic traces (1)(2) . These traces can include palm and plantar fingerprints; biological elements such as blood, semen, saliva, hair, bones, teeth, hair and vaginal secretions; and physicochemical traces such as chemicals, projectiles, melee weapons, firearms and sharp objects or instruments (3)(4)(5)(6) .
Nursing professionals, who are on the front line in the care of patients in emergency services, in addition to having specific attributions to preserve life and reduce sequelae, must collaborate with the preservation of the traces present in the victim, in the possible aggressor, in the objects and at the crime scene (3) . Such traces, of high presence in Nursing care in emergency services, are essential elements for the success of the criminal investigation and for integrity of the chain of custody, as such chain consists of maintenance and documentation of traces, from their identification, collection, possession and handling until their disposal (1) .
Collaboration of the Nursing professionals in forensic investigation can prevent the unnecessary loss or destruction of evidence; however, lack of knowledge in these professionals who work in the emergency services about proper preservation of traces exerts an impact on the work of the expert team (7) .
Although the action towards victims of crimes occurs in the Nursing practice, most of the professionals do not have access to information on the theme (3) . Lack of training or moments of permanent education on the preservation of forensic traces, a content transversal to the Forensic Nursing specialty, results in the nonassociation of forensic care as inherent to the Nursing actions in emergency services (2) .
In this context, knowing the scientific production about the preservation of forensic traces by Nursing professionals who work in emergency services is relevant, as it may enable nurses to access scientific information about the preservation of traces, given the growing reality of situations involving crime in emergency services. Thus, it is pointed out that this study will allow for the compilation and construction of new knowledge, which can be used in the training and qualification of Nursing professionals who work in the emergency services, in order to empower them with regard to the correct performance in situations in which forensic remains need to be preserved. In addition, although the review focus is on the Nursing team, it is noteworthy that this study is of potential interest to the multidisciplinary health team and managers whose professional performance permeates the context of emergency services.
Thus, this study mapped the scientific production on preservation of forensic traces by Nursing professionals working in emergency services.

Method Type of study
This is a scoping review that followed the stages recommended by the Joanna Briggs Institute (JBI) (8) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (9) . The review was developed in five stages: identification of the research question; survey of relevant studies; selection of the studies; data mapping; and presentation of the results (10) .

Study setting
This review was conducted in six databases: National

Period
The study was conducted between August and October 2021.

Population
The study population consisted of the 190 scientific articles found in the searches in the databases and in the gray literature available on Google Scholar.

Selection criteria
Articles with different types of research addressing the preservation of forensic traces by Nursing professionals in emergency services were included, without limitation regarding language or year of publication. For exclusion of the studies, we adopted the criteria of letters to the editor, abstracts of annals of events and not presenting information that contemplated the population, concept and context of interest of this study.

Study variables
The study variables were as follows: title of the article; year of publication; country; journal; language; objective; type of study; public studied; type of injury; location of the trace (crime scene, objects and Silva RX, Ferreira CAA, Sá GGM, Souto RQ, Barros LM, Galindo-Neto NM.. The results obtained in the databases were exported to the Rayyan reference manager, developed by the Qatar Computing Research Institute (QCRI) (12) , for removal of duplicates, selection and screening of THE studies by two researchers, independently and masked, and the divergences were resolved with the participation of a third examiner. After the search developed according to the strategy outlined above, the studies were selected.
In addition, there was a search in the gray literature available on Google Scholar and a survey of potentially belongings, victim's body or others); and information on the preservation of forensic traces. After data extraction, the findings of both reviewers were compared, any and all discrepancies were resolved and the information was grouped into a single table.

Instruments used to collect the information
The diverse information extracted from the studies was recorded in a data collection instrument adapted from a form recommended by the JBI, organized in a Microsoft Excel 2001 spreadsheet (11) .

Data collection
In a previous search in the JBI database, no reviews were found to investigate the issue.

Data treatment and analysis
For analysis, the data reduction method was adopted, which aims at conceptually classifying the results after critical reading (13) . For the review report, the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) were followed (9) .

Ethical aspects
As the studies used were of public domain access, there was no need to submit the study to the Research Ethics Committee. Silva RX, Ferreira CAA, Sá GGM, Souto RQ, Barros LM, Galindo-Neto NM..  Rev. Latino-Am. Enfermagem 2022;30:e3540.

Main results
To address the role of Nursing within an emergency department and the final impact on forensic cases with the evidence preserved (14) .
Emergency professionals are responsible for the evaluation, collection, documentation, and for properly following with the chain of custody.
To present how evidence is collected in the emergency department in a situation of sexual assault (15) .
It is necessary to evaluate, know the rudiments of collection, storage of physical evidence, document injuries by photographic means, avoid biological degradation and follow the chain of custody.
To address obstacles faced for the implementation of the sexual assault response team (16) .
The obstacles were funding, team composition and adequate training of professionals.
To describe the functions of the forensic nurse in the emergency department (17) .
Recognize a potential forensic situation, proceed with collection, preservation, complete documentation of objective and subjective signs, follow up in the chain of custody, notify closest relatives, see the link between patient, physician and investigator.
To review the literature related to the recognition and collection of forensic materials in emergency departments by nurses (18) .
Recognition and collection of evidence should be performed by nurses to forward to the authorities. These professionals must identify physical and nonphysical traces, document and maintain the chain of custody.
To evaluate the clinical Nursing practice as a sexual assault examiner in an urgency care center for sexual attacks (19) .
The practice consisted of physical evaluation, gathering evidence and documentation of assault and injuries, screening for Sexually Transmitted Infections and pregnancy, providing treatment and medication, and testifying in court.
To evaluate the Nursing programs as sexual assault examiner (20) .
Medical care was provided 24 hours a day for rape survivors. The minority of the victims received information to understand the medical services, such as pregnancy risk, contraception to prevent pregnancy and the risk of Sexually Transmitted Infections.
To compare the collection of sexual assault nurse examiners (SANEs * ) in standardized evidence kits with other emergency departments without a SANE * (21) .
The examiners trained in the SANE * program perform more complete collections and more compatible with the forensic evidence standards.
To evaluate the education level of clinical practice trauma nurses in a trauma center (22) .
Emergency room professionals received further instructions of forensic protocols on chain of custody maintenance, evidence gathering, and highquality documentation.
To describe the perception of the importance of forensic role behaviors performed by nurses in emergency departments ((23) .
In cases of child physical abuse, the forensic practice must be identified and performed. This is one of the main functions performed by forensic nurses.
To assess the impact of introducing a sexual assault and domestic violence program in the emergency department with forensic evidence collection (24) .
There was a significant increase in pelvic examinations, in the use of the forensic kit, and in the forensic chain. The rates of anogenital lesions, pregnancy and Sexually Transmitted Infections decreased. The flow in the emergency department was optimized.
To develop an evidence-based set of guidelines for forensic evidence collection (25) .
The guidelines address the use of equipment by the professionals; use of the evidence collection kit; general physical evaluation of the patient; adequate collection of fluids, belongings and materials; storage and proper documentation, use of photographs; collection of evidence left by the victim during evaluation.
To describe the types of forensic evidence of firearm injuries and to describe the nurses' role in treating victims of gunshot wound (26) .
The primary evidence on a gunshot victim is clothing, bullets, gunpowder, and primer. Nursing has the role of acting in the clinic, in communication and collaboration with the authorities.
To describe and compare the forensic knowledge, practice and experiences of nurses and emergency physicians (27) .
Physicians and nurses have the same level of knowledge, and they showed confidence in the collection and documentation of possible evidence.
To compare the care quality indicators in a pediatric emergency department before and after the implementation of a program of pediatric sexual assault nurse examiners (28) .
Implementation of the program maximized care, reduced the time of care, increased the collection of sexual violence kits, and the evaluation and documentation of pregnancy testing and of Sexually Transmitted Infections.
To show the role of collecting and preserving evidence as a Nursing competence of the emergency department (29) .
For collection and preservation, there should be informative evidence (stories, expressions, odors); tangible physical evidence (macroscopic and/or microscopic) through protocols and techniques, using forensic kits; to establish the chain of custody.
To describe the nurses' views on the forensic care provided to victims of violence and their families in emergency departments (30) .
Most of them knew about the care protocols, cooperated with the authorities and involved families in the victim's care process.
To identify categories of forensic patients in the intensive care unit and emergency department (31) .
The identification of 27 categories of forensic patients made it possible to properly recognize, document and collect evidence according to each lesion, before offering the necessary care for the patient's wounds.

Nursing professionals' knowledge about the preservation of forensic traces
• Safety of the professionals -Use Personal Protective Equipment.

• Firearm
-Remove the projectile from the patient's body.

• Signs of child abuse
-Identify physical and emotional abuse.
-Collect for investigation purposes. Actions performed by Nursing to maintain the chain of custody (7,(16)(17)25) . The synthesis of the scientific production is presented in Figure 5.

Objective Main results
To evaluate professionals who worked in 112 emergency centers on how to act in forensic cases (6) .
Most of the professionals were unable to recognize, preserve, protect and did not communicate adequately to the authorities.
To describe the need for a collaborative relationship between the advanced practice of Forensic Nursing in the emergency department and intensive care environments (32) .
Nurses are the link between the patient, the health system and the law. Their function is the recognition, collection, documentation, photodocumentation and completion of reports, so that the evidence is delivered to the authorities.
To address incidents with active snipers in the United States in public places, including hospitals (33) .
Spontaneous reaction, post-event actions and evidence collection procedures should be part of the continuous actions of emergency nurses.
To define Nursing care in cases of trauma on the collection and preservation of forensic evidence in the emergency department (34) .
Nurses should recognize the impact of trauma on the patients, early recognition of evidence, so that collection and preservation is part of the care plan, collaborate with other emergency professionals and guide the patients' privacy and rights.
To investigate the knowledge and practice of emergency professionals on forensic processes during care for victims of violence (7) .
Half of them were unaware of the collection, documentation and preservation procedures. There was no habit of collecting and documenting objects present in the victim's body, hospital materials and devices used during the procedures.
To determine the levels of knowledge of emergency department health professionals in the treatment of frequently encountered forensic cases (35) .
There was a low level of forensic training and the professionals, who are not prepared to carry out the practices, must make their own identification record for the authorities.
To determine the Nursing professionals' knowledge level regarding the approach to cases and forensic tests (36) .
The Nursing professionals did not have the knowledge and technical competence to perform forensic tasks; as they did not receive adequate training for this, they thought that the role would be the Police responsibility.
To evaluate the relationship between nurses' knowledge and performance of forensic evidence procedures (37) .
Most of the nurses knew the items for documentation and performed them in practice. Only 10.2% knew the procedures for preservation and evidence collection, but less than 1% practiced them. Rev. Latino-Am. Enfermagem 2022;30:e3540.

Procedures performed by Nursing to preserve traces in the victim's body
• Firearm -Wrap the shooter's hands in a paper bag for gunpowder collection and prime.
-Take photographs of the wounds.
-Do not puncture intravenous access in the hands of the possible aggressor.
-Dry outdoors and store in paper bag the first dressing in gunshot wounds.

• Violence in general
-Collect blood before administration of crystalloids, medications or blood products.
-Store the gastric contents in cans or empty bottles.
-In cases of bites, collect the wound with moistened swabs and photograph the injury site.
-Collect saliva with sterile and moist swab, on the tongue and cheek.
-Collect and store mouthwash water.
-Circle with a marker and take photographs of the wounds or injuries. -If nail scrapes occur, store aseptically.
-Perform pelvic examination in a multidisciplinary approach with a physician.
-Allow shower bath after collection and documentation of injuries.

• Run overs
-Store in paper bags the shards of glass on the victim or on the hospital gurney sheets.

Procedures performed by Nursing to preserve traces in objects
• Victim's clothes -Remove without cuts in the holes of firearm or melee arms.
-Cut along the seams, and store in a paper bag. -Undress the patient with the use of paper sheets in order to find strands of hair and dirt.

• Bed sheets
-Allow to dry at room temperature.
-Store hospital bed sheets in separate paper bags.

• Shoes
-Store each piece of shoe in a separate packaging.

Procedures performed by Nursing to document traces
-Record the patient's condition.

Actions performed by Nursing to maintain the chain of custody
• Care of the objects collected -Seal all containers with adhesive tapes, label with the collector's name, collection date and time.
-Do not discard the projectiles or any item that constitutes evidence.
-Give the guns to the police.
• Care with recording the facts -Complete the chain of custody form, with all object transfer information. to permanent education (7) . In this sense, the procedures processes, which caused insecurity (18,(34)(35)(36)(37) . In Turkey, this scenario was also identified: 80% of the nurses who attended to forensic cases were able to differentiate types of evidence; however, they did not know how to collect, store and refer to the competent authorities (6) .
In and recognition of traces in cases of trauma and sexual assault (7,18,(20)(21)(22)25,27,29,(34)(35)37) . It is inferred that Nursing has sufficient training to prioritize physiological, pharmacological and procedural aspects of such themes, which may even involve subjective issues such as humanization. However, they may be unaware of the judicial consequences of their assistance actions, so that they discard relevant evidence for criminal investigation.
This fact was observed in a research study conducted in New Zealand, which investigated nurses in the emergency department and whose results showed limited knowledge Rev. Latino-Am. Enfermagem 2022;30:e3540.
about criminal legislation, as well as that 84% reported considering the theme important for their professional practice (38) . These findings In addition to allowing understanding the processes in forensic cases, education for emergency nurses on how to preserve traces enables improvements in patient care.
However, training on this theme for Nursing is scarce, including the gap of intersectoral articulation with public safety (7,18,(34)(35)(36) . In the United States, it is common to offer online training courses, which have already shown a 25% increase in the participants' knowledge (39) . Therefore and establishes the use of protocol and forensic evidence kits, necessary for the collection of traces (15,19,21,24,28) .
The program also works with preventive measures for the victims, which include pregnancy tests, emergency gestational contraception and administration of prophylactic drugs for Sexually Transmitted Infections (STIs), as well as emergency contraceptives, clinical and psychological professional monitoring for 72 hours, in addition to storage of the evidence kit for up to six months, until the victim decides to use its content (40)(41)   The studies of the sample pointed to the preservation of traces performed by emergency nurses, which occurred in shoes, bed sheets and other objects of the victim (17)(18)23,25,29,33,(35)(36) . These findings differ from those found in a study conducted in Brazil, whose results showed that, although the Nursing professionals recognized the need to preserve traces, it did not occur in such items, due to lack of routine and absence of documentation/ registration about the victim's objects and belongings (7,23) .
Thus, it is perceived that to strengthen the practice in the Brazilian territory, it is necessary to devise and implement institutional protocols, in order to better guide the forensic practice by nurses working in emergency services.
After the collection stage, documentation of the traces must be done in a thorough and attentive manner by Nursing because it is through this procedure that it will be possible to structure diverse information and prepare arguments to be analyzed in order to solve the crime. In this review, contents were identified that include actions ranging from the record about the patient's condition to the detailing of the record about the objects found (19,21,(24)(25)27,29,(32)(33)(34)(35) . Such actions are in line with a study carried out in Portugal, which highlights the relevance of detailing the documentation and record, which must be descriptive and accompanied by Silva RX, Ferreira CAA, Sá GGM, Souto RQ, Barros LM, Galindo-Neto NM.. a photographic record (43) . Despite being often associated with the bureaucratic and tiring routine, documentation/ recording stage, with a wealth of details not only contributes to justice occurring through the resolution of a crime, but also culminates in legal support for the professional Nursing practice and can be triangulated with the professional's report/testimony, if summoned to give testimony to the Police and/or judicial authorities.
In the chain of custody, follow-up of the stages causes concern to nurses, as it does not consist only in storing the evidence in sealed and labeled containers, but also in the delivery of weapons and projectiles to the authors of the law and in the recording, by stamp and signature, of all the information therein contained (7,17,25) .
A case report for the implementation of the SANE course in Brazil pointed out that the nurses' actions can contribute to the suitability of the chain of custody in the health services (44) . In the case of Saudi Arabia, nurses' concern with legal responsibilities, in the face of forensic cases, proved to be a barrier to maintaining the chain of custody (45) . Thus, it is noteworthy that clarification about the stages that make up the chain of custody, as well as the importance of the nurses' role for the success of involving firearms, sexual violence, child abuse, and in the assistance provided to trauma victims.