Forensic Nursing: Interview with Karen B. Silva, RN-BC,  Ph.D., MFN, MSN

My Specialty

Forensic Nursing: Interview with Karen B. Silva, RN-BC, Ph.D., MFN, MSN

Examining and treating victims of violence

By Keith Carlson, RN, BSN, CPC, NC-BC
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Karen B. Silva, RN-BC, Ph.D., MFN, MSN
Education Program Coordinator and Instructor of Psychiatry
Cedars-Sinai Medical Center, Los Angeles 

What are your responsibilities at Cedars-Sinai?

I’m really a “jack of all trades.” Due to my psych background and related Ph.D., I provide clinical support pertaining to patient-related psychiatric and behavioral issues. I carry a beeper and am constantly responding to emergency calls for behavioral crises. I’m called by staff to manage behavioral issues such as extreme cases of family grief.

If there is a question of any kind of violence, including domestic violence, staff calls me so that we can conduct a complete physical examination. The nurses describe what they see from a clinical perspective, I talk to the patient and family members and we ascertain if the findings of the physical examination match these statements.

What is forensic nursing? Many of us think of “CSI” and what we see on TV.

Forensics is a broad term and there are subspecialties that are related to what you might see on “CSI.” In forensic nursing related to death investigations, we aren’t really interested in the criminal aspects of the death.

As an extension of the medical examiner, we collect data and material that will aid the medical examiner in identifying the cause, mechanism and time of death. We consider the position and condition of the body, the local climate, the environment and clues surrounding the body such as the proximity of pills or cigarette butts.

We also consider other objects that may reveal the person’s lifestyle or somehow be related to the cause of death or what occurred prior to death.

What about cases of sexual assault?

In cases of pediatric and adult sexual assault where there is an alleged victim in the emergency department who reports being assaulted, the police call us and we conduct a full body examination that can last over four hours.

In such a situation, we collect debris, hair, fibers, DNA samples and body fluids. We make note of bruises, lacerations and indications of violence. We examine the condition of the cervix, vagina and hymen using magnifying colposcopy. If there was oral sex involved, we examine oral mucosa and collect material. If the use of drugs is suspected, blood and urine samples are collected as well.

It is not our role to pass judgment or make our own findings. We collect data and history, leaving the detectives to work with the evidence we’ve gathered. After the examination is completed, we provide treatment to prevent STDs and pregnancy if desired by the patient.

Do you use “rape kits”?

Many emergency departments in the United States are equipped with standardized “rape kits” that are used by forensic nurses. The kits may vary slightly state by state, but it’s generally done in the same way. However, not all states and towns have rape kits and forensic nursing doesn’t have a strong presence in certain states.

In states with strong forensic programs, we work with the prosecutor’s office through a sexual assault nurse coordinator. Hospitals in those particular states have the essential equipment for forensic exams, including computers, rape kits, colposcopes, Wood’s lamps and high-definition cameras.. They also have a supply of clothes, shoes, personal care items and medications for the patients.

As forensic specialists, we’re often called into court to testify in the cases that we’ve examined. We may be called by either the prosecution or the defense. In some cases, we may be called in as expert witnesses.

Some forensic nurses become professional legal nurse consultants or even nurse attorneys.

What other types of exams can be conducted?

Forensic nurses can conduct psychiatric forensic examinations and treatment of individuals who are victims of violence. We can also work directly with perpetrators such as pedophiles in a correctional setting.

When we work with perpetrators, it is geared towards the examination and potential treatment of criminal behavior. We deal with their urges to commit crimes and the psychological effects of their thought processes and emotions.

Behavioral modification can be utilized with some sociopaths, so work with criminals is generally more behavior-based and interventional.

If you work with a criminal or a suspect, can you be called to testify in court?

Yes, there’s a chance, but it’s more likely for a psychiatrist or psychologist to be called than a nurse. There is a greater chance of being called if the nurse is the professional who collected DNA from the suspect in the case of a sexual crime.

However, when testifying in a trial, both psychologists and psychiatrists may use our clinical findings in forming their testimony.

How were you drawn into this specialty?

I’ve been a psychiatric nurse for 30 years. I’ve worked in acute adult patient care, a crisis unit for adults and children and responding to psychiatric crises in a busy ER. I did a few years of telemetry and other forms of medical nursing early in my career.

I am from Brazil. There, I had the opportunity to work in a psychiatric facility that shared grounds with a forensic psychiatric hospital prison, so I was exposed to this form of nursing practice. Once I came to the United States, I pursued this area of specialization.

Forensic nursing is a relatively new field, first recognized in 1995 by the American Nurses Association as a true nursing specialty. The Sexual Assault Nurse Examiner (SANE) certification was the first formal training for forensic nurses. Emergency room nurses had been doing this for years and they wanted more formal training and recognition as specialists.

Is there an educational component to forensic nursing?

Yes. We collaborate with governmental organizations in both the prevention and detection of human trafficking. Forensic nurses have a key role in educating communities and individuals about the signs of trafficking and how to prevent or report it.

Forensic nurses are closely involved with issues related to domestic and sexual violence. We speak with teenagers and young people about date rape, consensual sex and stalking behaviors.

In terms of parenting and childrearing, we teach about the relative fairness and safety of various forms of discipline, how far is too far and how to substitute task-based disciplinary actions for physical punishment (which can potentially turn violent and dangerous).

Nurses are natural educators and nursing is generally prevention-based. It’s our goal and responsibility to educate the population about the prevention of violence, assault, rape, drug and alcohol use and other negative behaviors. We can do this in schools, workplaces, community centers and other venues.

What about your work is most fulfilling for you?

I find that we can be the voice speaking for the deceased person. We can also interrupt or prevent violence by empowering and educating people and communities about its recognition and prevention.

Sometimes, we can also help a wrongfully accused person; this happens occasionally. We now have the use of DNA evidence [to help exonerate such people], something we didn’t have years ago.

As a forensic nurse with an extensive background in psychiatric nursing and counseling, I can provide emotional and psychological support for victims of violence as well as counseling and tools for the prevention of STDs, HIV and pregnancies resulting from sexual assault.

In this type of nursing, we can help stop child abuse from occurring and we can also help the child to heal from its effects. We can assist the victims of violence in dealing with stress and give them tools for coping. We begin the healing by holding the patient’s hands and connecting with them during intake. Each sexual assault patient guides the exam; we stop when they say stop. In that way, we empower them to take control of their lives.

As team players, we collaborate with the justice system, the medical examiner, families, victims and indeed perpetrators as well. We work at the intersection of nursing science and justice.

If a nurse is interested in forensics, what should he or she do?

The International Association of Forensic Nurses ( is a great place to begin looking for information. Any nurse can join the organization without being trained or certified in forensics.

A nurse interested in forensics can pursue SANE certification, which includes 40 hours of classroom education and 40 hours of hands-on mentoring and training. (This may vary from state to state.) To become board-certified, you need to practice clinically for two years prior to taking the exam under the auspices of the American Nurses Credentialing Center.

Finally, there are master’s-level degrees in forensic nursing as well as doctorate programs. Nurses in this area of specialty can pursue an M.S. or Ph.D. without first having board certification as a forensic nurse; they receive general training in all subspecialties of forensic nursing.

What are your future career plans?

My native country Brazil has the eighth highest rate of violence in the world. From 2005 to 2007, I educated several groups of emergency nurses in forensic nursing.

In 2009, I collaborated with Rita de Cássia Silva, the coordinator of a graduate program in emergency nursing at one of the most prestigious universities in Brazil, on the very first article published in Brazil about forensic nursing. We wrote it for a Brazilian federal university along with our recommendations for the introduction of the specialty of forensic nursing to the country.

We’ve since met with national and state nursing councils throughout Brazil. We’ll soon begin delivering specialized forensic training to emergency department staff with support from the federal government, which has declared that sexual assault victims must receive treatment from trained medical professionals.

In 2011, forensic nursing was recognized as a nursing specialty, but there are still no trained forensic nurses in Brazil. We plan to change that.   

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