Forensic Psychiatric Nursing -- A Legal Affair: An Expert Interview With Angela Frederick Amar, PhD, RN, and Paul

Thomas Clements, PhD, APRNBC, CGS, DF-IAFN\

October 21, 2010 Editor's note: Forensic nursing is nursing care with a legal component. Nurses who specialize in forensic nursing assist victims, offenders, and families in dealing with the criminal justice system and the associated mental health consequences of violence. A group of forensic nurses gathered for an interactive panel, led by 2 experts, to discuss key issues. This discussion was featured at the American Psychiatric Nurses Association 24th Annual Conference held in Louisville, Kentucky, October 13 to 16. To find out more about forensic nursing, Medscape Medical News interviewed Angela Frederick Amar, PhD, RN, and Paul Thomas Clements, PhD, APRN-BC, CGS, DF-IAFN. Dr. Amar is associate professor of nursing and director of the advanced practice forensic nursing program at the William F. Connell School of Nursing at Boston College, Massachusetts. She has practiced as a psychiatric nurse at both the generalist and advanced practice levels. Her research deals with interpersonal violence, mental health consequences, and reporting. Currently, she is working on a funded research project that explores violence and the policies and procedures on college campuses that influence the reporting of violence. Dr. Clements is associate clinical professor at the College of Nursing and Health Professions at Drexel University in Philadelphia, Pennsylvania. He has been a forensic psychiatric nurse for 17 years and has provided counseling and crisis intervention to more than 1500 families of murder victims, as well as to many surviving family members in the aftermath of suicide, industrial and occupational deaths, motor vehicle accidents, sudden infant death syndrome, and other types of sudden violent death. Dr. Clements is also a certified gang specialist. Currently, he is developing an online forensic healthcare certificate at Drexel University. Medscape: What is forensic nursing? Drs. Amar and Clements: Forensic nursing is nursing care with a legal component. Often times, this can mean that a crime has been committed and the client is involved with the criminal justice system as a victim, offender, or an involved family or significant other. Common practice situations include sexual assault, intimate partner violence, child maltreatment, death investigation, correctional nursing, forensic psychiatric nursing, legal nurse consultant, and forensic psychiatric liaison nursing. Medscape: What is the state of the science for this specialty practice? Drs. Amar and Clements: Forensic nursing, recognized as a specialty by the American Nurses Association in 1995, is a newer specialty and in the early stages of nursing science development. Beginning with the pioneering research of Dr. Ann Burgess, much of the forensic nursing research initially explored sexual assault, responses to sexual assault, and the role and efficacy of the sexual assault nurse examiner. The contemporary era of forensic nursing research has expanded to the pervasive public health issues of intimate partner violence, child maltreatment, and elder abuse. As the practice of forensic nursing continues to expand, so does the research. Medscape: What types of common psychopathologic conditions do forensic nurses manage? Drs. Amar and Clements: The common mental health consequences of experiencing violence include depression, posttraumatic stress disorder, acute stress disorder, somatization, substance abuse, and anxiety. Many offenders exhibit the above disorders as well as Axis II disorders, such as antisocial personality disorder.

Medscape: What are some typical responses to trauma and victimization? Drs. Amar and Clements: The common responses to trauma and victimization are the symptoms listed above. However, nursing research has provided evidence of variation in victim responses. There is no "typical" response for either victims or offenders. It is within this frame that the role of the forensic psychiatric nurse can be of significant importance; specifically, as nurses, educated within the bio-psycho-social assessment and intervention paradigm, their expertise with examination of mental health and behavioral components enhances the capacity to maximize successful intervention with victims and legal proceedings with offenders. Medscape: What is unique about forensic nursing practice? Drs. Amar and Clements: Forensic nursing always has an inherent legal component. The differentiating factor in practice is that forensic nurses are involved in evidence collection and the provision of court testimony. Nurses may testify as fact witnesses who collected evidence and as expert witnesses who can speak to the characteristics of victims and offenders of violent crime. Medscape: What strategies are important in forensic interviewing and evaluation? Drs. Amar and Clements: Nurses are very skilled at assessment and gathering information from clients. Forensic interviewing includes the use of unbiased or objective questions to gather information about the facts of the crime, related events in the person's history, and responses to the violence. Forensic psychiatric nurses may interview victims to determine damages incurred [as a result of] violence. The nurse is not serving as an advocate; rather, the nurse serves as an expert, evaluating the individual for mental health disorders that have resulted from victimization. Expert nurses may also relate the facts of the case to the current body of scientific literature on victims and offenders of violence, and they may draw scientific conclusions from the forensic evidence. Medscape: Are there evidence-based national guidelines for forensic nursing? Drs. Amar and Clements: The American Nurses Association, in conjunction with the International Association of Forensic Nursing, has established the scope and standards of forensic nursing practice. Medscape: Was there consensus reached by the forensic nursing panel? Drs. Amar and Clements: The interactive panel met to discuss the issues and challenges related to forensic psychiatric nursing, an area often overlooked in the big picture of forensic nursing. Given the serious immediate and long-term mental health consequences of violence, it is important that psychiatric nurses are knowledgeable about aspects of forensic nursing. There were actually several points on which the panel reached consensus. These included:

increasing the visibility of forensic psychiatric nursing by promoting awareness and education in forensic nursing with practicing nurses the necessity to expand undergraduate and graduate psychiatric nursing education to include aspects of forensic nursing within curricula the development of violence prevention strategies.

Over the next year, the Forensic Psychiatric Nursing Council of the American Psychiatric Nursing Association will be developing strategies to address the above areas. Drs. Amar and Clements have disclosed no relevant financial relationships.

Obstructive Sleep Apnea Often Overlooked in Psychiatric Patients

November 7, 2011 (San Francisco, California) A new study suggests that screening and assessing psychiatric patients for obstructive sleep apnea (OSA) could be an important, and sometimes overlooked, test for establishing the most accurate diagnosis and treatment plan, according to researchers here at the American Psychiatric Association 2011 Institute on Psychiatric Services (APA-IPS). As part of a pilot program, researchers at LDS Hospital of Intermountain Healthcare in Salt Lake City, Utah, used the Snoring Tiredness During Daytime, Observed Apnea, High Blood Pressure, Body Mass Index, Age, Neck Circumference, Gender (STOP-Bang) questionnaire to screen for OSA in patients admitted and treated for psychiatric illness. The results indicated that a significant number of these psychiatric patients had risk factors for or tested positive for OSA, said presenting researcher Vanita Jain, MD. The STOP-Bang questionnaire consists of 8 yes or no questions designed to screen for OSA symptoms and risk factors, including snoring, tiredness, elevated body mass index, older than 50 years, and large neck circumference. Three yes answers are considered to be an indicator of increased risk for OSA, Dr. Jain said. The researchers noted that the STOP-Bang questionnaire could be a useful tool for screening psychiatric inpatients for OSA in hospitals. During the first month of screening, 46 of 85 psychiatric inpatients who responded to the questionnaires scored positive for risk for OSA (54%) and underwent a second screening with overnight oximetry. Of these, 26 (56%) showed abnormal oximetry results, meaning a desaturation index higher than 10/hour. Three patients eventually were diagnosed with severe sleep apnea, and 7 with moderate sleep apnea. "These patients would have gone undiagnosed if not for the routine screening of psychiatric patients as part of our Care Process Model," Dr. Jain told Medscape Medical News. The Care Process Model at Intermountain Healthcare, she explained, is a guide for clinicians on treatment for certain medical conditions, using summaries of clinical literature and expert advice. Although sleep apnea and psychiatric disorders share some common symptoms, such as fatigue, insomnia, and daytime sleepiness, it is rare for patients with mental illness to be tested for OSA, she noted. Further studies at Intermountain Healthcare will follow-up patients who are screened for OSA with the Stop-Bang questionnaire, and who also test positive for sleep apnea after overnight oximetry. Treatment outcomes will be assessed in a prospective study, Dr. Jain noted. "Our hope is that once the patients' sleep disorders are addressed, then you can more easily take care of their mood symptoms," Dr. Jain said. The study on OSA points out the vital role that integrated healthcare needs to play in the diagnosis and treatment of psychiatric patients, commented Felicia K. Wong, MD, a psychiatrist at Kaiser Permanente in Los Angeles, California, and a specialist in psychosomatic medicine. "There are many medical and psychiatric conditions that overlap significantly, and sometimes we overlook medical problems that could be causing a patient's symptoms," Dr. Wong said.

Dr. Wong noted that untreated sleep apnea can result in troubling symptoms that disrupt patients' ability to function even when they are prescribed high doses of sleep medications and antidepressants. "If a patients' sleep apnea isn't properly diagnosed, then they will still have difficulty sleeping, and will still feel irritable and down, because the underlying medical issues haven't been addressed," she said. Dr. Jain and Dr. Wong have disclosed no relevant financial relationships. American Psychiatric Association 2011 Institute on Psychiatric Services (APA-IPS): Abstract 5-30. Presented October 29, 2011.

Community-Based Mental Health Programs Improve Youth Performance and Save Millions In School Costs
New data reveal lower dropout rates and improved social and emotional well-being for youth in system of care programs Systems of care -- coordinated networks of community-based mental health services and supports for children and youth with serious mental health challenges -- are able to dramatically improve the academic, behavioral and emotional performance of participating youth according to a new report by the Substance Abuse and Mental Health Services Administration (SAMHSA). The report, Working Together to Help Youth Thrive in Schools and Communities, measured performance outcomes of system of care programs and found that these improvements occurred among many young people within 12 months of their enrollment in these programs. For example, on average, 15 percent of youth (ages 14-18) nationally fail to reach the next grade level, but among youth who receive comprehensive services through system of care programs, only 8 percent had to repeat a grade. School systems, which had children participating in a systems of care program, saved $4.5 million that is attributed to more students being promoted to the next grade level. The savings is the amount that would have otherwise been spent in having the programs students repeat a grade. The report also reveals that system of care programs is associated with higher graduation rates among high school youth with emotional challenges. On average, 11 percent of youth with emotional challenges drop out of high school each year nationwide, compared to only 8 percent of youth in systems of care. Youth involved in systems of care also reported improved emotional and behavioral outcomes, such as significant decreases in reported levels of depression and anxiety and significant reductions in suicide attempts. At 12 months, youth in systems of care reported a decrease of 62 percent in suicide attemptsa leading cause of death among U.S. youth 15 to 24 years old. In addition, 16 percent of youth reported lower levels of depression and 21 percent reported lower levels of anxiety at clinically significant levels than when they entered services. Improving the outlook for children with mental health challenges is a critical part of improving our health and educational systems, said Eric Broderick, D.D.S., M.P.H., acting administrator of SAMHSA. These data show that systems of care can be an effective means of revitalizing the lives of young people and reducing long term costly consequences of inaction. The report is being released on National Childrens Mental Health Awareness Day, SAMHSAs annual demonstration of collaboration among numerous and diverse individuals, organizations, and agencies in the public and private sector working to provide greater access to community-based mental health services for children and youth with serious mental-health needs and their families.

St. Scholasticas College Tacloban Brgy. Manlurip, San Jose Tacloban city

Assignment In Psychiatric Nursing

Submitted by: Tegio, Jhon Carlo S. BSN3-B

Submitted to: Mrs. Azucena Abit, RN, MAN Clinical Instructor