Assistance to victims of violence in Emergency services from the Forensic Nursing perspective^*

Objective:

to analyze nurses’ role in collecting, identifying and preserving traces in Emergency care for victims of violence, from the perspective of these professionals.

Method:

a qualitative study with an exploratory and descriptive approach. It was developed through semi-structured interviews with 21 nurses from hospitals that are part of the intersectoral flow to assist victims of violence from two reference hospitals in this type of care, in a capital city from southern Brazil. Nurses that are members of the multiprofessional team working in the Emergency areas at the respective hospitals were included; in turn, the exclusion criteria corresponded to professionals relocated in Emergency areas during the pandemic. Data analysis was performed according to Thematic Content Analysis.

Results:

the data were discussed in five categories: 1) Professional qualification; 2) Institutional protocol and materials; 3) The professionals’ perceptions; 4) The professionals’ actions; and 5) Team structure.

Conclusion:

Nursing professionals’ skills in collecting, identifying and preserving traces in Emergency assistance provided to victims of violence need to be better organized, structured and standardized. The presence of Nursing professionals in the care of victims of violence in Emergency services is undeniable, but their importance is still underestimated and their potential contribution to the forensic approach is underused.

Descriptors:
Forensic Nursing; Nursing; Violence; Emergency; Nursing Team; Nursing Care

Objetivo:

analizar el papel del enfermero en la recolección, identificación y preservación de rastros en la atención de emergencia a las víctimas de violencia, desde la perspectiva de estos profesionales.

Método:

estudio cualitativo, con enfoque descriptivo exploratorio. Desarrollado a través de entrevistas semiestructuradas a 21 enfermeros de hospitales que forman parte del flujo intersectorial de atención a víctimas de violencia en dos hospitales de referencia de este servicio, en una capital del sur de Brasil. Se incluyeron enfermeros que forman parte del equipo multidisciplinario que trabaja en el servicio de urgencias de sus respectivos hospitales, y el criterio de exclusión fue profesionales reasignados al servicio de urgencias durante la pandemia. El análisis de los datos se realizó según análisis de contenido temático.

Resultados:

de los datos surgieron cinco categorías: 1) Calificación Profesional; 2) Protocolo Institucional y Materiales; 3) Percepción de los profesionales; 4) Acciones de los profesionales y 5) Estructura del equipo.

Conclusión:

es necesario organizar, estructurar y estandarizar mejora las competencias de los profesionales de enfermería para recolectar, identificar y preservar rastros en la atención de emergencia a las víctimas de violencia. La presencia de los enfermeros en la atención a las víctimas de violencia en los servicios de emergencia es innegable, pero aún se subestima su importancia y se subutiliza su contribución potencial en el abordaje pericial.

Descriptores:
Enfermería Forense; Enfermería; Violencia; Urgencias Médicas; Grupo de Enfermería; Atención de Enfermería

Objetivo:

analisar a atuação dos enfermeiros no recolhimento, identificação e preservação de vestígios no atendimento de emergência à vítima de violência, na perspectiva desses profissionais.

Método:

estudo qualitativo, com abordagem descritiva exploratória. Desenvolvido por meio de entrevista semiestruturada com 21 enfermeiros de hospitais que integram o fluxo intersetorial para atendimentos às vítimas de violência de dois hospitais de referência neste atendimento, em uma capital do sul do Brasil. Foram incluídos enfermeiros membros da equipe multiprofissional que atuam na emergência nos respectivos hospitais, e o critério de exclusão foi profissionais realocados na emergência durante a pandemia. A análise de dados foi realizada conforme análise de conteúdo temático.

Resultados:

os dados foram discutidos em cinco categorias: 1) Qualificação Profissional; 2) Protocolo Institucional e Materiais; 3) Percepções dos profissionais; 4) Ações dos profissionais e 5) Estrutura da equipe.

Conclusão:

as competências dos profissionais de enfermagem no recolhimento, identificação e preservação de vestígios no atendimento de emergência à vítima de violência precisam ser melhor organizadas, estruturadas e padronizadas. É incontestável a presença de profissionais enfermeiros nos atendimentos às vítimas de violência nos serviços de emergência, mas sua importância ainda é subestimada e sua potencial contribuição para a abordagem pericial é subutilizada.

Descritores:
Enfermagem Forense; Enfermagem; Violência; Emergência; Equipe de Enfermagem; Cuidado de Enfermagem

Highlights:

(1) Proper actions in the care of these victims can ensure the chain of custody.

(2) Institutions are still unfamiliar with the topic.

(3) Forensic practices are punctually and indirectly performed by nurses.

Introduction

Due to its multicausal and multifactorial origin, the World Health Organization conceptualizes violence as the use of physical force or authority, under threat or real, which can be against oneself or against a person, group or a community, and which has the potential to cause psychological damage, physical harms and even death. However, violence will lead to significant changes in the epidemiological profile of a given population, harming the individuals’ uniqueness and affecting them in the society ^{( 1 )} . In addition to physical injuries, the consequences are psychosocial, such as psychiatric disorders and difficulties re-socializing the victim, generating social costs and impacts on Public Health ^{( 2 )} .

There is greater care demand for individuals in situations of violence in Urgency and Emergency services, which can be considered the first contact with health services, although Primary Care also welcomes this type of demand. A multiprofessional, adequate and effective approach carried out by Forensic Nursing enables necessary interventions and monitoring, ensuring that human needs are met ^{( 3 )} .

Nurses are some of the professionals with the greatest presence in the scenario of care for victims of violence, and anamnesis, physical examination and Nursing diagnosis are decisive at the service’s gateway ^{( 4 )} . However, in the Brazilian scenario, this type of care is studied in a specific and restricted way, causing these professionals to suffer scarcity of the necessary knowledge to qualify the assistance provided ^{( 5 )} . In this sense, even when they have forensic knowledge due to their daily practice in the sector, professional nurses working in Emergency areas are limited to documentary actions, and most of them do not feel fully prepared to assist victims of violence due to lack of skills or practices in certain procedures. In this sense, some studies indicate that the prerogative of competence is related to specific training, such as the technique to recognize and preserve traces ^{( 6 - 7 )} .

However, the interconnection between Nursing and forensic sciences has already been evidenced in the United States of America since the 1970s, with a group of activists in feminist law who offered comprehensive care to victims of sexual violence. In addition, the International Association of Forensic Nurses (IAFN) was created in 1992 ^{( 8 )} .

Even with the professionalization of Forensic Nursing in the USA, there was resistance related to the legitimacy of how forensic examinations were performed and to how victims were cared for by Nursing professionals. Only from the inclusion of Nursing as a collaborator of justice did this resistance begin to decrease and the profession assumed a greater role in the process of collecting traces and forensic evidence ^{( 9 )} .

In Brazil, through Resolution 556/2017, the Federal Nursing Council ( Conselho Federal de Enfermagem , COFEN) establishes the role of Forensic Nurses, highlighting their competencies in situations such as trauma, violence, sexual and drug abuse, psychiatric pathologies; covering assistance to aggressors, populations, vulnerable populations, the prison system, forensic exams and consultancies, situations of mass disasters and various types of violence in addition to those addressed in hospital environments. Forensic nurses are required to have the specialization degree recognized by the Ministry of Education or designed by institutions registered with the respective regional or federal Nursing councils ^{( 10 )} .

The specific competencies of these professionals are as follows: preservation of traces, as well as of the chain of custody; collection of information through documentation and photographs: preparation of reports and opinions for the Judiciary Power: provision of advice in cases of litigation related to the Forensic area in the health care scope; bodily injuries; frauds; and other types of abuse ^{( 11 )} .

The importance of addressing the Forensic topic in Nursing training and not only in graduate courses is recognized, both to improve the assistance provided to victims of violence and to encourage a new action and research field ^{( 9 , 12 - 13 )} . Although some studies point to the effectiveness of Forensic Nursing education, its strengthening is indicated at all training levels and in continuing education ^{( 14 )} . There is an increase in the ability and confidence to recognize the forensic aspects of care among students, especially simulation exercises, in addition to preventing deficiencies and errors caused by lack of knowledge in forensic cases ^{( 14 - 15 )} .

Nurses have extensive care experience and also consider forensic education necessary for the clinical scenario, respecting ethical-legal principles and the responsibilities of recognizing, collecting and preserving evidence in the care of patients with complex psychosocial, psychological and physical needs ^{( 6 )} . In view of the above and for being an emerging topic not yet incorporated into Brazilian health institutions, this study aimed at analyzing nurses’ perspective in collecting, identifying and preserving traces in the assistance provided to victims of violence, from the perspective of these professionals. The perception about performance considered elements related to the qualification and actions developed by the professionals and teams.

Method

Type of study

This is a qualitative and descriptive study with an exploratory approach. Presentation of this study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) ^{( 15 )} .

Setting

The study was conducted in the municipality of Florianópolis, capital city of the state of Santa Catarina, at two public hospitals that are a reference in Emergency services: victims of domestic and sexual violence (Hospital A); and victims of violence in general (Hospital B).

Participants

The research participants were professional nurses who make up the care flow for patients in situations of violence in the selected locations. All 21 professionals were invited in person and agreed to take part in the research. Although this number refers to the entire population selected, inductive thematic saturation (support of the categories) and data saturation (new data only repeating the previous codings) were confirmed, bringing together two forms of saturation, focusing on the analysis and on the data itself, respectively ^{( 16 )} .

Period

Collection took place from August 2021 to January 2022.

Selection criteria

The inclusion criteria corresponded to nurses that are members of the multiprofessional team and that had worked in the Emergency areas of the respective hospitals for a minimum of two months. Although all nurses agreed to take part in the research, the exclusion criterion adopted encompassed professionals on vacation, legally on sick leave or away from the Emergency sector due to the study taking place in the midst of the COVID-19 pandemic.

Data collection

The participants had no previous relationship with the researcher. Access to the participants was preceded by contacts with the respective heads of the Emergency sectors to convey all the information to the professionals. Scheduling of the interviews for data collection was flexible, according to the situation of each locus and to the participants’ demands, and they were carried out in the workplace and respective shifts, in an environment that ensured privacy. The semi-structured interviews presented 10 key questions regarding the type of assistance provided to patients victims of violence, in addition to a descriptive question favoring the interviewees to express their opinion and experience on the topic proposed. Of all 21 individual interviews, 19 were conducted face-to-face (audio-recorded) and two via Google Meet (audio-recorded), lasting a mean of 30 minutes and conducted by a single researcher (first author), an MSc student nurse attending a Graduate Program in Nursing. The same researcher who conducted the interviews transcribed them to a Word document. In addition, the data collected were submitted to verification by the research participants, considering evaluation and validation regarding authenticity of the information.

Data treatment and analysis

The analysis of the qualitative material followed the Thematic Content Analysis technique, in which the centrality of the text is given through a word, phrase or summary. The researcher detected the meanings in a clipping and interpreted them ^{( 17 )} . The thematic analyses were carried out in three stages: pre-analysis; exploration of the material; and interpretation of the results obtained. The pre-analysis was initiated with the full transcription of the interviews to a Word document by one of the researchers. The exploration of the material was analyzed, and the excerpts from the open questions, previously highlighted, and the interpretation of the results of the interview materials were interrelated and contextualized with the study problem and objects.

Finally, rigor in the research was also consolidated by triangulation of researchers and peer review of the data collected and the interpretations of the results. In addition, both the researcher, responsible for the effectiveness of the interviews, and the team of researchers, considered knowledge about the possibility of bias, values and previous experiences that might be incorporated to the research.

Ethical aspects

The study meets the recommendations set forth in Resolutions 466/12 and 510/16 of the National Health Council ^{( 18 )} . The project was approved by the Ethics Committee, via Plataforma Brasil with CAAE: 48423221.0.0000.0121. The research participants were approached by the researcher during working hours and invited to take part in the research and to sign the Free and Informed Consent Form (FICF).

Results

Of the 21 (twenty-one) nurses participating in the study, seven worked at night and fourteen during the day. Most of the nurses did not have any graduate studies (10) at the specialization, MSc or PhD levels; four had an MSc degree; five had a Lato Sensu graduate degree and two had a specialization in Nursing (one of them in Criminal Forensics).

The data were organized and analyzed in five categories, each with its own subcategories (from 2 to 4) and registration units, which explain the content of the findings, as shown in Figure 1 below .

Figure 1
- Categories, subcategories and registration units. Florianópolis, SC, Brazil, 2022

Category	Subcategories	Registration units
The professionals’ perceptions	Relationship with the type of assistance provided	• Underage victims (sheltered for considering the personal aspect). • Female victims (due to gender difference). • The professionals do not consider being fit for the service to be provided.
	Relationship with the professional experience time	• The professionals consider themselves adequate for the service to be provided. • The professionals provide care regardless of the type of victim. • Relationship of appropriate performance to the experience of the profession with physical examinations.
Professional qualification	Institutional provision of courses/training	• The institution does not offer courses to improve the assistance provided to victims of violence.
	Preparation for trace collection and preservation	• The professionals perform the service when necessary, regardless of complementary training. • The professionals relate the technical practice with the opportunity for training in Criminal Forensics. • The professionals seek help from colleagues for service to be provided. • Skills acquired in the practice - more time and demand.
The professionals’ actions	Assistance through physical examination	• Conditioned to the victim’s acceptance, carried out in partnership with the physician on duty. • Trace collection and preservation by a specialized IML * team.
	Administrative - referrals	• Referral to a specialist, after clinical actions - administration of prophylactic medications.
	Administrative - communication with the Police	• The Police service is activated with the patient’s consent. • The Police service is triggered if admission is via rescue. • Choice of the victim not to trigger the Police service (the aggressor is the current or former partner).
	Administrative - completion of the Emergency service	• Hospital discharge. • Hospitalization/ICU † .
Institutional protocol and materials	Existence of protocols without indicating nurses’ role	• The institution does not encourage collection of the corpus delicti and/or secretions by Nursing professionals. • The institution recommends medical guidelines. • The institution has a training project for the assistance to be provided.
	Perspective regarding elaboration of protocols	• Operational protocols are only formulated for sexual violence and there is no specific sector to house these victims (institution in preparation).
	Existence of an intra- and extra-institutional Protocol	• There are no specific protocols for each type of care. • Specific reference and assistance flow protocols are available, but not articulated to the forensic examination. • There are operational protocols from the City Hall. • There are operational protocols from the City Hall, but the institution is developing assistance protocols for improvement.
	Institutional materials	• The institution offers support materials. • The institution offers materials that help, but do not encourage collection of the corpus delicti and/or secretions by Nursing professionals. • The institution does not offer materials that support the activity.
Structure of the multiprofessional team	Composition and distribution in shifts	• Comprised by a social worker, psychologist, physician, nurses and nursing technicians available for joint care. • Reduced at night shift - only physicians and nurses.

• ^*
  IML = Instituto Médico Legal (Forensic Medicine Institute);
• ^†
  ICU = Intensive Care Unit

For a better synthesis of the results, an illustrated infogram ( Figure 2 ) is presented, prepared by the authors with resources from the CANVA ^© 2022 Online Design and Publishing Tool, with permitted non-commercial uses (creativecommons.org/licenses/by-nc/4.0).

Figure 2
- Illustrated infogram for the study purposes. Florianópolis, SC, Brazil, 2022

Based on the results presented in the infogram and chart, the following categories are described and exemplified with excerpts extracted from the interviews.

The participants recognize technical unpreparedness for collecting and preserving traces in the assistance provided to victims of violence. Even so, they manifest acquisition of skills and knowledge inherent to the routines throughout the practice, even without the opportunity for specific training or knowledge to do so.

I never took any course on trace collection techniques, I never needed to, but when there is this type of patient, because I’m the oldest in the house, I generally know what to do (B5) .

I don’t have any technique for collecting and preserving traces, but I’d like to master techniques, I didn’t seek to go deeper because some types of violence are only assisted by medical professionals (B16).

There are disagreements regarding the availability of institutional protocols for care: some refer to Standard Operating Procedures (SOPs), the process of developing protocols or training projects to assist victims of violence in general; others are unaware about the provision of materials to assist these victims, and, in addition, there are those who are not interested in knowing more about the topic. When only a protocol from a municipal health authority is mentioned, it is recognized that the institution does not propose or legitimize greater autonomy of nurses, limiting itself to maintaining the duties of each member from the multidisciplinary team already defined by that instance.

The hospital even has flowchart-style material for care, but I’ve never seen these materials... once it was commented to the managers about carrying out new training sessions [...], but I didn’t know more about it and in the routine hustle and bustle I didn’t go after it (B10).

The institution offers materials, such as POPs to standardize care for victims of violence, and the Hospital is starting training sessions and a single protocol on this type of assistance because the institution is a reference, and what we used was made by the City Hall (A2).

The institution doesn’t encourage anything other than physical examination and basic anamnesis of these patients performed by us in Nursing [...] we were unable to assist in anything else (A3).

When protocols and guidelines are unknown, care is based on medical guidelines. Even when specific protocols are known for each type of care and to which extent they ease referrals to extra-institutional reference services, there is certain perception of the absence of an appropriate place to shelter victims of sexual violence, other than with other emergency patients.

Depending on the type of victim and if some doctors prefer the approaches that they themselves understand, and as we have few materials, we end up doing it their way and then we refer them according to routine and need (B9).

Regardless of the perception about aptitude for care, there are sensations of discomfort or embarrassment when assisting victims of violence, especially when it comes to minors or to the opposite sex. Others justify their disconnection due to experience time, limiting their action only in cases of sexual violence, which should be referred to a specialized service.

I don’t feel comfortable assisting victims of similar ages to my kids (children and pre-adolescents), as I keep imagining them in this situation and what I’d do as a mother and not as a professional (A1).

I usually don’t feel comfortable providing care to young women victims of sexual violence who arrive at the institution, I think they feel uncomfortable because I’m a man and have to perform a physical examination on them (A2).

As I’ve been working in the sector for a long time, I’ve become used to these consultations, it has become natural to see patients come in certain states, I’ve become used to the type of exam we perform (B8).

Regarding professional actions, even with the victim’s authorization to perform physical examinations, these are carried out with the presence of at least two professionals, usually a physician and a nurse, regardless of the shift. Oftentimes, due to collection of secretions, the physical examination is responsibility of the Forensic Medicine Institute (IML), which is immediately triggered.

The patients receive prophylactic treatments, are instructed and immediately referred to specialty outpatient services (social worker, psychologists and gynecology), except in the night shift, which does not have these professionals available. As the full structure of the multiprofessional teams is not ensured in all shifts, there are only physicians, nurses and nursing technicians for care at night. The outcomes take place according to type of occurrence and severity, between and ICU admission and discharge.

For night care, I (nurse), the physician and the technical team are usually here, when a patient arrives as a victim of sexual violence, full assistance is provided, prophylactic measures are taken, and then she’s instructed to look for the specialty outpatient services to continue the protocol (A2).

Communication with the authorities takes place indirectly in the workplace by Police officers that were present at the rescue or by the Mobile Emergency Service ( Serviço de Atendimento Móvel de Urgência , SAMU), without reports of requests and/or clarifications by the courts. Regarding such communication with legal authorities, there are different stances, which only take place with the victim’s consent or which are carried out regardless of the victim’s will, due to the seriousness of the situation and already informed since the rescue. In addition to that, many victims choose not to contact the Police when the aggressor is their current or “former” partner.

When they arrive by the SAMU (Mobile Emergency Care Service) and are identified as violence, such as by firearms or melee weapons, some patients already arrive with Police officers to investigate the case or the SAMU professionals themselves already warn the authorities, except sometimes that we had to call them (B9).

Victims of sexual violence, even if they don’t want us to contact the Police because of the seriousness of the case, it’s provided by law that professionals who don’t file a Police report can be tried as accomplices (A3).

Discussion

Based on the nurses’ perception, in the assistance provided to the victims that would somehow enable collecting, identifying and preserving traces, in both scenarios studied they act and consider the topic in different ways. In both cases, nurses on the front line of care provide the first assistance to victims of violence, regardless of their time working in the sector or whether they consider themselves fit or prepared for this type of care. This fact corroborates the need for changes and training of all those involved in the so-called chain of custody, that is, the procedures to preserve and document chronology of the traces in the evidence production process ^{( 19 )} .

In addition to that, there is lack of human resources and knowledge about the role of Forensic Nursing among the challenges inherent to the Nursing practice in this type of context. Collection of traces is also a subspecialty already traditionally performed only by the Criminal Police ^{( 5 , 20 )} .

Professional competence is a multifaceted concept, which can be defined based on theoretical approaches and fields of action; it connects with professional experience, which in turn exerts impacts on stability and permanence in the institution and should induce intellectual growth consistent with the demands. However, influences from the context and culture can promote mechanized professional actions and little stimulus for new studies and expansion of the field of action itself ^{( 21 )} .

In this study, an important gap in training or qualification for the forensic professional practice was found. Therefore, it can be inferred that this aspect is in nurses’ performance and maturity in the respective work process. In addition, although both institutions are configured as teaching hospitals, this aspect did not change the situation of lack of training aimed at the best care practices for victims of violence. In this sense, investment from undergraduation to continuing education and in the systematization of care, where elaboration of protocols is included, are discussed to advance together, as care quality depends on the qualification of the professional team. Constant updates are fundamental for the provision of humanized and technical quality care in such delicate situations as violence ^{( 20 , 22 )} .

The lack of training/updating opportunities promoted by the services is added to the absence of individual initiative for this type of improvement, perhaps due to lack of knowledge about the potential participation of Nursing professionals in collecting and preserving traces. Forensic Nursing needs to recognize its active role, mastering knowledge and conquering spaces for participation in the stages for the manipulation of forensic evidence, even in the educational context, by including forensic content from undergraduate to graduate studies ^{( 23 )} .

The theme of Forensic Nursing is still little discussed in the services and there is diverse evidence that these professionals have not received training and do not recognize this new area ^{( 12 )} , which should be the object of transformations in the training processes of the profession ^{( 14 - 15 )} .

Lack of protocols, guidelines and institutional conditions, to be clearly established, was pointed out in both institutions, denoting certain a demand to update consensual and scientifically based practices for collecting traces in cases of violence. The literature reports about forensic nurses’ actions such as: assistance to victims in appropriate places, providing confidentiality and security; interview, physical examination, tests, test collections, with other health professionals; and assistance in the proper identification, collection and preservation of forensic traces. Such actions generate resource savings, strengthening laws in favor of the victims. They integrate a care model that assists criminal justice in all the chain of custody stages, as Nursing works with other health professionals, focusing on the well-being and knowledge of the profession ^{( 24 )} .

Most of the professionals participating in both hospitals consider themselves able to provide care to the victims but, paradoxically, they do not feel prepared or master the necessary forensic techniques, even because they do not perceive space and openness to put this type of technique into practice in the institutions.

Emergency nurses’ limited knowledge in relation to the forensic demands is not an exclusively Brazilian reality. In the international scenario, hospitals or institutional policies do not allow nurses to collect evidence, due to lack of training and because they consider the contamination risks in the collection of evidence that would harm the chain of custody and the legal process ^{( 7 - 25 )} . In addition to the limitation of specific training, there is the exclusive perception of the role of physicians, making it difficult to collaborate in areas such as Nursing and generating resistance from the team itself for articulated actions ^{( 25 )} .

It is indispensable to have an adequate professional stance in the care of any type of violence, as well as knowledge about the services available and actions for the outcome of criminal investigations ^{( 23 )} .

In this study, one of the hospitals adopts a flowchart in which the procedures are related to collecting, preserving and identifying traces under medical responsibility, while the collection of corpus delicti exams in charge of the professionals from the Forensic Medicine Institute (IML). This same scenario makes the notification of care to victims of sexual violence compulsory, which is a type of mandatory communication to the health authorities carried out by health professionals under occurrence, suspicion or confirmation of diseases, health problems, or Public Health events ^{( 4 )} . After welcoming the victim, the compulsory notification is filled out and forwarded by the hospital to the program for the Prevention and Assistance to Victims of Violence ( Prevenção e Atendimento às Vítimas de Violência , PAV), in addition to making referrals to the Social Work and Psychology areas, according to the flowchart established. The other hospital presents a gap in the process for developing the flow of notifications and referrals to be made, as the professionals state that they are not instructed or trained to refer victims to reference services, which is also reported in other scenarios ^{( 22 )} .

Although experience of providing legal clarifications regarding the care of victims of violence is not reported in the study, nurses qualified with forensic techniques become truth facilitators and can testify in courts as specialized witnesses. Forensic Nursing knowledge in health care provision can help professionals to improve the assistance provided and minimize the negative consequences for the victims not only in the provision of emotional care, but in supporting the teams that collect traces and in the preservation of more accurate evidence ^{( 26 )} .

Differences of multiprofessional teams in the care of victims of violence were notably observed in relation to the teams’ shifts. Both Hospital A and Hospital B reported that the daytime teams were more complete and had more professionals available and varied in the car provided, focusing on the opportunity and time of referral (or not) to specialty outpatient services.

Depending on the type of trace collection and therapeutic procedures, trained nurses can collaborate with the extra-institutional multidisciplinary team (forensics, federal agents, judges, prosecutor’s office). From the victims’ admission to their discharge or death, there is always a Nursing professional present, who may even request the presence of a legal or Police representative ^{( 27 )} .

The study suggests that the lack of a team duly qualified team in forensic skills can be a hindrance to make these professionals more present and qualified in the collection of evidence, reinforcing the exclusivity of this performance by medical professionals. Another reason reported is the fact that forensic professionals have a limited relationship with Emergency nurses, feeding the limited capacity to collect evidence and the lack of perception about this action as the role of nurses ^{( 28 )} .

Forensic Nursing has implications for the clinical practice, whereas collaborative work between well-structured teams promotes more comprehensive care, well-developed protocols, welcoming by organized and competent professionals, and appropriate legal evidence ^{( 26 , 28 )} .

For forensic studies, it is important that emergency nurses’ skills and knowledge are seen as a way to improve more comprehensive care for the patients (victims), without confusion of roles or perception of loss of power among colleagues. Although nurses face opposition from other professionals, the importance of multiprofessional care stands out, without only one profession highlighted, as is the case in relation to forensic medical professionals. As Nursing gradually occupies these spaces, it generates potential to develop forensic skills, and qualifies and strengthens itself in the scientific environment ^{( 29 )} .

When analyzing the Forensic Obstetrics field through a literature review, the emergence of professionalism in Forensic Nursing was recognized as a new specialty with educational, research, supervision and leadership roles, including an association aimed at promoting forensic professional performance ^{( 30 )} .

In addition to that, Forensic Medicine should not be only reserved for medical professionals. Emergency nurses specifically trained in Forensic Science are important to ensure that patients receive the best legal medical care ^{( 25 )} . In addition, in the Unified Health System ( Sistema Único de Saúde , SUS) there are regulations to collect traces in Emergency units. Even so, there is no ordinance that recognizes health professionals in the chain of custody of the evidence and validation of the traces by the Criminalistics institutes, conflicting nurses’ role in the care provided and in collecting traces for legal purposes ^{( 5 )} .

Forensic Nursing evaluations can only be performed by professionals duly qualified for these types of actions, due to the uniqueness of the involvement of legal spheres from the first moment. An integrative literature review found national studies on nurses’ difficulties for not feeling prepared to perform some of the procedures listed, mainly related to collecting and preserving evidence, although they were known by the professionals ^{( 31 )} . In addition to that, bureaucratic actions were more indicated as activities developed by Nursing professionals, to the detriment of procedures such as physical examinations to collect traces ^{( 12 )} .

Therefore, it is necessary to offer training sessions for professionals that are designated both to perform the service and to be collectors of traces of crimes and violence, so that the chain of custody stages can be properly followed, in order to avoid failures or invalidation of the forensic process ^{( 32 )} .

This study was carried out during the COVID-19 pandemic, which triggered certain delay in the data collection stage, manifested by recurrent unavailability in participation of the professionals due to the work demand. Therefore, although this situation was mitigated by the nurses’ full willingness to participate in the research, it is argued that this aspect is a study limitation, as the face-to-face interviews were repeatedly rescheduled and also interrupted. The potential is that the participants expressed their willingness to take part in the research.

Conclusion

In this study it was shown that forensic practices are occasionally and indirectly performed by Nursing professionals in Emergency areas, although these professionals themselves fail to recognize these practices and their potential.

The necessary inclusion of Nursing in forensic theory studies stands out, as many of the procedures performed by other professionals are part of nurses’ daily professional routine. Thus, the Nursing professionals that usually provide the first contact with these victims play a fundamental role in the chain of custody and investigation, contributing to the purposes of justice, generating proper actions in the care of these victims and ensuring traceability of the traces.

Deepening of the knowledge in Forensic Nursing practices and theories is essential for the professional and educational development of these professionals. However, it is shown that institutions are still unfamiliar with the topic, resulting in greater qualification difficulties, minimizing the effective and competent participation of these professionals in assistance and research.

The study contributes to better understanding the Forensic Nursing area, pointing to the need to include and expand its practices in hospital emergencies. The need for knowledge, training and practical participation of professionals duly qualified to provide care and collect traces for legal purposes in the assistance offered to patients who are victims of violence is evident.

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• *
  Paper extracted from master’s thesis “Enfermagem forense: atuação do enfermeiro nos serviços de emergência frente às vítimas de violência”, presented to Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.

• How to cite this article

  Citolin MO, Vargas MAO, Santos DG, Hilleshein AG, Brasil G, Ramos FRS. Assistance to victims of violence in Emergency services from the Forensic Nursing perspective. Rev. Latino-Am. Enfermagem. 2024;32:e4137 [cited year month day]. Available from: URL . https://doi.org/10.1590/1518-8345.6780.4137
• All authors approved the final version of the text.

Edited by

Associate Editor:

Sueli Aparecida Frari Galera

Publication Dates

• Publication in this collection
  19 Apr 2024
• Date of issue
  2024

History

• Received
  31 Mar 2023
• Accepted
  30 Nov 2023