Forensic care

A Q&A with nurse practitioner Tracey Markham

by Brita Frost

Source: APNA Primary Times Summer 2024-5

Tracey Markham is at the vanguard of forensic nursing in Australia. As a forensic nurse practitioner, she has pursued extensive training both locally and internationally and now works to train and develop other forensic nurses. Her role as Forensic Nurse Practitioner – Interpersonal Violence at Yarrow Place Rape and Sexual Assault Service in Adelaide is complex and nuanced, requiring trauma-informed patient care. 

How did you come to be working as a forensic nurse practitioner? 

For me, it took time to get to this position and I did a lot of study. I did a forensic nursing course at Flinders University in South Australia in 2003. The course doesn’t exist anymore and at the end of that course, I was the sole graduate. I then attended Duquesne University in Pennsylvania and did their sexual assault nurse examiner course. 

In Australia, the term ‘forensic nurse’ is not generally used well. While forensic nursing has been around for a long time now, there's a lot of confusion around the role and what a forensic nurse does. I think forensic mental health is a role that is more commonly understood and spoken about. Internationally, particularly in the US, Canada and the UK, a forensic nurse has a very broad scope and the role of a sexual assault nurse examiner is common. The role has an extended scope, standards of practice, credentialing processes and there is a good understanding of how the health and legal systems intersect. 

What types of patients and health conditions do you most frequently encounter in your practice? 

A sexual assault nurse examiner plays a crucial role in medical care, and sometimes legal proceedings, for individuals who have experienced sexual assault and/or domestic violence. Our priority is medical care. If someone aged 16 or over has recently been sexually assaulted, they have the option to access related health care at Yarrow Place. The medical consultation includes addressing physical injuries, providing treatment, offering preventative care for sexually transmitted infection and providing emergency contraception.   

One of my responsibilities as a sexual assault nurse examiner is to collect and preserve forensic evidence. It involves gathering evidence from the victim's body, their clothing and any personal items that may have been involved in the assault. The goal is to ensure that the evidence is collected in a way that maintains integrity for use in legal proceedings. We also meticulously document the findings, including detailed descriptions of what occurred during the assault and injuries, and we take photographs.  

We’re very trauma informed. We offer emotional support and crisis intervention and help the victim navigate the immediate aftermath of the assault. We also assess current mental health and provide any referrals indicated. On occasion, the role may require us to act as expert witnesses for the court, and we may be called to testify. We testify as to the examination we performed and give an opinion about injury. In court, we must present our findings in a clear non-biased, objective manner as we can be questioned by both the defence and the prosecution. We are not there as an advocate for the client. We are there as a non-biased party to explain the process of forensic medical examination and what we've seen, to help the court understand the medical and forensic aspects of the case. 

How do you collaborate with other healthcare professionals to provide comprehensive team-based care for your patients? 

Our team is a multidisciplinary team of doctors, me as a nurse practitioner, two registered nurses and social workers who are trained in crisis care and sexual assault counselling. We also provide referrals outside of our service if people need further ongoing care for any reason. So, we might collaborate with psychiatrists and other mental health clinicians, the person's GP and we often collaborate with hospital ED and surgical staff as well.  

What are the most challenging aspects of your role? 

The people I see are dealing with trauma, often cumulative traumas. They've been sexually assaulted. The intimate parts of their body have been violated and I very quickly need to build a rapport with them and examine those intimate parts. Our examination is very invasive and it can take a number of hours. The patient may have already been to the police, or they've been to the hospital, they may have spoken to a counsellor and then finally they get to me and I'm asking the same questions all over again. It can be very stressful. They're exhausted. They're feeling all sorts of emotions. Our examination includes the collection of evidence, healthcare and treatment. A bit of preparation goes into the setup of an examination. I need to be very careful about the collection of evidence, making sure that I don’t contaminate and that I’m collecting the right things at the right time. All while navigating the complexity of trauma and care. 

What are the most rewarding aspects of your role? 

The most rewarding aspect is breaking down the myths. I try to help the patient understand that sexual assault is never the victim's fault.  

There are still a lot of myths around the body. People believe that you can tell if someone’s been sexually assaulted, whereas most victims we see don't have physical injuries because of the way the body is built and the elasticity of the genitals. The other myth that we debunk is that sexual assault is always an aggressively violent episode when often it's not. Often drugs and alcohol are used, or the flight, fight, freeze or fawn response is activated. Victims are often psychologically frozen during the event, or they do what they are told to prevent injury and protect themselves. There are so many nuances to it.  

So, I guess for me, the most rewarding part is if I can give the person some control back and promote their recovery. Also, to help them understand that this is a crisis; that the way they're feeling is okay and most people survive and, with time, can recover. 

How does your scope of practice differ from that of a registered nurse in a hospital setting? 

I am a nurse practitioner. I can diagnose disease, formulate treatment plans, and prescribe treatment. I am trained in responding to adult and child sexual assault, elder abuse and domestic violence. At times, I might assist with postmortem examinations for the coroner. But like a registered nurse, my focus is on patient care.  

In terms of health care, I do a lot of sexual health and I do a lot of women's health. In my scope of practice, I might look at unusual bleeding, talk to people about different forms of contraception, insert contraception (such as Implanon NXT), discuss the different aspects of the patient’s medical care with them, as well as any possible complications. I also do a lot of mental health assessment and safety planning, but if it's ongoing, I refer the patient to a mental health clinician. I’m always assessing risk. My role is holistic and comprehensive. 

How do you stay current with the latest healthcare guidelines and treatments relevant to your role? 

I never stop training! After my initial study, a Bachelor of Nursing, I completed a Certificate in Forensic Nursing. I then completed sexual assault training through Yarrow Place, a Graduate Diploma in Mental Health and a Certificate in Sexual Health through Shine SA. I've since upskilled in women's health, completing an Advanced Certificate in Women's Health and I’m now finishing my Professional Diploma in Women’s Health.  

I often do continuing professional development (CPD). I'm currently the education officer for Forensic and Medical Sexual Assault Clinicians Australia (FAMSACA), which is a nonprofit organisation for forensic clinicians. I also facilitate training for Monash University in their Sexual Violence Response Training. I am also forever upskilling in more general CPD as well: things like bloodborne infections, sexual health, abnormal bleeding, women's health topics, contraception, pharmacology, ECGs. Everything is relevant to the care that I provide.  

What advice would you give to nurses who are considering a career change? 

I have a lot of people contact me regarding this pathway in nursing. To them I say, ‘Watch this space!’ I hope over the next few years there will be significant growth.  

There are so many options out there for people interested in pursuing a career in this field. Once you have your nursing degree, you can do courses through Yarrow Place, NSW Health Education Centre Against Violence or Monash University. The International Association of Forensic Nurses also has training programs. But it can be as easy as getting the right clinical exposure in relevant settings, as extra study isn’t mandatory.  

If you’re a primary health care nurse looking to shift into forensic nursing, I think it’s important to seek opportunities to work in settings related to forensic nursing, such as emergency departments, sexual assault response teams and correctional facilities. Volunteering or shadowing professionals in the field can also provide valuable insights. 

I also think you need to think a little bit differently. While you're thinking about the health of the patient, you're also thinking about how an injury could have got there; the possible mechanisms of the injury, such as how a bruise was caused.  

It’s vital to have the baseline, extended practice skills in sexual health and genital examinations. They're sadly not taught when you go through your bachelor degree. It’s extra learning. It is imperative to really know and understand sexual health and the normal and abnormal variants of the intimate parts of a person’s body. Also, to have good assessment skills and to know how to use tools such as vaginal speculums. And just being trauma-informed, non-judgmental, non-biased and flexible. You have to be flexible because every person that comes and sits in front of you is different. 

Interested in improving your capacity to care for victim-survivors of sexual violence? Women’s and Children’s Health Network Yarrow Place provides training that equips staff to work in this area. Learn more on their website.