For many thousands of recently arrived torture and abuse survivors, the United States holds the promises of freedom, safety, and a better life. However, navigating a complex and sometimes inhospitable immigration system is not an easy task, especially for those with limited English skills, little trust in authority, and often minimal evidence to substantiate their cases in court.
Fortunately, there are several forms of legal reliefs available to asylum seekers and foreign-born survivors of crime, including sexual and domestic violence (U.S. Citizenship and Immigration Services, n.d.). Clinicians with advanced medicoforensic training offer valuable services to these survivors, including forensic physical and psychological evaluations to document the sequelae of violence. Written affidavits, which capture the findings of such evaluations, can be included as supportive documentation in applications for T/U visas, asylum, and other immigration-specific legal relief (Peart et al., 2016; Scruggs et al., 2016). Although limited, program data suggest that, when forensic evaluations are conducted, affidavits can positively influence legal outcomes for the survivors seeking them; the asylum grant rate for torture or abuse survivors nationally was approximately 35%, but with legal representation and supporting clinical forensic documentation, the success rate is as high as 80%-90% ("Asylum Decisions and Denials Jump in 2018," n.d.; Lustig et al., 2008; Peart et al., 2016).
Currently, immigration-specific medicoforensic care is often delivered by volunteer physicians with varying degrees of advanced training in forensics (Peart et al., 2016; Stadtmauer et al., 2010). In many situations, survivors are forced to travel great distances, at their own cost, to access the limited number of physician providers who currently offer such services (Scruggs et al., 2016). These factors contribute to an inability of many asylum seekers to obtain such services.
Forensic nurses, although almost universally untapped to address this gap, are aptly positioned to meet the critical medicolegal needs of this uniquely vulnerable population. Published literature about the role of nurses in providing medicolegal services to support applications for immigration-specific legal relief for foreign-born survivors of torture, abuse, and other crimes is extremely limited. There is no known nurse-led and managed program offering such services in the United States or globally, although some nurses have begun partnering with other agencies to conduct forensic physical or psychological evaluations (Boersma, 2003; Payne, 2018). By virtue of the required preparation and regulation of forensic nurses, this expert cadre of over 4,000 clinicians across the United States, including in-border states, is already trained and competent in the skills needed to provide such specialty care to asylum seekers and others (e.g., trauma-informed care, crisis assessment, detailed physical examination and documentation, photodocumentation, referral planning, and linkages to community resources; American Nurses Association & International Association of Forensic Nurses, 2017; International Association of Forensic Nurses, 2018). Thus, forensic nurses are an opportune group to engage in the enhanced tasks specific to conducting immigration-specific forensic physical evaluations (American Nurses Association & International Association of Forensic Nurses, 2017).
As part of an ongoing initiative to provide improved access to services for Baltimore's immigrant, refugee, and asylee populations (Adams et al., 2016), in 2017, forensic nursing services were expanded to include a new suite of nurse-led services including provision of forensic physical evaluations and related documentation for asylum seekers for use in civil immigration proceedings. Specifically, nurses conducted a comprehensive medicoforensic history, photodocumentation and assessment of physical findings (e.g., scars, skeletal deformities), and completion of an affidavit to be included as part of the patient's application for asylum. These services were designed to meet a gap identified by community stakeholders who noted that, typically, these services were delivered by volunteer physicians and were not consistently available in a timely manner in the local Baltimore area. Services were implemented by the Forensic Nurse Examiner (FNE) Program located in the Mercy Medical Center Emergency Department in Baltimore, MD. The FNE Program is the city's designated site for forensic patients and the only organization in Baltimore to offer forensic nursing and family violence response services to adult victims of sexual assault, intimate partner violence, human trafficking, and elder abuse. The purpose of this research initiative was to examine both the feasibility and acceptance of this nurse-led service delivery model for offering forensic physical evaluations to foreign-born community members seeking immigration reliefs.
Methods
Overview
A sequential mixed-methods study was conducted to examine the feasibility and acceptability of the newly implemented forensic nursing services for foreign-born survivors of violence. The study was designed and implemented from a research team grounded in action, feminist, and emancipatory research perspectives (Corbett et al., 2007; Kagan et al., 2010; Kirkham & Anderson, 2010). Although the long-term goal of the project is to better serve the immigrant and refugee populations, we were aware at the onset of the project of our own limitations in safely accessing these individuals for research or program improvement purposes. Therefore, we chose as a first step to focus our efforts on building relationships and partnerships with trusted legal service providers who have the credibility and longevity within the immigrant and refugee community locally.
Data Collection
Process data such as length of time between referral and examination, type of legal relief sought (e.g., asylum, T/U visa, Convention Against Torture), and community partner making the referral were obtained through a review of administrative records between May 2017 and December 2018 after the implementation of this expanded service option. Qualitative data regarding the experiences and perceptions of the implementation, referrals, and clinical service provision were obtained through five semistructured interviews with service providers (immigration attorneys, case managers, and forensic nurses) between March 2019 and April 2019. The interview guide broadly included items related to the interviewee's background in working with foreign-born individuals and their experiences with forensic examinations, and nursing services; probes specific to challenges, barriers, and benefits were also included. The guide was developed by the authors whose experience is detailed in the "statement of reflexivity." Interviews were audio-recorded and transcribed, and identifying information was redacted for analysis. All service providers who were involved in the program implementation process and not part of the research team were invited to participate (one declined to be interviewed because of being on leave during data collection). Service providers reviewed a written consent document with the interviewer and returned a digitally signed copy before beginning the interview. Given the first author's status as the, primary forensic nurse for the program, and her routine contact with program stakeholders, the second author conducted all interviews to promote opportunities for candid responses from participants. Individuals who completed interviews were provided a $20 http://Amazon.com gift card for their time. All study procedures were approved by the Mercy Medical Center Institutional Review Board.
Data Analysis
First, descriptive analyses were conducted to summarize process data for the program and cases conducted during the study period. Qualitative interview data were coded second using the qualitative analysis and data management software program Dedoose (SocioCultural Research Consultants, LLC, 2018). A qualitative descriptive analysis approach was utilized (Miles & Huberman, 1994; Sandelowski, 2000). All transcripts were coded by both authors using an a priori codebook and hierarchy developed based on the interview guide and review of the initial interview. Regular meetings between the authors occurred to discuss the codebook and agree upon changes. After initial application of the codebook, both authors reviewed coded data, created written summaries of data within each code, and met to further summarize codes within descriptive categories. The first author was also involved in project implementation, and her field notes from the implementation process were used to further assist in the analysis at this point. As the pilot nature of the program prevented us from having more stakeholders to interview, we did not use saturation as a data collection or analysis end point but chose to present a descriptive analysis of the data that was obtainable (Sandelowski, 2000).
Statement of Reflexivity
Both authors are cisgender female and registered nurses by training. We bring together our experiences in practice, research, public health, and international development-each with over a decade of experiences working to improve the lives of individuals impacted by trauma and violence. Our work is informed by clinical practice in the area of forensic nursing and refugee health, and the choice to partake in this study was guided strongly by underlying knowledge that building partnerships with and learning from individuals in our community was a key first step to building sustainable programs.
Results
Overview of Forensic Cases
During the 20 months of reviewed administrative data, eight patients were referred, and eight forensic physical evaluations were conducted. All of the patients were female and seeking asylum (not T or U visas or other types of legal relief in the United States) and represented diverse countries of origins in Latin American, South East Asian, and African regions. Telephonic interpreter services were used to support six evaluations. Additional details regarding the characteristics of clients can be found in Table 1.
Provider Feedback
Service providers interviewed included immigration attorneys (n = 3), a social worker (n = 1), and a forensic nurse (n = 1). Providers ranged in age from 31 to 47 years, had been working in their respective professions for 3-16 years, and had a focus on working with immigrant populations for 1-13 years. Three of the providers were female, and two were male. All five identified as White, with two also identifying as Hispanic or Latinx. Consistent with the design of the interview guide and data collection, providers' overall responses were categorized into benefits and barriers to forensic physical evaluations for foreign-born individuals seeking legal immigration relief.
Benefits
Providers universally expressed that the service was acceptable and beneficial to themselves and to the patients or clients whom they served. Each of the legal service providers stated high importance of and satisfaction with the quality of these nurse-led services for their client(s). They noted the services provided were timely, responsive, and accommodating to the unique needs of their clients who often have complicated trauma and legal histories. One legal provider noted that being involved in a partnership with the forensic nursing program from the onset was helpful in establishing a common understanding of the unique needs of their clients:
Part of our training was to educate the forensic nurse examiners about their written evaluations that we need to use to support our clients' legal claims[horizontal ellipsis]. They were amazing-the nurses-in just being open to understanding the legal claims that we were making and the components that we needed to make sure were addressed in the evaluation[horizontal ellipsis]. it's very unique in the asylum context. I felt they were very receptive and open to understanding what our unique needs were and have really been able to meet them.
Despite concerns about clients' willingness and ability to participate in a forensic physical evaluation because of the intense nature of such services, legal and nursing providers largely reported that patients' experiences with forensic nurses were positive:
Being an undocumented immigrant in this country is hard, and it just fosters within you a protective condition, where you are very distrusting of anyone. I'm generalizing. It's not true with everyone. Those challenges, but really I would say that, within the confines of [the hospital] and the institution and the program as it exists right now, [nurse's name] did everything she can to make the client feel comfortable, and indeed it was successful. It was a positive outcome.
In addition to nurses providing an essential service, legal providers also noted specific benefits in the way the referral system was designed to minimize burden to clients and the legal partner organizations. This included a direct referral system that bypassed an emergency department admission despite being colocated in the department, flexible scheduling hours, consistent use and availability of translation services, and service delivery at no cost to the patient or legal organization.
They've been super great about being flexible about their appointment times[horizontal ellipsis]. They have interpretation services at the hospital. They conduct the exam. They draft a very extensive report with diagrams. They usually have a very quick turnaround, which I thoroughly appreciate. Usually within a week or 10 days. They send back the report to me.
Barriers
Barriers to access and delivery of health services for foreign-born patients are numerous, and the same applies to forensic nursing services for this population. Language differences between providers and clients were a primary concern for all providers, and suggestions included adding multilingual staff, improving access to interpretation services across the hospital (e.g., when calling for appointments or to pick up paperwork in addition to at the time of an examination), and additional skills and practice in working with interpreters for the individuals conducting examinations to facilitate competence and confidence. The forensic nurse noted:
I think if I kept doing it, you would get really skilled at working with a translator and using it effectively. I think that'd be a huge benefit across any health care [system].
Another common challenge to working with immigrant populations is establishing rapport and addressing issues of trust. Health, legal, and social service providers recognized the plethora of reasons that asylum-seeking and foreign-born clients may not trust any healthcare providers, including lack of organized healthcare systems in their country of origin, a prior negative experience, challenges in communication and language barriers, or general mistrust of governments and individuals of authority. One legal service provider interviewee noted:
Here in the United States, doctors and nurses in the medical community are seen either neutrally or positively, but that has not always been the case in Latin America. There have been nefarious practices done under the auspices of medicine in those countries, and people are aware of that now. There's just stigma with all things.
The ongoing partnership between the forensic nursing program and the immigration attorney groups was identified as an important facilitator to mitigate this challenge and support rapport-building between the forensic nurse and patient.
There was a unique handoff period between the...social worker that brought them [and the forensic nurse]. [The social worker] would make them feel comfortable going with [the forensic nurse] alone, and we would have a meet-and-greet period [prior to the exam] that was unique to the process but helpful[horizontal ellipsis].
A structural barrier noted by many was the lack of funding available for this type of nonacute forensic evaluation service. It was determined at the outset of the pilot program that, because of the common financial vulnerabilities of this patient population, forensic nursing evaluation services would be provided at no cost to patients or referring attorneys. Unlike many other services rendered by FNEs (acute post-sexual-assault care, child sexual abuse examinations, elderly abuse services), there are currently no publicly available reimbursement mechanisms available to cover this expanded suite of services. Associated costs of time for forensic nurse care provision were absorbed by the FNE program's organizational funds.
Patient-level barriers also arose around transportation and limited availability to schedule examinations because of complex life circumstances. These challenges led to longer-than-desired referral to examination times in some cases (see Table 1).
Definitely one of the main [barriers] is transportation. I work a lot with child custody cases. Many times the child does not have any adult in their life who has the time or the means to transport them to an appointment like that. We've finagled with our resources and volunteers to try to get them that transportation. Sometimes we make it work. Sometimes we do not. Sometimes I've tried to make referrals to Mercy but the client is not able to get there. We have to find another way to get them that appointment somewhere else. My priority is to always refer to Mercy because I think they do a stellar job.
Furthermore, without one central location in which forensic nurses are colocated with others, asylum seekers are required to seek services at multiple sites (one for a medicoforensic examination; another for a forensic psychologic evaluation, if indicated; and yet another for general medical care, etc.).
The Same Skills But Different Timeline
Findings highlighted ways in which the skill sets required to conduct forensic physical evaluations align with the scope of practice for sexual assault and forensic nursing. The forensic nurse interviewed noted:
The whole process is pretty much the same, and it's just a different time frame. It's getting a history, looking at injuries, and documenting while working with victims of violence. I have those skills to have those conversations, but it's just a little more complexity. I did feel overall that I had the base to get me through it.
Similarities noted by the forensic nurse extended throughout the patient interview and physical examination, completion of the medical record documentation, and drafting of an affidavit for inclusion in the patient's application for asylum. In addition, the collaboration with the legal team and case manager was seen as similar to the sexual assault response team model of care.
The major difference observed by the forensic nurse was a much longer interval between the reported trauma and the examination. Typically, forensic nurses are engaged with patients during the first hours or days after an assault when injury and emotions are acute; in the case of this service, violence against a patient may have occurred years earlier. Rather than being in denial or "shock," the patient may be experiencing other longer-term physical and mental sequelae, such as scarring and posttraumatic stress disorder.
Discussion
We present the initial findings from a pilot program to inform the forensic nursing community, immigration attorneys, and related social sector partners of the potential opportunities, lessons learned, and benefits associated with engaging forensic nurses to perform forensic physical evaluations for immigration reliefs. This program was designed to test a new suite of medioforensic services by nurses, and as with any new initiative or program, the time and resource demand for designing and establishing the program, developing protocols, and forming and maintaining community partner relationships was high. Before program launch, the lead author spent over a year meeting with community partners to establish priorities and build trust. The importance of devoting time to such activities cannot be understated.
The initiative was iteratively refined based on program learning and ongoing communication and collaboration between partners. The team performed "real-time" updates throughout the implementation period, including developing a set of preevaluation tips for attorneys to review with clients to ensure that patients are clear on the purpose and limits of the evaluation they would be receiving before their arrival at the hospital. The partnership also provided important support to patients throughout their entire process. All patients were referred to the forensic nursing program by attorneys who were familiar with their cases and deemed that evaluation and affidavit would be helpful to their clients' application for asylum. Rather than a self-referral system, this attorney-initiated mechanism helped ensure that forensic nursing resources were allocated to appropriate cases and that resources were in place. Patients were sometimes accompanied to appointments by case managers or social workers from the organizations that were serving the patients to meet their immediate legal needs and beyond. In some respects, these individuals served much as patient advocates do in sexual assault examinations, acting to be a nonmedical presence for patients (Department of Justice Office on Violence Against Women, 2013). They were also able to provide continuity of information between the medical team and legal teams.
Specific challenges and opportunities for improvement and growth were noted in the course of this research. The overarching challenge of access to services for patients seeking immigration relief was noted by all involved in the project. Lack of legal standing in the United States prevents individuals from accessing healthcare related to lack of insurance, inability to access providers, fear of legal ramifications, and language barriers among others (Callaghan et al., 2019; Kuczewski, 2019; Reynolds & Childers, 2020). Providing forensic nursing services has the ability to have a great individual impact as a successful immigration proceeding can offer patients access to a wide range of services and opportunities previously inaccessible. Although this pilot program was able to address many of these access concerns within the context of this initiative, at the wider systems and community level, these concerns remain rampant and contribute to negative health outcomes among immigrants and refugees (Szaflarski & Bauldry, 2019). Suggestions for continued improvement of integration within existing systems mirrored those often seen in medical home and community-based care initiatives (e.g., colocation of forensic medical and forensic psychiatric services, providing forensic services in a primary care setting; Ader et al., 2015; McNiel et al., 2014).
Implications for Clinical Forensic Nursing Practice
The results from this pilot program and feedback from key stakeholders highlight the importance of forensic physical evaluations for individuals seeking legal immigration reliefs and the ability of forensic nurses to provide this care. Although there are numerous clinical and legal similarities between this newly expanded suite of services and the routine sexual assault and medicoforensic care nurses already provided, additional collaboration and learning exchange with new community partners was essential to ensure competent forensic care and culturally sensitive practice. Education and skills-building around conducting and documenting complex patient histories, comprehensive understanding of long-term wound healing, and working with interpreter services were all important components of this training (American Nurses Association & International Association of Forensic Nurses, 2017; Department of Justice Office on Violence Against Women, 2013). The training also included sessions led by immigration attorneys who provided nurses with detailed information about common types of legal immigration reliefs requested in this community, as well as key components of physical forensic evaluation affidavit reports. Community partners also provided training on cultural competence around working with foreign-born populations, including Latinx. Although not formally explored within the scope of this study, such additional training and awareness-raising may have contributed to improved cultural adaptability of all of the program's services, including for acute care clients. Community-based models of service delivery may be better positioned than hospital-based models to address identified barriers around fears and access to the health system.
Recommendations for Future Research
As with any pilot program, the future research opportunities are plentiful (see Table 2). A key aspect for future exploration is the impact of services on key outcomes of interest to ensure that the model is consistent with prior outcome data on the use of the affidavits in successful immigration relief (Lustig et al., 2008; Peart et al., 2016). Further understanding of patient experiences with care is also imperative. For example, one legal provider commented on the issue of forensic nurse gender preference (a female patient's preference to have a female provider). There is a complex interplay between being sensitive to the needs of patients who may prefer a particular gender for their healthcare providers and the realities of the overwhelmingly female status of the nursing profession and the ethical and professional need to not perpetuate gender-based stereotypes that require additional research attention. Finally, examining the financial implications of this care model is essential to its long-term success and sustainability. Determining a cost-efficient model that reduces or eliminates financial burden to clients and nurses, and identifying opportunities for funding, is necessary for sustainability.
Limitations
The data presented must be taken in context with their limitations. As this was a feasibility and acceptability study, the patient and service provider sample numbers were small and limit generalizability and analyses. Similarly, as this work was conducted at one clinical site with a small number of legal service partners referring patients into the pilot program, the patient and provider characteristics captured in this study may not be the same as in other locations and are therefore not broadly generalizable. Additional sites or stakeholders may result in identifying new challenges, solutions, barriers, and benefits that this pilot group did not identify.
Given the nature of participatory work, there are close connections between the research team and the participants. This may make it difficult for participants to provide honest or negative feedback-utilizing quantitative programmatic review data to supplement our qualitative analysis is one way to support these early program feasibility and acceptability findings.
Conclusions
Forensic nurses are well positioned to provide essential forensic physical evaluation services to individuals seeking immigration relief and can meet a critical need where gaps currently exist. Published literature about the role of nurses in providing medicolegal services to support applications for immigration-specific legal relief for foreign-born survivors of torture, abuse, and other crimes is extremely limited. The data from this pilot initiative will directly inform and shape an emerging frontier for nurses to offer valuable, and potentially life-changing, services to thousands of foreign-born survivors across the country. Forensic nurses are a growing professional group, and the underlying principles and key skills of forensic nurses (American Nurses Association & International Association of Forensic Nurses, 2017) present a template from which to build services and skills specific for those seeking immigration relief.
Acknowledgments
The authors would like to thank the Mercy Medical Center Forensic Nurse Examiner Program and Debra Holbrook for supporting this work. They would also like to thank our partner organizations, Tahirih Justice Center and Kids in Need of Defense.
References