1. the Evolution of the Nurse's Role in Death Investigation

1. The Evolution of the Nurse’s Role in Death Investigation Jane E. Rutty Introduction This chapter begins by examining the general role of the nurse from a historical perspective to the current position in health care. The question as to whether the coronial service in England and Wales is in need of reform is debated, and com- parisons to other death investigation frameworks being practiced around the world are discussed. The term forensic nursing is defined, and the emerging new nursing roles is analyzed. The chapter closes by suggesting there may be a gap in the provision of nursing care in the field of death investigation within the United Kingdom and Europe. The Historical Role of the Nurse in Health Care The word nurse originates from the Latin word nutrire meaning “to nourish.”1 The Western version of nursing has a long history and can be traced back as far as the Middle Ages.2 In the mid-19th century, most nursing care was carried out at home as part of women’s unpaid domestic duties. Hospital patients, who were mostly destitute, were attended by women in religious orders or by lay women trained informally on the job. However, they also had a reputation for drunkenness and immoral conduct. Since the Reformation in the 16th century and the suppression of monasteries, the quality of nursing and hospitals suffered in all the Protestant European coun- tries but most severely in England. When Henry VIII established the Church of England in 1534, he seized more than 600 charitable institutions and suppressed all religious orders. This seizure of church properties had a direct negative effect on women and nursing. Women lost political and administrative control of nursing operations. Inexperienced civil administrators took over from religious profession- als who were steeped in a culture of care that had evolved since the beginning of the Christian church. As a consequence, women lost their voice in both hospital administration and nursing management, leading the whole medical system to begin a downward spiral of mismanagement, crowding, filth, and contagion.3 It was these conditions that prompted Florence Nightingale’s vocation.4 1 2 Essentials of Autopsy Practice Nursing has its modern origins from the Crimean War of 1854–1856, when there was a need to care for wounded soldiers abroad. Florence Nightingale (1820–1910), a British nurse, fulfilled this role when she organized a group of women to deliver care under her supervision and that of the war surgeons in Scutari, Turkey.5,6 Upon her return from the Crimean War, Florence Nightingale founded in 1860 one of the first nursing schools in the world, the Nightingale School and Home for Nurses at St. Thomas’ Hospital in London.2 Perhaps the largest achievement in nursing history since Nightingale’s reforms was The Nurses, Midwives and Health Visitors Act of 1979 (amended in 1992 and 2002), which set up the framework for the United Kingdom Central Council, the National Boards, and the Professional Register for Nursing, Midwifery and Health Visiting. Both the Council and Boards were dissolved in 2002 and replaced by the Nursing and Midwifery Council. The Role of the Nurse in Health Care Today Nursing is a complex activity that varies considerably according to where it is practiced. Defining what nursing is has always been difficult because its whole essence is its adaptability to varying needs and settings. Nightingale7 stated in 1859: “Yet no man, not even a doctor, ever gives any other definition of what a nurse should be than this . .” “devoted and obedient”. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.” A definition of nursing adopted by the International Council of Nurses in 1960 and presently the most widely accepted definition in nursing was given by Henderson,8 who proclaimed in 1966 that “The unique function of the nurse is to assist the individual; sick or well, in the per- formance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the recovery strength, will or knowl- edge. And to do this in such a way as to help him gain independence as rapidly as possible. This aspect of her work, she initiates and controls; of this she is the master.” Henderson’s definition of nursing contains many elements that constitute the substantive nature of nursing today and is recognized all over the world as captur- ing the essence of what nurses do. However, in 2003 the Royal College of Nursing (RCN), after a 4-month consultation exercise that attracted the highest number of responses in the history of the RCN (160,000), redefined the core of nursing as follows9: “The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.” Despite these attempts to define nursing over a number of centuries, there is no common agreement within the profession. The problem lies in the difficulty in defining nursing, because nurses work in a wide variety of fields ranging from the largely preventative, advisory work of health visitors at one end of the scale to the highly technical, curatively orientated field of intensive care nursing at the other end. However, the advantage of the RCN definition is that it has the potential to The Evolution of the Nurse’s Role in Death Investigation 3 unite nurses across specialties but also to explain their differences, and it is a useful tool for explaining nursing values. The Expansion and Advancement of Nursing Practice The setting within which contemporary nursing works seems to be continuously changing with the introduction of new concepts and innovations, such as the nurse practitioner, specialist practice, advanced practice, consultant nursing, primary nursing, and surgeon’s assistant. These concepts all increase the nursing role outside what historically were traditionally and established defined limits. However, this is not to state that this change is a bad thing. Following the publication of the documents “Junior Doctors: The New Deal”10 in 1991 and “The Scope of Professional Practice”11 in 1992, the issues related to the “expanding role of the nurse” have been at the forefront of both nursing and medical literature. These documents bestow nurses more independence, autonomy, and liberty to expand their roles than ever before while heightening their understanding of personal accountability. Many see role expansion as an exciting opportunity to develop new subspecial- ties. However, expanding the nursing role has been controversial, and there has been disagreement within the nursing profession as to what approach should be taken. There is no national standard or catalogue of expanded roles, and practices differ from region to region and even within hospitals,12 never mind country to country. Therefore the debate remains intense. An example of where nursing is expanding and advancing outside the traditional boundaries of health care was suggested in 1993 by Dr. Mike Green,13 Emeritus Professor in Forensic Pathology at the University of Sheffield. He believes that nursing staff in general are becoming increasingly more involved in legal processes, particularly with regard to their observations, records, and recall of events. Inter- nationally, nurses have expanded and advanced their role more extensively within aspects of the legal profession, with the ultimate example of the ability of nurses to be coroners coming from the United States.14–21 However, why has there been this major boundary shift and role advancement in providing nursing services within the coronial system in the United States and not in the United Kingdom or Europe? The Coroner Service: A Relic in Need of Reform In 1999, Derrick Pounder,22 a professor of forensic medicine at the University of Dundee, suggested that the coroner service in England and Wales was a relic in need of reform, particularly when considering the implications of the Human Rights Act.23 Pounder believed that the coroner’s investigation is an enforceable intrusion by the state into what would otherwise be a private family matter, the death of a loved one. Striking the balance between the reasonable needs of the state to inves- tigate and the rights of the next of kin to privacy and religious ritual is not easy, with present evidence suggesting this process is not done well in England and Wales. Among the rights in the European convention are the right to respect for privacy and family life (article 8) and freedom of thought, conscience, and religion (article 9). The new act in clause 6 provides that1 4 Essentials of Autopsy Practice “it is unlawful for a public authority to act in a way which is incompatible with a convention right.” This provided a starting point for questioning some current practices in the coroner service. According to the Home Office survey, 190,000 deaths, representing one third of all deaths in England and Wales, were reported to the coroner in 1996,24 whereas in 1970 the number was 130,000, representing 20% of all deaths. The increase is largely accounted for by natural deaths voluntarily referred to the coroner by a doctor. Referrals by doctors now represent 60% of the coroner’s case load.25 Pounder22 considered the directing of such a large number of natural deaths into the medicolegal investigative system to be both intrusive (for the families con- cerned) and costly. Of the 190,000 deaths reported, 68% were subject to postmortem examinations under the legal authority of the coroner.

Load more