Welcome, everyone. Thank you for joining us today for individualizing care, providing medical forensic exams across all skin tones. We totally appreciate you joining us today. We have myself and Chantel Hammond, who will be presenting to you. We do have a few housekeeping items to address first. So we'll start off with acknowledgments. I want to make sure that we're acknowledging the Office on Violence Against Women as they have provided funding to make this webinar possible for you. I wanted to make sure that you understand that we have no disclosures or we want to disclose no conflicts of interest and that as a member of IAFN, you are going to be able to access. This webinar isn't going to go well if my mouth doesn't work. You will be able to access CEs after the completion of the evaluation of this webinar. And the final announcement is that the International Association of Forensic Nursing is an accredited provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. With all that said, my name is Angelita Oluwu. I am a forensic nursing director with the International Association of Forensic Nurses, and I am also going to be one of your presenters today. And with that, I'll let Chantel introduce herself. Hi, everyone. My name is Chantel Hammond. I'm a forensic nurse specialist with the International Association of Forensic Nursing, and I'm very excited to be presenting along Angelita today on this very important topic. Thanks for having me here. So thank you, Chantel, for agreeing to join me today. Our learning outcomes today are really to discuss the needs for forensic nurses to be able to provide culturally sensitive and appropriate trauma-informed care. We're going to make sure that we explore the different ways that you all will be able to maintain a patient-centered approach throughout the exam process, and that we talk a little bit about injury identification techniques that can best be utilized across skin tone. And additionally, we want to make sure that everyone kind of walks away understanding that there are some specific considerations when it comes to things such as evidence collection, discharge, and follow-up. Anyone can be a victim of violence, trauma, or maltreatment. It's our responsibility as forensic nurses to be able to respond to all patients, no matter their background, using a patient-centered, culturally appropriate, trauma-informed approach. Forensic nurses must understand the community and culture of the patients they respond to and care for. So what that means is it starts with us as the clinician. It is our responsibility first. We cannot put that burden on the patient for them to try to explain what their backgrounds are. We really have to put them in the center of the care. However, that starts within us. So I think for us to be able to actually have some of these discussions, we do have to start with a few simple definitions. So again, this is not a training on implicit bias or a training specific on bias, but we do acknowledge that everybody comes to us with different understandings regarding terms. So based on how we're going to utilize these terms throughout this presentation, we figured we'd make sure to provide you some context to it. So bias is the cognitive tendency among humans to make systemic decisions in certain circumstances based on cognitive factors rather than evidence. Basically, it's an evaluation of something or someone that can be positive or negative in nature. So bias becomes a concern when it interferes with how we actually come about with making our decisions. Explicit bias can be defined as the attitude and assumptions that we acknowledge as a part of our own personal beliefs. And also the assessment of this type of bias can be done through self-report. So basically, you know, you have the ability to understand what your biases are and acknowledge them up front. Whereas implicit bias, also known as unconscious bias, is the opposite. And the problem that comes along with this is that sometimes it affects how we communicate with each other. It affects how we deliver care to the patients that we are providing care to. A lot of times it comes in as like unintentional attitudes or discriminatory behaviors, and they will affect actually how we go about doing some of the things we do or how we understand things around race, ethnicity, age, sexual orientation, and gender expression. So what we want to happen is we really want for people to understand that explicit bias is found to be kind of the underpin of discrimination or discriminatory actions. We have to understand that patients who experience bias in their past may expect negative interactions when they're seeking healthcare. So, for example, if I go into a hospital where I had my mom, I went with my mom and something negative happened or she shared to me that something negative happened in her experience, I'm going to enter that platform in a whole different state of mind from the very moment that I enter through the doors. I may not go in there with the intention or with the thought process that everybody is going to be looking at me and working super hard to make sure that I have the best experience. I may have the expectation that I will have that same similar negative experience that my mother may have experienced. So we have to keep that in mind, that sometimes patients do walk into places and carry those things as well. The other thing that we need to make sure that everyone understands is that we as nurses, we as clinicians, we have to be able to acknowledge and check around biases. We have to understand what our biases are, and we have to understand that when we analyze those things, we're stepping back and we are actually utilizing those biases, whether we know they're there or not, to maneuver how we walk through things in our day-to-day experiences. And then we have to be mindful in how we actually address our biases and how we overcome our biases to be able to make sure that we are actually creating space for ourselves to actually learn how we can do things different and also learn that other people experience things differently than we do. So let's talk about cultural competency and then we're going to go from cultural competency to talk about cultural humility. Both of those terms I feel that people use them a lot and also sometimes they'll try to say one versus the other, but let's first start with understanding them. Cultural competency is the ability to provide care to patients with diverse values, beliefs, and behaviors, including tailoring health care delivery to meet patients' social, cultural, and linguistic needs. Oftentimes when people talk about cultural competency, they think of it, I mean we're nurses, we're clinicians, we think of it in a way of I have to be competent, like I must understand this culture and be competent within this culture. Cultural humility is an ongoing process of self-reflection and self-critique, whereby the individual not only learns about another's culture, but one starts with an examination of their own beliefs, culture, and cultural identities, excuse me. So as clinicians, cultural humility and competence should be incorporated into the practice because they are both ongoing processes, to be honest. I know we think of cultural humility as an ongoing process, but so is competence because the practice is changing, people's culture changes, and how they interact with the world changes, so it's always going to be an ongoing process. And we must address the cultural needs of our patients in order to deliver quality care. You can study and learn about a culture, however the focus should be less on being the expert of that culture and more on being an ally. You are there to support, listen, and understand the needs of the community that you serve. So we do have a poll question to try to make it as interactive. You know, usually we're able sometimes to see faces, but when we're in this webinar form, we can't see faces and interact in that way, so we really want to interact with you and use this poll. And so our question is, have you ever received any training on the following? So implicit bias, cultural humility, and cultural competency. And if yes, can you please put in the chat which one of these trainings that you did experience in the past? And it looks like we have some mixes there, some people who experience implicit bias which is very common now I think within getting, at least for nurses to get our CEs we have to go through implicit bias training and then IFN also offers implicit bias trainings. So a mix and there's some people who haven't had any training. Thanks, guys, for actually participating and giving us some answers to that. So that's actually pretty exciting to see that many of you have actually had multiple different types of training. Sometimes we just see, you know, a minimum standard that's met there. So kudos to you, and we appreciate you guys responding to that. So we want to talk to you guys a little bit about a trauma-informed approach. One of the big things that we try to make sure that we're getting across is the fact that, you know, clinicians should be engaging in their care to patients in a trauma-informed manner. And we hear a lot about trauma-informed care, but we really are, from today's webinar, trying to be a little bit more intentional in understanding what we mean by trauma-informed. And we also want everybody to understand that it's not just about a trauma-informed approach, understanding that we're caring for patients that experience personal violence, sexual violence, that this happened in this encounter, but instead really taking that approach to every single patient that you provide care to, regardless if you are seeing them as a forensic nurse or if you're seeing them in a different role as a nurse, maybe you have a secondary position. So that's one of the things that we really hope that you take away from today's presentation. So we have to think about a few things when we think about a trauma-informed approach to caring for our patients. A lot of times we automatically think about the four standards that SAMHSA has set for a trauma-informed approach. So realize, recognize, respond, and resist re-traumatization, and that all of those things are consistent, and that is the goal. But I take a little bit of a different approach when I think about those four R's, and this representation on the slide kind of breaks it down in a manner of how I look at things. So if we look at the first one in the upper left-hand corner, understand the source of the patient's trauma, for me, when I think about it, this kind of falls into the realize. We have to understand that the source of a patient's trauma can be multilayered. That's really important for us to understand, because there are always going to be specific issues that we don't always know about right up front, and it may not necessarily be related at all to the reason that they actually came to us to get care. So for example, if I have a patient that came in with a broken arm, and I think that everything that's going on about how they present to me and, you know, how they're responding to the people around them is all in relation to this broken arm, and I automatically just decide this is actually what this is about, you know, they're upset because they got into a fight and they got this broken arm, I may miss a lot of things about that patient. But if I actually take some time to acknowledge that, first of all, the patient is here and has this going on, but also paying attention to their body language, asking appropriate questions, learning a little bit more about what they're experiencing in the moment, I may begin to get clues about other things. So if I go with that same scenario about the patient with the broken arm, it could be that the background for that patient could be that maybe they got into a fight with their family member that they're staying with because they have nowhere else to go, and they're not upset that they got into a fight, they're not even upset that they got a broken arm, but they really could be upset that the police made them come to the hospital to get this broken arm treated, and they don't have health care, they don't know where they're going to return to since they got into this fight with their cousin or whoever the family member was. And so they're kind of just in a space in their head about like, this is the things that I'm worried about. What we as clinicians may be really worried about, are you in pain? Why are you upset? Like, why are you upset this broken arm? Like, we'll get this fixed. Everything will be all right. But the reality is the focus may be on something totally different. So we just have to make sure that we understand that, especially with the patients that we see on a regular basis, there are many, many layers to what brings them into our facility and what traumas they have experienced before they even stepped in front of us. The other thing is that we have to actually acknowledge the patient as a whole. And for me, that falls under realize. So we have to understand that the source of the patient's trauma can, I'm sorry, we have to realize and acknowledge that the patient may bring with them all kinds of things to the encounter. Some of those things may not be actually detectable, and we may not necessarily be able to actually assess them through screening processes, but we can actually pay attention to different things that may trigger, that may let us know that they're being triggered, paying attention to body language, paying attention to how they respond, and then taking a step back to maybe ask some of those secondary questions to see what other services, what other things can we do to actually support them through some of the things that they're experiencing and get a little bit more information to be able to actually support them through the process of what they're experiencing, not just in the moment right in front of you, but also beyond that, like thinking ahead. We'll talk about, we'll talk about addressing discharge and referral needs beyond, but also thinking about that while you're talking to them. And then supporting the patient's healing, that's going to be the response for me. So how the nurse actually responds to the patient affects how the patient is going to respond to them, if you choose, if they even choose to disclose. So by that, I mean, if I am talking to my patient and I'm purely focused on certain specific things, and I don't allow myself to leave space for the patient to actually engage with me in a manner that they feel is appropriate, in a manner that's comfortable with them, they're going to be able to tell that. And they're going to be able to actually respond and respond in the way that they feel best by that. So by that, I mean, if for some reason that patient is actually fearful about something that may not have anything to do directly with you, but maybe they're fearful that law enforcement will show up at the door, or maybe they're fearful that you'll make a report on something related to what they tell you. And if you don't pick up on some of that fear and actually stop to acknowledge that and assess the situation a little bit more, you may miss out and that patient may never open up and they may continue to give you that same presentation that's kind of shut down or, or standoffish a little bit. So really, we do want to do take some extra steps to make sure that we are engaging the patient and actually supporting them in a way that's meaningful for them and that they understand that that's what we're doing. And then the fourth one is going to be be aware of the culture, the facility and the atmosphere provided by patients. So for me, that is resist re-traumatization. So that one, I feel like can be pretty self-explanatory, but I am going to take a few minutes to just kind of break it down a little bit more. One thing that we don't think about is the fact that triggers come in all shapes and forms for everybody, and it's very individualized, right? So we don't always know what's going to, what's going to trigger a patient to actually become, get sent into a place where they don't want to actually work with us anymore or be communicated with us anymore. But we can be cognizant of the patients that are coming to us, the community that we're serving and how our actual facility and the staff within our facility actually interact and engage with those people. And so later in this presentation, we'll talk a little bit more about how to make your, your setting a safe space, but I think it's really important for us to actually think about that because for us, depending on how your program is actually set up, there may be multiple people that actually encounter that patient before you actually encounter that patient, whether it be a nurse that's triaging, whether it be a medic, whether it be a receptionist or a secretary, there's usually someone else that actually has that first, that first engagement and that first engagement or that second engagement before you even come into play can be the one that actually changes that patient's mind or makes it mix up their mind to determine that this isn't a place that I feel safe and I want to be able to disclose the things I need to disclose. So it's really important for us to be able to make sure that we're conscious of that, make sure that we are evaluating what things look like, and also make sure that we understand what are the different signs for people when it comes to triggers, again, realizing that it's not always going to be something that's going to be verbalized by the patient, but being conscious of watching for watching body language or paying attention to how they're responding to us so that we can also set up a plan and have a strategy to actually help the patient through those triggers in the moment, and also try to plan for future visits, if we have to re-encounter that patient, maybe on a follow-up visit to make sure that they still feel like they're in a safe place. Oops, sorry. So in addition to that, we have to also think about other forms or other sources of traumas that may exist. So I already said to you that there's always got to be layers to the patients, but we also know for sure that there's also coexisting forms of trauma. So we may have a patient that comes in for a reported sexual assault, but that patient may also be experiencing coexisting traumatizations on a regular basis that we should be screening for and also be considering as we are working with the patient. There's also the consideration for generational and historical trauma. That is a huge thing in many, many communities, especially when it's even thinking about accessing care and accessing systems. A lot of times we as clinicians don't think about ourselves as a systems-based source for patients. We know what our job is and we know that we're here for good things, but we also have to remember that all patients don't always have good experiences when they access healthcare. And so we really have to be conscious of that as we do our exams, as we talk about what we're going to do through these exams, as we explain to the patients what we are hoping that they will provide to us, that there may be additional things that have encountered that they may not feel comfortable doing, or they may not feel comfortable unless you allow space for them to feel comfortable. And a good example of that is like with hate crimes. So if we have patients that maybe are transgender, that part of their actual assault may include injuries that are a part of a hate crime. We have to be able to acknowledge that, address that, and also provide resources to make sure that, again, we're promoting the healing for them, not just for the fact that they were sexually assaulted. There are multiple things that they've been traumatized by through these types of events. So we have to make sure that we are keeping those things in mind. And then also past physical and sexual abuse. And I would even take it a step beyond that and think about if you are a nurse that cares for both adult, adolescent, and pediatric patients, think about past sexual abuse or past traumatic abuses of that actual parent that you're asking to be the support person for that child. We have to kind of consider those things when we're working with our patients and their families to make sure that we are meeting their needs in a way that's meaningful for them and that's going to work for them. The patient-centered approach, we hear that all the time, right? We hear it when we first become forensic nurses, saying nurses are forensic nurses, about how we need to make sure that we have a patient-focused approach, but what does that actually mean? Providing care that is respectful of and responsive to individual patients' preferences, needs, and values, and ensuring that patients' values guide all clinical decisions. So the way that this presentation is going is we're starting with the clinician, right? We're evaluating within ourselves. Then we're thinking about the environment and the community that we're working within, making sure that we are responsive to that community. We're going in thinking about trauma and using a trauma-informed approach, which ties into patient-focused approach because we're understanding what traumas that patient may have experienced either currently or previously before coming to us. So the patient and their needs must always come first. Our exam is tailored to the individual needs of our patients. So I love this diagram here because it always puts the patient in the center of it, right? We're aligning our care with the patient. Our care is specific, so we're providing a patient with care that is specific to their needs and circumstances to promote the healing and the well-being of the patient. It's centered, and it reflects the patient as well. So care provided should be specific to the needs, circumstances, and preferences of the patient. Delivery of care should involve and be centered around the patient. Care provided should reflect the patient's choices, values, culture, social, economic context, putting the patient and their needs in the middle of all care, treatment plans, resources, and wraparound services that may be provided and offered. So even though we are the clinicians, we're the expert in this field, the patients are the experts of their own selves. So we have to involve them from the very beginning with the work that we do and the services that we provide. I think that you bring up a really good point. We ask a lot of questions of our patients about what their experiences are and what happened to them. But I feel like sometimes we don't always do the job of actually hearing some of the things that they may actually be concerned about, even when it comes to their own health care. And I think that we just have to remember exactly that. Like, even when you think about your own self and when you go in to see a physician or you go in for a checkup, like, you have things that you want to have addressed and you may have your own agenda. And I'm sure that every single one of us has encountered a health clinician that actually kind of had their own agenda when they came in and you didn't get your questions asked or you felt like you didn't get the response you were looking for. And then you kind of walk away feeling like, ah. Like, I think if we think about it from that perspective, we can actually kind of take a step back when we're working with our patients and really be reflective of what are they concerned with, as well as what we're concerned with as clinicians. You know, Angelita, that's a good point. And when we're thinking about that, I feel like as nurses, we can start off as task-oriented. We think about this long exam that we're about to start with this patient. We have all these things that we have to check off and do. And really just taking a moment to slow down and create that space to have that emotional connection with your patient. Absolutely. Yeah, I agree. And talking about creating space, let's talk about that a little bit more. So, you know, I think that a lot of people kind of recognize that where we're working at doesn't always feel like it's the space that it needs to be for the patients that we are providing care to. And we also acknowledge that every single program, every single nurse, every single area looks really different in how you may be set up, how you may be responding to your patients, just based on how your program may be or what your resources are in your community or even how your hospital is set up, right? We totally acknowledge that. But with that being said, we do ask that you kind of step back as a whole, regardless of how you respond to your patients. So regardless if you have your own separate exam room or your own separate lobby or you have a sitting area where you're able to do your medical history, all of those things, regardless of how it looks physically, we want you to think about some other things as you think about creating a safe space. So the first thing is, I brought this up before, but what is the culture of your facility? So that's really, really important, because if you have, if you know that the culture of your facility is a little bit problematic, you've heard that from various patients across the board, like, well, this was my experience or, you know, I don't know if I really care for that hospital or that health care system because I've heard this about them or I had this happen. That is the reflection of the culture of your facility. And that is how the community may look at your facility. If you know that you have personally felt discomfort in some way or felt like you couldn't open up to certain people about certain things within your facility, all those things are considered the culture of your facility. And so when you think about that, you have to take a few steps beyond that and say, if I'm experiencing this, if I'm hearing these things, I'm seeing these things, what are the people in the community that are coming in for care or not coming in for care, what are they experiencing? And what are the steps that we can take to improve that? That's a big jump, but the first thing you have to do is actually acknowledge it, because we understand that some things are systemic and we can't always change those things right away, but we can chip at them, we can work towards it, and we can think about how they affect the small area of space that we can actually structure to make sure that by the time the patient gets to us, how can I make the difference about what may have happened before then? The next thing I want you to think about is what is front-facing for patients in your facility, right? So what does the art look like? What do they have access to? What can actually happen? So if I am providing care to patients that are tribal and maybe there are some spiritual rituals that those patients actually would prefer to happen before they actually go into an exam room and have an exam, do I have something in my policy that allows for me to actually have that occur? If I have a person that is really spiritually based or they lead their way, do I have access to someone if they want to actually have someone come in based on their needs? Or do I have a policy in place that allows them to actually have someone meet with them there at your facility? So what does that look like? What does the art look like? What does your, you can think about why we have child advocacy centers because that's a child-friendly atmosphere. They're always set up in a place that's inviting for families to come. If I go into a place that has nothing that feels inviting to me that doesn't acknowledge me and doesn't show me that I am welcome or that the care I need can be addressed there, so I'm thinking like IPV, if there's nothing that tells me that you provide any kind of resource or any kind of care for patients that experience IPV, if I'm not there for any other reason, I may not know to come back there for this reason. I hope that makes sense. What do patients have access to and what accommodations can be available? I think I kind of covered that. But even when we think about accommodations, we know that there are laws that talk about people with disabilities and making sure we have accommodations for that. But really look at your facilities and think about, is your facility actually set up to actually accommodate people with disabilities? I think that's really important to understand. And I have just one little quick example of that. It has nothing to do with sexual assault, but I had an ankle injury. It was awful. It was awful. I was on crutches for way too long. The bathroom for the urgent care that I had to go to was super close to the urgent care, which was great, but I was in a wheelchair. The doors were super tight. I had no one to help me get into the bathroom. By the time I got to two doors in the bathroom and then tried to make a right, the disability or the accessible stall was all the way at the opposite end. The sink was at a different end and the napkins was back on the other end. When I was in there for the first time in my life, I said, no one thought this through. Like, no one thought this through, because this is the worst setup that a person with a disability or any kind of that needed any kind of accessibility accommodation would actually be able to maintain, especially if they were on their own. So just another example for you. Think outside the box. There's all kinds of things that can come up. You can never plan for everything, but you can look around and say, how do I have things set up right now? What policies do we have in place? What are the things that we may need? Who do we provide care to? We're making accommodations based on who you're providing care to and what the patient in the community that you serve is really important. Angelia, before we move on, I actually love that you took that moment to do like a self-reflective personal experience about you having your ankle injury. And I just want us all to just do a quick practice of that. So like, think about a time, and I've experienced this, but think about a time you entered a space where you didn't see anybody that looked like you. You didn't know anybody there. This was a new space that you've entered in. It was very unfamiliar. Maybe you're traveling to different cities or communities or countries, whatever that may be, or maybe you're entering for the first time. I've been out of school for a long time, and now I'm going into the classroom for the first time. Think about a time when you were uncomfortable walking into a space and how that may feel. Now think about a patient who's just experienced trauma, sexual assault, intimate partner violence, whatever form of trauma, and how they may feel entering a foreign or uncomfortable space and then having to talk about a very personal, vulnerable, traumatic experience that they've just gone through. That's going to be very difficult. And as clinicians, we're not going to be able to provide the care or get the information that we need if we don't create these spaces for our patients to let them feel at least comfortable. If I could just walk into a room and just see a picture of someone who looked like me. I mean, we don't have twins out there. I mean, we don't have doppelgangers. What are those called? When you have someone that looks exactly like you. Doppelgangers. Yeah, doppelgangers. But if I had anything that resembled a family member or a friend, when I'm walking into this clinic or hospital, maybe I might feel like, oh, this hospital values people who look like me, who come from the same background as me, and maybe they will hear me when I'm about to express this very sensitive topic that happened to me. Yeah, it looks like Karen put something in the chat about having a similar experience, having a similar experience when she was in Colombia and she didn't speak Spanish and how intimidating it felt even at the airport. Absolutely. Thanks for sharing that. Yeah, it gets tough. It can be tough. Those are all great points. Thanks, Chantel. And I do hope that we all kind of reflect on that just a little bit because I think that is super important. Okay. And additionally, we want to really think about what do your relationships look like outside of your hospital walls? And I know for some people, that may be like a hard thought. Like, well, I do exams out of the ER. That's where I'm at. Like, I don't have to know the resources outside of those walls. Or you may feel like, how could I know those resources? Like, I don't know. Like, where am I even supposed to know that? Or you may have a social worker that you feel like is supposed to know that. Or you may have another, you may depend on your advocate for that. But one thing that I want to make sure that we understand is that like relationship building and partnerships, having partnerships in the community is really, really an important part of being a forensic nurse. And one of the other things that we have to think about is how we engage with the patients and actually connecting them with the partnerships that we have in the community. So we want to be able to provide a warm handoff regardless of how we're doing it or who we're doing it with. And that's from clinician to clinician, but that should also stand when we are looking into the community to actually send patients to other places. You actually want to be able to say, you know, I have actually met and engaged with Chantelle from such and such organization. You know, she is amazing. Here are the resources that they actually have. And I actually do feel like they will be a good fit for you. And the reason that I say that is that traditionally we have certain people that are certain organizations that we automatically partner with, but we also have to go back to some of the things that we talk about, that we just talked about, about the experiences or the experiences of others or the traumas that come along with those things and the systemic issues that happen. So it doesn't mean that the resources and the organizations that we regularly partner with have intentionally done something to anyone that was meant to harm them, right? But it could be that the experience that this person may have or have had, or may just not feel comfortable with, they won't be a good fit for them. And you have to be able to say, what else do I have? You can't just say, well, this is all there is, right? You really have to understand what else is there to offer them. And so sometimes for that to be, for that to happen, that means that you may have to, again, think outside the box and actually get to know other people outside of the people that may be the standard folks that you may always partner with or work with. This can go into a whole different conversation, but thinking about the SART that you work or the response teams that you are a part of or that are in your community, really getting to know them and getting to understand who they work with, who they know outside of that small group, and allowing some of those people to be actually at the table. It's really a key thing because every single organization as it's set up doesn't always fit for every single person that may have experienced what they're there to provide services for. So we have to be able to look outside, even if it's at a neighboring community, to be able to know what's available to the patients that are going to be a good fit for those patients. Does the staff working with the patient reflect the cultures being represented in the community being served? So Chantel kind of already hit on that a little bit. Like, what do I see when I walk through the door? She mentioned the picture. But really, we want to see somebody that looks like you. You want to be able to talk to someone that actually may be able to speak the same language that you speak. You want to be able to make sure that whoever, or at least someone there, can understand what you may be experiencing. There are plenty of things that I cannot, I can't step into a male's shoes. I cannot say that I understand what a male looks like. I want to be able to make sure that when a male comes in to get a medical forensic exam, that I also have males that can actually be present or that can do it if that patient actually requests a male. Like, we really do want to think about diversifying our staff to make sure that we are actually being reflective of the communities that are being serviced. And the other part of it is that sometimes the people, if they actually come from the community and they actually work in the facility, they have an idea of actually what's happening in that community. And sometimes they may be the person that you may have to tap into to understand who are those other partners that you haven't tapped into? What other relationships are available that you haven't tried to access yet? So keep that in mind. Does the facility environment reflect the culture of the community? I kind of talked about that already as well when I said, like, what does it look like in your facility? What are we allowed to do here? You know, is there a rule that says that I can't request a chaplain or I can't have my spiritual leader come with me to my exam if I choose to? Is there a rule that says that I cannot have the room cleansed before I actually go and get the exam done? Like, we really need to talk about that and really understand why it's important. And it's specifically when we're looking at, when we're working in areas where we are in communities of people of color, like, what does that look like and what are the needs of that community? What do we want to incorporate? And then we have to figure out ways to actually be able to do that and give space to do that. One way that we can do that is by identifying the needs and then acknowledging those needs. So be aware and responsive to how cultural identities, whether that's race, ethnicity, gender, religion, ability, disability, language, limited English proficiency, immigration status, there's a whole list, gender identity and expression, even age. Think about how all those different things, how different marginalized communities may influence the things that they may experience during the exam process. Right? So you want to think about exactly what Angelia said, what cultural and specific needs or requests that they may have. You're going to prepare ahead of starting the exam if possible, right? We don't know who's going to walk through our door, but we do know who is in our community. We do know a history of patients that we've served in the past. And so we can prepare ahead of time if possible. And then if unsure, make space for adaptations by involving the patient and asking them. So we're wrapping it back around to patient-centered approach, right? I don't know. I've never worked with a patient like this before, or it doesn't even matter if you worked with the patient before. Everyone is different. So how can I give space to this patient to express what needs they have prior to starting this exam? How can I acknowledge that? I think a good example of this can be like something everybody, I feel like almost everybody, depending on your nursing background, may be able to relate to. You know, if we have a patient that we know has limited mobility and we're going to have to get them cleaned up and changed and change the bed, we already know when we get all hands on deck, we get all our supplies together. We know, Chantel, I'm going to need your help for turning, you need to hold, like every, there's a whole thing that we do, right? And we're ready for it. The same thing needs to happen when it comes to the medical forensic exam and preparing, right? You have time to gather this information. We're going to talk about the process in a few minutes, but you all know the process. You have time that you're actually gathering that information. So what I think I'm asking you to do, and probably Chantel too, is to, as you gather the information, actually take it in and acknowledge. Oh, these are things that I'm going to need to think about before I actually get set up for my exam, right? Obviously, if I have a person in a wheelchair, I obviously know that I may need some additional assistance with holding the patient in certain positions, right? But every single, every single patient doesn't have that right up front in front of them. So I have to actually assess the situation as I gather that information. I think, I think that's the best way I can give an example. Like we have that all hands on deck thing in our back pocket anyway, it's just remembering when to pull it out. No, that's a good point. And the reality is identifying and acknowledging and preparing, that's being proactive. We get so stuck in the acute phase of the exam. And the truth of the matter is that we have to use our clinical judgment. And part of that is being prepared for the patients that we're serving. Patient empowerment and autonomy. So the patient is the agent of their body and their experience. I mean, we can repeat this, it sounds like a little mantra, like a chant, like if you need to put it in your staff room, like just to remember that the patient is the agent of their own body and their experience. So we have to acknowledge, empower and listen to them. Patients that have experienced sexual or intimate partner violence have already had so much taken from them. It is important for clinicians to empower their patients with information and options, allowing space and autonomy to make informed decisions about their care and how they choose to engage in the legal systems and in the medical systems, or even whatever resources you provide for them post exam. So the patient, again, is the agent of their bodies and experience. Acknowledge that, share it with the patient and listen to them. So a great example of this is we kind of talked about it before, like all the different traumas and experiences that people can experience prior to even coming into the medical forensic exam. And one thing that I think as clinicians, we don't really recognize is how racism is a trauma. Someone who experienced racism, prejudice, anything like that, it can be traumatic for them. And one thing that marginalized communities, no matter if it's by race, gender, gender expression, no matter how that community is marginalized, one thing that is very common is that they have a distrust of systems, whether that's the healthcare legal system, whoever may be helping them, they have a distrust. So how we help that patient trust us and start that process of trust and support is by empowering them, taking a moment to listen to them and actually listen and then apply the things that they're saying that can help break down that barrier that they're already going to come in, may, should I say, may come in to that space with that distrust of seeking care after being sexually assaulted or experiencing intimate partner violence. All valid points. Nicely said. Uh-oh, I hit it too many times. Okay, so we're gonna start talking about the actual exam process. But again, just to reiterate some of the things that we've already said, just keep in mind that regardless of what your patient looks like, regardless of where your patient comes from, regardless of what you believe or what your patient actually believes, that patient actually deserves to receive a quality medical forensic exam. That medical forensic exam should be... I think we may have gotten frozen. But what Angelina is saying is... I think we stated it already. It needs to be... Oh, I froze. I'm sorry. And that is not always my friend. And it is Friday. I think it's Friday. Okay, so basically what I was saying is that regardless of what the patient looks like, regardless of where the patient comes from, regardless of the belief of the nurse or the belief of the patient, that patient deserves and has a right to a actual quality medical forensic exam. And that exam should actually be tailored to the individual needs of the patient. And you've heard us say that. We're never gonna stop saying it. It's in the protocols, like it's important. And it's there for a reason. So we want you to make sure that you recognize that all the components of the medical forensic exam, all the techniques and the tools that are used, they aren't always reflective of all the populations of patients that come into, to be provided care, right? Research is an ongoing thing. We have already... I'm sure many of you have already heard and acknowledged the fact that research looks really different across communities, across the board, across patient populations. So there's so much research that still needs to actually be done and conducted in a manner that actually gathers adequate data for all populations. But what we do know is that what we have is gonna hopefully continue to grow. And what we hope for is that we actually learn ways to address patients across all skin tones and that we start to adopt these things into practice, both in the healthcare setting, general healthcare setting, but specifically in the forensic nursing healthcare setting. And so that's kind of what we're gonna talk about a little bit more right now. So I think that it's always kind of important to think about the process that we typically are going through when we're doing the actual, when we're doing the medical forensic exam. And for the most part, usually what's happening first is us obtaining a history and that history should be a complete and thorough history, starting with the medical history of the patient. And I know that there's sometimes there's some back and forth about that, but remembering kind of what Chantel mentioned earlier about actually not always taking things from the patient, but actually slowing down a little bit and allowing us to provide things for the patient. So a good way to build rapport is to really actually start your process the same way you would start your process with any other patient that you are encountering, but just obtaining a medical history that actually helps the patient to understand you're not just there because you are interested in learning about the assault and what happened to them and making sure that they get evidence collected. It helps them to understand that you are actually looking at them a whole, you're creating a treatment plan for that patient as a whole, not just in regards to what evidence you can collect, okay? So a medical history is super important and it has to be a thorough and complete medical history. Things that you wanna make sure that you're thinking about when you're gathering your medical history specific to this patient population are, again, are there any culturally specific needs that need to be considered for this patient? Are there any language or terminology considerations that may exist? So hopefully if you've gotten to this point, you've already considered if you have language barriers and if you need an actual interpreter or you need the interpretation services. And if you need them, then you need to actually engage in them and work that into your process and not just makeshift. We need to actually make space to allow that patient to actually make sure that we are doing them justice and we're also doing justice on our own to make sure that we understand what the patient's needs are as well. Terminology considerations are also important. A lot of times we take time to educate and that is an important thing and we should be educating, but we shouldn't be doing it in a way that is demeaning to the patient as in what they're telling you is wrong with the terminology that they're utilizing. It should be done in a way to let them know this may be the technical term and you might hear this term further along as you go through this process should you choose to continue beyond the hospital for this process, but still allowing them space to be able to use the terminology that they want to and they're comfortable to use during your medical forensic exam. And also not being afraid to ask questions in an appropriate manner if you're unfamiliar with terminology. So this goes across the board. If a patient is explaining something or sharing information about whether it's their medical history, something that they have experienced in their medical history or even in their history of events or their history of what happened to them, stop when they're done and go back and clarify exactly what the term was that you didn't understand and let them know why you're clarifying it at that time. Has the patient had regular access to preventative care? Super important depending on where you're at, right? So first of all, you should be thinking of it from the perspective of if this person does not receive regular preventative care, what my assessment of this patient should be super, super thorough, not just focused on the actual fact that they were assaulted or that won't want evidence to be collected. I have an opportunity to actually address healthcare needs for this patient that may be beyond the actual assault. So making sure that as clinicians, we are making sure that we're prioritizing the healthcare needs of the patient. But also thinking about when you're getting ready for discharge and follow-up, if they're not accessing preventative care, are there barriers that exist that may come into play for any follow-up care that you may have planned for them? And how do we address those barriers? How do we actually plan effectively to create that discharge process or that discharge plan that's gonna work for that patient? Identifying any chronic conditions, how they may actually present in that patient. Are you familiar with whatever chronic condition that they have? So a simple one is eczema. We're doing skin assessment. If you're not familiar what eczema looks like in a person of color, that's gonna be difficult for you to not think that you may come across something that may be injury-related versus not. So it's really important to understand like what are their chronic conditions and how it looks for them and how versus how it may look on another patient. And again, you may not have all the answers and you may not know upfront, but that's where we call on our lifelines, right? If we don't know something about a particular disorder, same thing we would do in any other setting, we take some time to actually look more into it before we make rash decisions about it. Are there any medical exam adaptations that need to occur? So again, does this patient have any kind of mobility disabilities? Does the patient have any kind of assistive devices that I need to actually make sure that they hold on to or that they have access to during the exam process to assist in me communicating with them and then being able to communicate back with me? Is the room set up in a way that's appropriate that makes sure that I can actually engage with the patient in a meaningful way with them? Are they comfortable? Are they safe? What are the adaptations that may need to happen here? Are there any past surgeries? So that's always a question that we ask, but I post that in there for you to think about it on multiple layers. So when we're thinking about risk assessments, when we're thinking about assessing for possibility of pregnancy, like that's not just about the assigned at birth female, we have to think about the patients that may be transgender that may still have female reproductive organs. You need to be able to have those conversations. Did they have a total hysterectomy? What kind of organs are still there? Doing a complete organ inventory on that patient is really important. And then if you do have a patient that has had any kind of surgeries, gender affirming surgeries, when did that happen? Has it been complete? So that you'll have a better idea of what your exam looks like. And then are there any clinically specific findings that you need to be thinking about upfront when you're thinking about how I'm going to continue to assess this patient? And we'll talk a little bit more about technique in a few minutes, but really thinking that through is really important ahead of time. Like we said, planning ahead versus being reactive at the end. What medications does the patient regularly take? Whether we think considering all medications, not just prescribed medications, not just over-the-counter medications. Are they taking any medications that they may have gotten from somewhere else or that are not prescribed to them? And then are their vaccinations current? What do you have access to provide them? And if it is not within your facility's policy or ability to actually provide vaccinations that may be needed, where does that patient access those vaccinations? What information can you provide to them to get what they need? A complete anal genital urinary history is really important on all of our patients as well. Again, thinking about was there anything that has occurred? Is there any modifications that I may have to do when I get ready to do my anal genital exam? Are there any additional considerations that I may have to think about as I prepare to do my exam? I mentioned the anatomical inventory before when I was thinking about what organs that patient may have, but the anatomical inventory is a kind of a thorough, what does that, a thorough overview of what that patient actually has, if they had any kind of gender affirming surgery and what's still existent. And that could be a part of their chart. So it's not something that will be continuously asked of that patient. Psychosocial history is super important as well when you're thinking about not just what's currently happening with the patient, but also thinking about safety, both there during the exam room, during the discharge, and then even moving beyond. What are the support systems that this patient have? What are the behaviors? So we think of psychosocial a lot of times as do you smoke, do you drink? Like how often do you do it? But really thinking about what are some of the coping mechanisms of this patient that has experienced multiple layers of trauma and has to go back on their own and move forward. And especially in situations where maybe you don't have an advocate, which we really hope that you're advocating for that to happen, or the patient has denied an advocate, really thinking outside that box about how we make sure that patient's needs are met beyond the exam room and what does it look like for them. Anything that you wanna add there, Chantel? No, I think that was very thorough in just thinking about that, but like psychosocial history as well as like safety and are they going back to, like we think about our intimate partner violence patients, like are they going back to their abuser or the space where they were abused? And then what does that look like? How can we create a safety plan for them? Because Angelita touched on it. There are a lot of places sometimes that do not have access to advocates. The advocates may not be there during the exam. Maybe they're a follow-up service when we really do hope that the nurse and advocate can work together as a team to really care for patients. But in cases when that doesn't happen, we as clinicians have to be the patient's advocate for their care. And that goes beyond just the medical forensic exam. We are the ones who have to create that safety plan, who may have to create that discharge and follow-up plan for that patient. We have to be thorough in the care that we provide. The other thing that I just wanted to touch on about psychosocial history is one of the things that I said earlier, I brought in about child sexual abuse. And when we have younger patients that we are looking for their parents to support them, there are times that we actually are not just only there for the patient. Like anytime we have a patient that's a minor that comes to you with family, and sometimes even when we have adults that come with family, like their family is basically our patient as well. We have to be able to understand that. But I'm gonna go back specifically to the child sexual abuse. If you have a pediatric patient that you're providing care to, and that caregiver has actually had previous sexual abuse to them, especially child sexual abuse that they have never actually had addressed or worked with anybody on, they may have a really hard time actually getting to the point where they can acknowledge what's happening right there in that space. So understanding that sometimes we do have to make space for family to actually work through some of this. And again, super, super helpful to have an advocate there. Like that is really when some, we want an advocate there in that situation. If you don't have access to an advocate, who else can you engage? So if you're in a hospital setting, maybe there's a child life specialist that could come in and work with a child while you work with the family. But just acknowledging that there are times that you have to think outside the box on these things, and that there are underlying things that may be present that you actually have to think ahead for. So moving on to like the history of events. So considerations to think about here could be like, what are you gonna be doing to actually guide your physical assessment for this patient, right? So as you get the information that they're sharing with you, you're listening to them, you're hearing everything that they have shared, but also really listening genuinely, I'm gonna say this is about skin tone. If I have a darker skin patient, and they're telling me where they have pain, like I was hurting here, I was hurting there, I'm really gonna be honing in onto those things, because when I do my physical assessment, I wanna make sure that I understood that they share with me that they had pain in those places. Because if I look at the darker skin and I can't see a humongous inflamed bruise right there, I still wanna acknowledge that there may very well be injury that I just can't see right in front of me right this second. I wanna be able to acknowledge those things. I wanna make sure that I'm meeting the patient where they're at. So by that, I mean, I am stopping to actually understand where that patient is at. And I'm gonna hop on into talking about language and verbiage, but even if I have a patient that I can clearly see is like in an uncomfortable state or they're super anxious, I'm gonna be able to stop my exam and give space to acknowledge that right now, they're in a different place. And I wanna help them to get to a place where they can actually engage with me. So actually meeting that patient where they're at and being conscious of that is super important. If I have a patient that may not speak on the language level that I actually speak on or that the rest of my team actually speaks on, I'm gonna make sure that they're understanding what I'm communicating to them. I'm gonna make sure that I'm understanding what they're trying to communicate to me. I'm not gonna make assumptions about these things. I'm gonna make sure again that we're utilizing terminology that's effective for them and that I'm utilizing terminology that they're comfortable with. That whole not making assumptions is so important across the board. Like in so many places, it's not just about the part about getting history. It's not just a part about doing that. It's like, don't make assumptions across the board. Involve the patient, engage with the patient, allow the patient to provide you with information and ask them clarifying questions is so key because a lot of times on the times that we fail, we fail because we automatically make an assumption. We make assumptions sometimes before we even walk in and start talking to the patient. We make assumptions sometimes when we hear a language that a person speaks. Assumptions have a tendency to kind of flare up all the time in these situations. So we wanna make sure that we really try our best to check assumptions at the door and try our best to be open to actually stopping to understand where we're at and meet the needs and understanding how to identify those needs of the patient is really important. So I have a chat question for you. Aside from injury and identification, what are some challenges or barriers that you perceive as that a clinician may experience and we're providing a physical assessment to patients with darker tones? And you can definitely, if you provide care to patients of darker or cross skin tones and you have your own experiences, you can definitely throw those in the chat as well. We just wanted to open that question up for anybody to actually be able to answer that. And we'll give a few minutes for people to actually type. And it's okay if you feel like you can't share experience or can't think of an experience in this moment or haven't really had a lot of experience in assessing patients across skin tones. So we're gonna also talk about some of those assessment techniques. But I just wanna read off some of the things that are going on in the chat right now. Heather mentioned identifying normal skin variations. That is so important because we know that normal looks different across skin tones, right? Something that may be normal in a lighter pigmented skin tone may not look the same in a darker pigmented skin tone. So what exactly is normal so that we can identify abnormal? Yep, a lot about how injured is it. Yep, I was just agreeing, a lot about injury. So thank you guys for sharing that. There's a little bit more, normal skin variations, distrust of medical care and fear from people, minimization of pain, yep. Okay, I think those are all definitely valid and we're definitely gonna talk on the injury piece of it. We've talked a lot about the distrust part of it and fear that people experience. So absolutely, again, normal variants such as Mongolian spots that can mimic bruising. I think I actually, I know we aren't quite to that spot yet but I do think we can address something like Mongolian spots. And I'm bringing it up here just because we've talked a lot about making sure that we communicate with the patient but that when you're doing your physical assessment is also a great time to actually be communicating with the patient about that or the patient's family. So for instance, if you're seeing something that appears to be a bruise and especially as Chantel is gonna talk to you about when you're doing your assessment, when you take those extra steps to maybe ask questions about, has this always been here? Have you noticed this before type deal? So I don't wanna steal Chantel's fire though. Okay, so thinking about the physical assessment, what I'm gonna talk about on these screens are just some additional considerations. So I'm not gonna sit here and tell you the things that you already know, such as we need to do full assessments of scalp and all these things. But I'm gonna talk about some specific things, right? So when it comes to hair and scalp, really thinking about considerations for different hair types and what your techniques are, right? So for one thing, one thing I wanna point out is like there are still places that actually still unfortunately do like hair plucking as much as we want to not be doing those things. But the reality is that there are places that that still does happen. So when you are working with patients with different hair types than maybe you're used to, you actually wanna be making sure that you actually have the patient's hair. First of all, there's a potential that the patient may have a wig on or the potential that the patient may have hair weave. You wanna make sure that you actually are identifying what this patient actually has as far as their hair, what their hairstyle is, what it is that you're trying to get to, and then working with the patient to make sure they understand what you're getting ready to do. Cause if you come at them with some scissors, they may actually be like, wait a minute, let's talk about what that's gonna look like. They need to have that. Then it needs to be transparent what your goal is, how much hair you're trying to take, and also to be able to even identify if you're actually taking their hair. That's kind of important. The other thing is like sometimes when we do assessments, I'm thinking about people who may have braids or even like I have locks, you probably can't tell, but I have locks. If I were to have my hair up in a bun or something like that, it may be a little bit harder for you to assess in a normal type. So how do we have that conversation with the patient about if their hair is like braided up? Is this something that they can actually not take down such as take the braids down, but can they let their hair fall down so that you can visualize the scalp? What are the options that you have? You may have to have actual conversation about what's happening with the hairstyle that they have and what you can actually do to make your assessment. Because if a person, I'm gonna keep going with the braids and the locks. If a person is assaulted and part of their assault is someone grabbing them or dragging them by their hair or their braids, you probably are gonna see some alopecia or some redness to their scalp, right? And you need to be able to assess that. You need to be able to document that. We can't just say, well, they have their hair up in a bun. I didn't do anything with it. No, we really wanna be able to do a thorough assessment. So again, that requires you to communicate with the patient, ask the patient questions to have a better understanding of what you have access to. And then also being able to document appropriately. So even if you don't see alopecia or you don't see inflaming redness in their scalp, did you palpate? Is there pain there associated with it? All of these are things that you're gonna be documenting, right? Thinking about the entire skin surface. I'm gonna go, oh, I'm not at that yet. That's okay. Entire skin surface. So piercing, tattoos, really important. The thing about tattoos though, depending on the color of your skin or the pigmentation in your skin, tattoos sometimes can cover up things and you can't see injury as well, especially in people of color. So again, making sure that we're doing all the things that we need to do to actually assess that patient is really important. So not just saying, do I see a bruise or I can't see the bruise, just like if I were assessing any other patient with the concern of that, I would absolutely be palpating. I would be asking very specific questions. I would be looking for swelling. I would be looking to see if there's any difference in the skin on the other end. So if I had the left arm, I'm gonna be comparing to the right arm. If I can't look at it and just identify, I'm gonna be using my natural nursing process to do a thorough assessment to assess the level of injury that this patient has. Piercings, just a reminder, we're not asking the patient to turn over piercings. We're not taking piercings. We are though, making sure that we're thinking ahead about piercings. Has a piercing been yanked out? Has that caused injury to the patient that we need to be assessing and documenting? Was there any kind of piercing in an area where we're gonna be swabbing? Do I need to be looking around that piercing to make sure there's, even if the piercing still exists, there's no additional injury that has occurred with the potential for infection? We wanna think about all those things when we're assessing the patient. So I know you guys know all this, but it's just kind of a reiteration that what this can look like. Making sure that you are doing the mouth, throat, ears, nose, and understanding what color variations may look like for patients. So, a lot of times when we think about, we look in a person's mouth or we look in a person's nose, it's maybe bright pink or maybe bright red, but for some people, it may be a paler whitish color or an off-white or opaque color. So just making sure we understand what variations may occur when we are assessing these things and how injury may look different when you have a person of color. And in a little bit, Chantel's gonna give you an example of exactly in those areas what we mean. When you're looking for, but when you're assessing the neck, especially around strangulation, same kind of thing. Like if you can't see fingerprints, ask the patient, do the patient, does the patient feel like their neck is swollen? Is the patient having pain? Did they have it at the time that it was occurring? They could have come to you hours later. And although we see a lot of times that that swelling and injury gets worse, it could be that some of that has already subsided. So asking those questions about what was happening during the time of the actual assault is also just as important about as it is when you're documenting what you're seeing, what the patient is experiencing when they're right in front of you. Extremities, making sure that you are thoroughly looking at extremities, including hands, nails, feet, toes, toenails. And if there is things such as acrylic nails or nails that are done, not automatically jumping to take those things away from the patient. Say, oh, we need this, really talk to the patient. What are the other options that you have? Can you swab the nails? Can you clip part of the nails? Like why are we looking at the nails? Why are we looking at the nails and thinking of evidence collection? Because even in a trans patient, we have to think about how that patient came into your exam room and how they're walking away. And then making sure that they feel comfortable walking out of that exam room. And if they feel like they're the same whole person that walked in, that they were not taking things away from them that they need to be able to help them, to be able to help everyone understand who they identify as. So it's really important. Torso, so your breast, your back, your abdomen. I'm thinking specifically about the breast. Everyone knows that the areola of the breast looks totally different depending on what culture you're from. But also thinking about injury. If you have a person that maybe you're looking for a bite mark and it's fresh, you may not have an automatic red spot. Is there swelling there? Is there broken skin? Is the patient complaining of pain? What are the other assessments that you do on a patient to make sure that there's no injury for that patient? And then for genitalia, especially for female genitalia, acknowledging that genitalia can look really different across cultures. So yes, we all have the exact same anatomy when it comes to terminology and structure and how it's set up, but how it looks can look really different. So for instance, for some cultures, the labia minora may be more prominent than the labia majora. And if you have never seen that before, you have to be able to make sure that you can go back to your basics that you learned in the very beginning to be able to make sure you are identifying the structures appropriately as they are. Or if you have a patient that has had gender affirming surgery and there's been some reconstruction there, being able to make sure that you're able to identify structures and actually document them appropriately is totally, totally, totally important. Anything you wanna add, Chantel? Yeah, I actually was gonna give an example of a horrible experience that someone close to me had experienced in terms of going to the gynecologist and having a genital exam. And the gynecologist actually, as they were doing their external exam, asked them, why is your labia so dark? Right, that is very problematic because one, this for this person probably has looked like this their entire lives, right? And so now you're making them feel like there's something wrong with them. Or is something wrong with me? Did I not notice it this whole time because the way that my body presents doesn't present the same as others that you may be used to, that you've seen in textbooks, that you were educated about because I'm different than something is wrong with me. You have to couple that on someone who experienced an assault. They're already thinking is something wrong with me. And then you're telling them how they live their entire lives is completely wrong. And then you could be missing an injury. Is it dark throughout their entire external genitalia? Is it one spot? Are you comparing, right? And Julia talked about like the extremities, but are you comparing one side versus the other? Is it pain there? So you really have to think about the things that we're saying to our patients. And it goes back to those biases, right? Because unintentional biases happen because of the experiences that we have before, right? We see videos or we're educated a certain way or in our medical textbooks, we see one type being represented and taught about and so when we see something different, we have this assumption, right? That something may be wrong or all of a sudden now I can't assess this patient because it doesn't look the way that I've seen before. So just being very mindful when we are assessing very sensitive areas of our patients. And the other thing I can add to that that kind of wraps around exactly what you're saying, but also goes back to having conversation with the patient and culture and thinking about a language and terminology is, and this is not what this webinar is about. So we're not gonna get in a huge detail about it, but female genital cutting or some people call it female genital mutilation. Also understanding that, you know, I don't know if any of the, any of you on this webinar have ever had a patient that you have abrided care to that has had female genital cutting or has the scars from that. We do have to be mindful of even that, right? How we assess that and how we understand it and also how the patient understands it and perceives it and how we communicate about that. That is something that can sometimes be a sensitive subject for the patient, depending on how old they are, depending on how they felt about the female genital cutting. So just keeping those things in mind, like that may look really different and learning a little bit more about that is also very important. Okay, so additional things that we wanna make sure we're keeping in mind. Lighting, lighting is really important when we're talking about patients of color, making sure you have good lighting. We talked about knowing your facility and what you have access to. If you know that you do exams in rooms that have no access to lighting and you're gonna have to do an exam on a patient of color, you may wanna try and figure out how you're gonna work that out because you're gonna need the appropriate lighting for that to be able, first of all, to do a good assessment, but also thinking about what it's gonna look like for your photos, right? If you're taking photos. And then also, what does the background look like? So obviously we learned a lot about photography in our classes around forensic nursing, but really when we're taking our pictures for our patients, if we can have some contrast to the color, that actually will be helpful for you. Another suggestion is around the use of a color scale. So we're familiar with the, my brain just went blank. You might be like, oh, the ABL scale? My brain went blank. ABFO scale for photos and measurement, but there's also a color scale that you can use. And that's really helpful in differentiating color, especially when you're trying to get color to show up for bruising for people of color. Super simple. You can order them just like you order the ABFO and have some available to your team. It's super important. We talked a lot about normal variant versus an abnormal finding. If you are unsure, unfamiliar, making sure you have that lifeline, whether it's your coordinator or whether it's another advanced clinician that you have access to, that's really important. Injury identification and description. So again, communicating with the patient, doing your assessment, documenting exactly what you're seeing, what they're experiencing. All of those things are really important when you're trying to make sure that you have clear documentation of the injury that may be in front of you. Is this injury an acute injury versus a non-acute injury, right? If you can't just see it by, just by eyesight, you got to do the same process that you would. What are you seeing? Are you seeing an injury that looks like it's a healing injury or is it a fresh open wound? Is it a wound that looks like it's getting ready to heal? So if we think about the stages of a burn and how that may heal, you will start to see pigmentation start to come back to the scan. So if your injury is on a surface area that's a pigmented scan, there are things that you can actually think about when you're thinking about, is this acute versus non-acute, but also asking those secondary questions to the patient to do your assessment. And then of course, appropriate documentation of all the things that you do. So this here kind of goes into further detail and some of the things Angelia might've already mentioned when we were going over the physical assessment. This is a diagram that you can look at. There have been multiple studies regarding assessing pressure ulcers in patients of color, dermatologic disorders in patients of color and what that looks like across skin tones. And as forensic nurses, we can adapt those practices and techniques within to our own practice. Many of you may already practice these techniques as they do reflect foundational nursing assessment skills, right? So bringing it back to the foundation of clinical assessment. So when we talk about lighting, Angelia brought up a good point about looking at your environment. Maybe I'm in an ER and we're in the basement, right? So we don't have a room with natural lighting. But specifically in assessing patients with darker pigmented skin, you wanna either use natural light or a halogen light. If you were to use a fluorescent light, that gives off a blue tint to the skin. And so you may not accurately be able to assess that skin. And then also when you're trying to take photographs that might alter the way that that skin looks. You're going to listen to the patient. We keep bringing it back to those foundational things, patient-centered care. You're getting a full history from that patient. You're listening to what they're saying. If they say, he bit me here or this hurts, you're gonna keep a mental note or even if you have to write those things down because you're gonna go back to it when you're assessing your patient. And then listen to what they say. When you're palpating, does it hurt? And then when I say listen, I don't only mean with your ears, but then also looking at body language. Is my patient wincing? Are they kind of moving away from me when I'm palpating that area indicating that there could be some tenderness or discomfort there? So those verbal and nonverbal cues. You're gonna look, you're doing your full head-to-toe assessment and you're comparing. So we talked about comparing different anatomical places on their body, the arms, both of the labia. So you're comparing to see what that skin looks like in that surrounding area because some people may not turn red, right? We think about redness or erythema and that's a very common finding. A lot of times we focus on bruising, but there are so many other injuries that people can experience within a sexual assault. And redness is one of the most common as well. Everybody may not turn red, they may turn darker, right? Their skin may turn darker and that could be an acute finding for that patient. So that's where follow-up is key as well because I don't know if this hyperpigmentation is normal for this patient or if this was something that was due to the assault and that's how their skin shows irritation. And we're also listening to our patient. Was that there before or was it not? Is this painful? And you're gonna feel. If I don't see anything, I'm still documenting that I looked, that I felt. I'm documenting the patient's quotes, like the quotes that hurts or six out of 10 pain, whatever that is, I'm documenting that and putting that on that patient's diagram and on their chart, even if I don't visibly see an injury. But I'm gonna feel for warmth, I'm gonna feel for edema, tenderness. I'm palpating from head to toe because those are all the things that I'm going to document on that patient's chart because it's not an excuse to say that I didn't see anything and so I'm not gonna document, right? There are other things that you can put on that chart indicating that that patient may have had an injury that doesn't have to come from you visibly seeing an injury. We all know that having identical injuries still heavily influence the legal outcome of cases, right? We know that. Forensic nurses must be able to speak to why the injury may not be present or even why the injury may not be visible. Just because an injury is not visible does not mean that it is not there. We must conduct a full head to toe assessment and document all findings. To take it a step further, follow up is key. As some patients' injuries may become visible after the acute exam, right? The priority of the health of the patients is always priority. As forensic nurses, we alleviate pain, we assess things by identifying that injury. So we have to put healthcare first. And then also think about, we say that we're looking at normal variants, but what does an emergency, medical emergency, look like in this patient, right? If we think about, for example, patients who experienced strangulation and so they may be hypoxic and even ethnic and we think that the traditional, oh, the lips turning blue, right? And so this person may have a decrease in their oxygenation, but not everybody's lips turns blue. Maybe it may be a gray color, right? So what does a medical emergency versus abnormal versus normal look for these patients? Because it may look different. So I know we're running short on time, but I do, if you could stick around for these last few slides, because I do want to do a couple of activities with you all to kind of keep our wheels turning on how we assess patients. So in a chat, how would you go about assessing these two different patients? While you guys do your typing, I'm just going to chime in and just acknowledge that we are coming up at the end of time. Like Chantel said, we're going to, we don't have very many more slides, so we're going to finish out the webinar. Mary-Kate is going to be putting the evaluation link in the chat pretty soon, and Mary-Kate is going to be putting the evaluation link in the chat, and then you guys can take the evaluation link from there to complete. It'll also come to you via email as well, and we probably will be over in just a few minutes, like five to seven minutes. Thanks, everyone. And as we're assessing this, this is a very common, like, red flag, right, the bullseye. So does anybody, I'm sure y'all know what this means when a patient has this on their arms or legs? It looks like there's a lot of people saying a palpate, a salsa for tenderness and warm, palpate for induration and pain, ask the patient how they react to bug bites, assess for fluid buildup and tenderness, thorough history, inspection, palpation, measurement with the ruler, looking at, looking at line C, sounds like Julie's thinking about main tick bites. And we all know if this is not addressed emergently, that that could lead to further medical issues and emergency issues within that patient. So this is an example of being able to assess an injury, and that it, here's our textbook, the blighted pigmented picture is our textbook view of line C's, right, or a tick bite, right? We see this, and that's what we're looking for, whereas the other picture, A, doesn't necessarily look like that textbook picture, right? And so we need to be able to recognize things because we could cause further damage in our patients if we're not assessing our patients accurately. And so the next one is just saying, which is more severe, and the point is that it's the same finding, it's just differently across skin tones, right? And so one is not going to be more severe than the other. They both, it's the same cost for that injury or that binding on that patient, and so therefore the severity is the same, right? I think we're both both pressing the key to go for. Yeah, so again, same type of injury different skin tone and the thing that I want to focus on is the reason why I'm thinking about skin tones and that's about culture or ethnicities is that it doesn't matter what your background is that people can have different skin tones from any culture or ethnicity right and so it's really that we're looking at the scale of a lighter skin tone versus the darker skin tone what that how that injury may present and also we're thinking about with assessing injuries that it can be the same injury just presenting differently and so I just want to show here and Angelia please chime in if you have anything else to say in terms of these injuries and these pictures but one thing that we always avoid is dating injuries right and somebody could look at the darker pigmented picture with the the injuries and say oh this this bruise looks darker so that injury can't be acute which is not true right because we don't know there are multiple reasons why bruising or injuries may appear differently on people not just because of their skin tone but it could be how they were injured it could be what medications they're on what chronic illnesses or medical conditions do they have that makes it that their injuries appear differently on their skin so that's that's addressing the whole patient when we're thinking about identifying those injuries I don't have anything to add there I think you're doing a great job and then in terms of additional techniques we know that we love to use different tools right when it comes to assessing patients within for especially within forensic nursing so in addition to direct visualization obtaining a comprehensive medical history of the events some clinicians do choose to use exam adjuncts below to assist in the documentation of their injuries so that could be als that could be using different filters different way that's different things that people could use whether that's tolutadine blue dye but the reality is that all those techniques are still very much undergoing different research and being validated and so my biggest advice when we when we talk about using different techniques is direct visualization and properly assessing your patient from head to toe is still going to be the gold standard when we're talking about our patients because we can think about even if I use a blood pressure machine right we have to use our clinical judgment I could use a blood pressure cuff and that blood pressure cuff could say that the patient's blood pressure is like 60 over 10 but my patient is sitting there looking at you talking right so the point is that these additional techniques are used to assist in the exam but you cannot rely on those techniques in order to assess your patient identify injuries and then evidence collection considerations I kind of was intertwining those as I went through the exam process but basically really consider what you're asking of the patient before you actually take it and really think about why you need it be able to explain that to them and keep in mind that there may be reasons that they may actually not be able to give you that and from give you those either those articles or allow you to collect evidence of course they have patient autonomy but I want you to think beyond that when you with the person that you have in front of you so for an example thinking about clothing if I have a person that has a head covering that is specific to their religion I'm not going to take that head covering from them I'm going to figure out what other things can I do to actually collect evidence in terms of that whether it be documentation whether it be a photo whether it be swabbing like what else is what are my options here and have conversations with the patient around that and when it comes to the drug facilitated sexual assault kit collection really the biggest thing that I think that you guys should just really keep in mind is who the patient is individually in front of you explaining to them what comes along with the drug facilitated sexual assault kit collection what does it what are the things that they have to think about in order to make the best decision for them if they're okay with you collecting that blood and urine and then discharge considerations we kind of touched on those things too but think about it a little bit more in terms of when they're getting ready to go what do they have access to so if I'm going to be prescribed them seven days worth of medication do they have access to pharmacy do they have health care insurance to cover it or am I able to provide them with medications there while they're there are they a patient that may be homeless or at risk and they may may not even be a candidate to even offer that prescription really be conscious of those things when you are planning your care and then follow-up appointments is there a way that you can make sure you work with advocacy to make sure that they get there if it's super important I think that both of those bullets can be put together when we're thinking about HIV care right so if I'm doing HIV prophylaxis really thinking like what does this look like for this patient in terms of being able to access it to provide it to take it regularly and to get the follow-up care that's necessary for it even with your STI follow-up testing or or concerns beyond that so just think outside the box a little bit sometimes because we kind of get in the habit of understanding like these are the things we need to make sure you know and that's it turn it over to them and the expectation is for the patient to just do it and then we're frustrated when they don't when we haven't we actually haven't considered what barriers may actually exist for them to actually achieve the outcomes that we're actually trying to set them up for and then paperwork and discharge instructions making sure that they're really appropriate for the patient in terms of the language that we're using and also in terms of the literacy level of that patient so if we're creating these long extensive discharge papers and we have a person with the literacy level of fourth grade they don't always align with each other so making sure that we're giving them stuff that they can look at when they get back and understand but also that we're taking time to actually understand it as well I mean to explain it to them while they're with us and I won't go back into patient safety because we've touched on that throughout the process of this webinar because that's exactly what you should be doing throughout your exam process and then things for you to really continue to think about as you do this just just the considerations like Chantel already said was the patient actually involved in development of your plan right so you have a whole plan of care that you created and then you're doing a whole discharge plan and safety plan for the end did you actually engage the patient in this process to make sure that what you are planning for them actually suits them and addresses all the things that they are prioritizing as their needs as well as what you are prioritizing as a clinician and then is that is that discharge plan actually achievable for that patient from your perspective as well as from the patient's perspective take a few minutes to think about it and actually like assess that with the patient think outside the box when you're looking for resources when you're looking for follow-up when you're you know when you're thinking about who you have in front of you if it doesn't fit into your standard like I said before what else do you have access to and if not how do we build those relationships make sure that you are connecting the patient with advocacy even if the advocacy is not available to you during the time of the exam it is essential that you actually connect the patient with advocacy especially in time especially when the patient may have a different cultural background or that they were working with or their spiritual they're based in their spirituality sometimes advocacy has a better connection to make sure that they get what they needed in those particular areas where you may not automatically have that and then make sure that you are reinforcing the importance of accessing follow-up care that you're asking them to actually work on and then make sure that you personally are understanding that there are barriers that exist that are systematic and that you may have to work with the patient individually to get some of those addressed and that we're going to wrap it up okay I'm Angelita again that's Chantel our contact information is here we appreciate you guys being here with us on a Friday afternoon Chantel thank you so much for being here today and presenting with me on this and we have multiple webinars coming up through SafeTA over the next month please feel free to actually jump into these webinars register for these webinars you can go to safeta.org under the webinars tab to see all the upcoming webinars and register as well we appreciate you all being here and Chantel I can't tell you how much I appreciate you being here with us today as well thank you guys thank you and then a final note as I said before your evaluation link was in the chat and in the resource box and it'll also come out to you via email after the webinar

cultural sensitivity

cultural awareness

medical history

physical examination

evidence collection

safe environment

differences in skin tones

clear communication

interpretation services

chronic conditions

mobility disabilities

psychosocial factors

patient safety