The study aimed to investigate the FOP and POI of FN role behaviors of ED nurses and the distance between performed behaviors and perceived importance. Most behaviors were performed below average, with only eight items exceeding the average. Despite this, the nurses considered all role behaviors important based on the mean scores. The mean scores of the perception of importance were significantly higher than the frequency of performed role behaviors reflecting a gap between ideal and current performance. This finding aligns with the previous study by Lynch (1990), which found a gap between the frequency of role behavior performance and the value placed on behaviors by ED nurses [26].
Abdul and Brysiewicz (2009) found that ED nurses did not frequently perform FN role behaviors [27], yet they rated a high percentage of these behaviors as very important. Nurses’ practice relies on their knowledge and skills [31], and inadequate knowledge and skills in forensic issues may hinder their ability to provide quality care in forensic cases [27]. In this study, the gap between the performance of FN role behaviors and the perceived importance of ED nurses may stem from limited knowledge about FN, as the majority 93.4% of ED nurses received no education on the topic. Even participants with higher education levels did not perform FN role behaviors more frequently, indicating a lack of FN education in nursing programs. This lack of knowledge about FN has been reported in Iran [28] and other contexts [19, 32, 33]. To ensure competent forensic nursing practice, it is crucial to incorporate FN education into both undergraduate and graduate nursing curricula, as well as in-service training and courses for clinical nurses. This education should equip nurses with the necessary knowledge and skills to identify and handle cases involving violence, abuse, neglect, child and elderly abuse, sexual assault, and domestic violence. They should be able to conduct unbiased interviews, document findings discreetly, and make appropriate referrals for the victims. Additionally, nurses should be familiar with legal and ethical considerations in FN, including informed consent, confidentiality, and mandatory reporting.
The results of this study showed that the five lowest-performed role behaviors of FN were related to the forensic nurse specialist role. They included “functioning as a nurse educator to the staff in forensic matters, acting as an expert witness in court, operating primarily in the ED, acting as a consultant in forensic matters for other hospital departments, and searching for information (e.g. where child or spouse abuse is suspected). However, these role behaviors were not commonly performed, they were considered important and necessary in the EDs. In contrast to other studies where operating primarily in the ED was ranked as the fourth [26] and second [27] most frequently performed behavior, our study showed it to be the lowest-performing behavior. This difference may be due to the lack of forensic nurse specialists in Iranian clinical settings, highlighting the need for recognition of the FN specialty. A forensic nurse specialist is a dedicated nurse who provides specialized care to victims of intentional or unintentional trauma. This nurse coordinates services, conducts medical history and physical exams, takes medical-forensic photography, identifies and collects evidence, and documents victims’ conditions [2]. In Iran, FN is still in its early stages of development, but there is increasing recognition of the importance of this field. There is a need for FN programs courses, and resources to support nurses in their clinical practice which may not be readily available in EDs in Iran.
Based on the results, the first highest-performed FN role behavior was “informing forensic physicians about admitting a patient who died on arrival without receiving care”. Furthermore, this behavior ranked as the first highest-perceived importance role behavior. This item focuses on informing the medical examiner when a patient arrives at the hospital already deceased without receiving any medical treatment. The notification is crucial for forensic purposes, allowing the examiner to investigate the cause of death and gather evidence for potential legal investigations. As expected, this item showed the first strongest correlation between FOP and POI, suggesting that the more nurses engaged in this behavior, the more they perceived it as important. Lynch (1990) found similar results [26]. However, Abdul and Brysiewicz (2009) identified “the forensic nurse specialist functions as a nurse educator to the staff in forensic matters” as the first rank of FOP [27]. This may be due to adherence to existing regulations in Iranian EDs, which require referring unexplained or suspicious deaths to forensic physicians. Nurses’ fear of litigation and emphasis on their primary role may contribute to this finding. One possible explanation could be that nurses prioritize their primary role and the nature of this behavior that overlaps between the FN role and routine initial care in the ED. This may lead nurses to be more sensitive to routine care-related regulations. The current regulations appear to encourage ED nurses to adhere to a uniform set of standards, enhance their documentation and reporting practices, and increase their professional responsibility. Consequently, it is crucial to establish and implement context-specific FN regulations and protocols to ensure proper documentation, reporting, and professional responsibility.
The finding also indicated that the second highest-performed FN role behavior was “the ED nurse assures accurate documentation for investigative purposes and legal protection of both the nurse and the patient”. It indicated ED nurses frequently performed this behavior and believed it to be important. This finding can be caused by ED nurses’ concerns for protection from being accused of negligence and legal prosecution by patients and families. Nursing records are one of the most reliable documentation [34] and serve as a legal record of the care provided [35, 36]. Thus, legal issues are a critical aspect of forensic nursing practice, and ED nurses should be aware of their legal responsibilities and obligations related to reporting cases of violence or abuse.
The finding also showed the least POI role behavior was “reading dental charts and being aware of the forensic dental comparison”. The participants did not consider this behavior as important. Forensic dentistry involves identifying, documenting, recovering, and preserving all signs in the soft and hard tissues of the mouth to provide forensic evidence [37]. Lynch (1990) reported this item was included in the questionnaire as a control item to ensure the reliability of the results, and high scores were not expected. Similarly, our findings may indicate that nurses perceive this behavior beyond the scope of practice and should be performed by a forensic deontologist.
The findings showed that the item with the second strongest correlation (a negative correlation) between FOP and POI was “assisting police investigators in their mission” suggesting that the more nurses performed this behavior, the less they perceived it as important. Although ED nurses performed this behavior as the fourth frequent item, they did not perceive it as an important part of their role. This finding was confirmed by the result of the other two items regarding interaction with the judicial system including “the ED nurse has a working knowledge of the duties and responsibilities of the police investigator” and “the ED nurse is skilled in sharing information of sexual assault cases with law enforcement officer and medico-legal investigator”. These findings may suggest that nurses may lack the necessary knowledge and skills to effectively engage with the legal system. Additionally, their practice may be influenced more by their personal experiences rather than following nursing principles. Hence, it is essential to provide ED nurses with specific expertise and abilities so that they can effectively support police investigators in their work. This involves acquiring various skills, such as the ability to gather biological samples, record injuries, and safeguard any relevant physical evidence for the investigation.
According to the findings the role behavior with the third strongest correlation between FOP and POI was “distinguishing an animal bite wound from a human one” indicating that the more nurses performed this behavior, the more they perceived it as important. Similarly, Lynch 1990 and Abdul and Brysiewicz 2009 [26, 27], nurses performed this item above the average and perceived it as very important. Forensic nurses are likely to encounter a diverse range of wounds, and understanding the characteristics of gunshot wounds fired from various distances is crucial for identifying crimes. According to Johnson (2023), the presence of gunpowder on victims and suspects may be linked to self-defense and self-harm, highlighting the importance of determining the distance from which the weapon was fired [38]. It seems ED nurses did not adequately value these behaviors due to their limited knowledge, which warrants further attention.
According to the findings, the fourth strongest correlation between FOP and POI belonged to the item “incorporating a proper collection of forensic evidence with patient care for victims of trauma” reflecting that the more nurses performed this behavior, the more they perceived it as important. Participants performed this role the third most frequently even though implementation of this task requires knowledge and expertise. In contrast to this, Lynch (1990) [26] found this item eighteenth FOP rank. This inconsistency may reflect concerns about variations in non-standard practices and approaches used by ED nurses to identify and preserve evidence, which may compromise the integrity of valuable evidence [39]. Missing evidence in EDs can compromise and undermine the victim’s right to justice [26].
Furthermore, apart from the item “assisting police investigators in their mission” which showed a negative relationship between FOP and POI, three other items also exhibited a negative correlation. These items were related to the role behaviors of forensic nurse specialists, such as “operating primarily in the ED, acting as a consultant in forensic matters for other hospital departments, and searching for information”. However, participants believed that these behaviors were seldom carried out in EDs, but they still considered the presence of forensic nurse specialists and the performance of their role behaviors in EDs to be significant.
Regarding the relationship between FOP and POI of FN role behaviors with nurses’ demographic information, the two similar studies [26, 27] did not provide any information. However, this study’s findings showed that participants who worked night shifts performed FN role behaviors more frequently. This may be due to their increased exposure to trauma and violence victims during night shifts. In Iran, for example, 65% of road accidents occur at night [40]. Additionally, participants who had personal experiences with legal and judicial claims reported performing FN role behaviors more frequently, possibly due to their familiarity and sensitivity to legal and forensic issues that influence their clinical practices when dealing with forensic cases. Female participants perceived forensic nursing role behaviors as more important than male participants, which may be related to the gender differences in communication styles and interpersonal skills. Male nurses generally prefer to work in clinical settings where patients are sicker, conditions change quickly, and the workload is higher. They are more inclined to perform high-risk and stressful tasks [41] and engage in more physical activities. They are less empathetic and better equipped to deal with emergencies and can cope better with crises [42]. It is worthwhile to note, however, that these gender differences are not universal and may vary depending on individual backgrounds, experiences, and cultural norms.
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