Written by Kathy Bell &
Note: This article was written before the coronavirus
outbreak became a pandemic — an event that has brought personal protective
equipment to the forefront of any health care discussion or decision. Please
remember that masks and gloves should always be prioritized to protect patients
and health care providers from the spread of infectious disease.
The Sexual Assault Forensic Evidence Reporting
Act of 2013 recommended the development of best practices and protocols for the
collection and processing of DNA evidence in sexual assault cases. Over the
course of two years, a multidisciplinary group of subject-matter experts met
and developed the National Best Practices for Sexual Assault Kits: A
Multidisciplinary Approach. The document, published by the National
Institute of Justice in 2017, contained 35 recommendations designed to ensure
consistency and uniformity in the multidisciplinary approach to the collection
and management of evidence specific to sexual assault patients.
The focus of this article is to specifically
highlight and discuss Recommendation 11 from the National Best Practices
which reads, “Due to increased sensitivity in DNA technologies, masks and
gloves should be used by all medical-forensic nurses and others in the
collection and packaging of evidence, especially during the collection of
intimate samples.” This recommendation will necessitate a practice change for
many forensic nurses. It states that “all efforts” should be employed to
prevent potential contamination of samples by health care professionals. To
that end, while it has become standard practice for forensic nurses to wear
gloves and frequently change them during examinations and evidence collection,
there has been some reluctance from the forensic nursing community to
incorporate the usage of masks into their practice while caring for sexual
Locard’s exchange principle states that “every
contact leaves a trace.” Essentially, when something comes into contact with
anything else, each will take something or leave something behind.
Deoxyribonucleic acid (DNA) is the genetic material that makes up all living
things and is frequently used in criminal investigation. DNA technologies have
become increasingly sensitive in recent years (Forensic DNA Research, 2019; Butler,
2015). Technological advancements have consistently improved the ability of the
scientific community to detect DNA. With improved methodologies, low-level or
previously undetected contamination may now be detected and potentially cause
DNA interpretational difficulties (Tupper et al., 2019). Additionally, as human
DNA is “pervasive throughout the environment, contamination may not be
completely avoided.” (ibid)
As the sensitivity of these tests continues to
improve, so do concerns regarding the potential increasing risks for accidental
cross contamination. According to Carly Balk (2015), “When DNA contamination
occurs in forensic science it has the potential to change the outcome in a
criminal investigation and may have significant social and financial
repercussions.” Contamination is defined as the “inadvertent addition of an
individual's DNA” to an evidence sample before, during, or after a sample collection
(Vandewoestyne et al., 2011). Contamination can occur directly or indirectly.
Direct contamination is defined by the Scientific Working Group on DNA Analysis
Methods (SWGDAM) as involving the “transfer of DNA from the source of the
contamination to the evidentiary item or DNA sample” (2017). SWGDAM goes on to
state that direct contamination can occur accidentally without actual direct
physical contact through acts such as speaking, sneezing, or coughing on an
evidentiary item. Indirect contamination is then defined as the transfer of DNA
through a vector such as gloves, tools, pens, packaging, and work surfaces.
With DNA analysis, major and minor contributors
are evaluated from samples. When multiple contributors are present, the person
with the highest amount of DNA in a profile is considered the major
contributor. The minor contributor is typically substantially less of the total
DNA obtained from the sample. The minor
contributor may not be present at all locations evaluated. Figure 2 shows
a two-person mixture with a major contributor and a minor contributor. This
part of the profile is 6 out of 23 locations that are evaluated. The major
contributor is the person with the higher peaks at vWA (second location). The
major peak heights are 14,180 and 14,971; the minor peak height is at 3,330. The
minor is about 23% of the major here.
A sexual assault evidence collection kit (SAECK)
is a package containing materials used to collect samples or evidence from the
patient’s body (victim or suspect) by a medical professional such as a Sexual
Assault Nurse Examiner (SANE), also known as a forensic nurse (National Best
Practices, 2017). Common contents of a SAECK include swabs and envelopes
designed for the collection of biological material and debris from the
patient’s or suspect’s body which link the patient to the suspect or crime
scene, or the suspect to the crime scene or patient. SAECK contents vary by
jurisdiction, but generally recommend the collection of unknown items such as
swabs from the skin and body orifices, and known standard samples such as
blood, hair, and buccal swabs. Items collected are typically dependent on what
the patient reports occurred during the assault. Additionally, an experienced
forensic nurse will have knowledge of patterns of injury that result in the
transfer of biological materials from the crime scene or suspect.
Nurses traditionally are trained to establish a
therapeutic relationship to facilitate effective communication. In informal
discussions with experienced forensic nurses, several themes emerge regarding
resistance to the practice change of wearing a mask during evidence
collection. Providers most commonly cite the following concerns:
1) I have never been told
that my evidence was contaminated.
2) I do not wish to place a
barrier or covering over my face while communicating with a patient who has
just experienced a recent sexual assault or trauma. In other words, it is
important that patients feel comfortable with the examination.
3) A mask would unnecessarily
upset the pediatric population.
Developing trust and
rapport is an integral component of the nurse-patient relationship and is
utilized by all nurses to improve the patient care experience. Evidence
collection is but one part of the medical forensic encounter, and forensic
nurses often spend several hours with patients establishing rapport and
offering evidence collection with a SAECK for patients who have experienced
The key to developing that
trust and rapport, particularly with patients who have been victimized, is
understanding and using a trauma-informed approach to victim engagement. Trauma-informed
care is the principle that care is provided with an awareness of the patient’s
recent traumatic experiences and embracing the philosophy to “do no harm”. In
other words, care is taken by the forensic nurse to ensure that the patient’s
care plan seeks to avoid further traumatization. A similar concept used when
working with patients who have been recently traumatized is the victim-centered
approach. Victim-centered care is defined by the National Institute of Justice (2017)
as the “systematic focus on the needs and concerns of a victim to ensure the
compassionate and sensitive delivery of services in a non-judgmental manner.” Using
the elements of these two concepts will minimize the possibility of
re-victimization by those who are there to help them.
Research has demonstrated
that a patient who feels “accepted and noticed” will be more likely to
participate in developing a trusting relationship (Erickson & Nilsson,
2008). The development of a trusting relationship is critical when caring for a
patient who has been victimized. Of key concern to forensic nurses is the worry
that by complying with recommendations intended initially for those working in
a laboratory setting, use of a barrier such as a mask might damage the
establishment of a therapeutic nursing relationship. Studies show the use of
forensic nurses to conduct forensic medical examinations of sexual assault
victims contributes to higher prosecution and conviction rates (NIJ, 2017).
Face-to-face communication relies almost
exclusively on the senses of hearing, sight, and touch. Mehrabian’s Communication
Theory divides communication into three elements: nonverbal, tone, and words (Betts,
2009). Other research indicates that tone of voice is more important than
posture or words that are used. Wearing a mask can potentially hinder effective
communication by muffling the tone of voice and content of what is being said
because it makes it harder to hear. These concerns become increasingly
important when caring for children, the hard of hearing, and the elderly.
Recommendations from SWGDAM state that a face
mask or face mask and shield should be worn by nurses during evidence
collection from patients. They state that the mask should “completely cover the
mouth and nose” and that if a shield is worn, it should “completely cover the
mouth, nose and eyes.” Additionally, “if a face mask or shield is adjusted with
a gloved hand, the glove should be changed before proceeding to the next
procedural step.” (SWGDAM, 2017)
The initial response of some forensic nurses
regarding the use of face masks, particularly around children and adolescents,
is negative. Little is known about the “fear factor” of children when masks are
worn in their presence (Forgie et al., 2009).
The use of a trauma-informed approach places an emphasis on attending to the
victims’ emotional safety, as well as their physical safety. Every precaution
should be taken to avoid contamination, but it is important to maintain a
patient-centered approach. (NIJ, 2017).
In an effort to determine practice and experiences
toward wearing a mask during evidence collection, forensic nurses from a
national nursing organization were surveyed. There was a total of 80 responses
representing practices from several states. Although not a scientific study,
the survey shed light on the use of masks during evidence collection. The eight
survey questions are listed below.
1) Do you
wear a mask during sexual assault evidence collection?
2) If Yes or Sometimes
to previous question, do you wear it during the entire exam, or only during examination
of intimate body parts (i.e. genitalia, breasts)?
3) If you do not wear
masks, are you aware of any case contamination?
4) If there has been
contamination by examiner, what was the program's response?
5) Do you examine
prepubescent and post-pubescent victims?
6) What was the overall
pediatric response to the mask?
7) What was overall
adolescent response to the mask?
8) What was the overall
adult response to the mask?
Overwhelmingly, 77% of nurses responded that
they did not wear a mask during evidence collection (Figure 3). Of those
that responded Yes to wearing a mask, later in the survey they commented it was
mostly worn to prevent the spread of upper-respiratory infections rather than
any consideration of possible contamination of evidence.
Only four respondents (5%), had ever been made
aware of any type of contamination. A few commented that they have done several
thousand cases and never been told there was any type of contamination (Figure
The majority of respondents worked for programs that
evaluated children, adolescents, and adults. Because so few respondents stated
they wore masks, it would be impossible to get any useful idea of any age
group’s reaction to the nurse wearing a mask. Of those that stated they wore
masks during evidence collection, all stated that the adolescents responded
neutrally or positively to the wearing of masks. Of those that stated they wore
masks during evidence collection with children, two reported positive
responses, while three reported negative responses to mask use. A wide range of
variables could influence the response of patients to the wearing of masks
during evidence collection, including developmental age, practitioner approach
and rapport, and possibly previous experiences with masked caretakers (Forgie
et al., 2009).
Clearly, it is important for forensic nurses to
understand the mechanisms of DNA transfer—not just from the perspective of
guiding care and evidence collection, but also in order to minimize the risks
of possible accidental contamination by the health care provider during evidence
collection from patients.
As DNA testing methodologies have become more
sensitive and able to generate DNA profiles from increasingly smaller quantities
of DNA, recommendations have begun to state that health care practitioners
should utilize additional barrier methods, such as masks, when caring for
patients who have been the victims of crimes, particularly sexual assault. These
recommendations appear to rely on leaps of logic, that contamination is inevitable,
and a mask should be utilized in addition to gloves to prevent accidental
At this time, the authors are unable to locate
any published research or case studies offering examples of accidental
contamination by a forensic nurse not wearing a mask and a negative impact on
subsequent criminal prosecution. Existing research currently focuses on
accidental contamination within the laboratory setting only. Further research
is needed in order to determine if forensic nurses wearing masks is a necessary
compromise between patient care and forensic laboratory standards.
One must ask, are forensic nurses really
contaminating samples? If so, what is the prevalence of this issue and are there
alternatives that have not been considered to ensure that victims of crime are
treated in a trauma-informed manner? In order to meet the forensic standards,
as well as provide a trauma informed response, alternatives should be
researched. One possibility might be for forensic nurses to have their DNA
profiles identified, similar to protocols used by forensic laboratories in
cases of identified contamination. Another example would be the use of
pediatric-friendly masks, or having the child or a teddy bear wear a mask as
well. Or, the practitioner might wear a shield only, as research has indicated
that children are more spooked by masks than shields because they can still see
the provider’s face (Forgie et al., 2009).
Additional research specifically addressing the
prevalence of accidental contamination by forensic nurses in a health care
setting is recommended.
Kathy Bell MS, RN, DF-AFN joined the
Tulsa Police Department in 1994. She provides the day-to-day operations
management of the forensic nurse examiner programs. Bell is a forensic nurse, performing
examinations for victims of sexual assault, domestic violence, elder abuse, and
drug-endangered children. She is designated Distinguished Fellow and Founding
Board member of the Academy of Forensic Nursing.
Catherine Rossi FNP-BC,
RN, MSN, SANE-A, SANE-P, DF-AFN is a board-certified Family Nurse
Practitioner and board-certified Sexual Assault Nurse Examiner for pediatrics,
adults, and adolescents. She practices with and directs the Forensic
Nursing Program with Cone Health System in central North Carolina which she
established and has managed since 1997. Rossi currently serves as the President
of the Academy of Forensic Nursing.
Balk, C. (2015). “Reducing
Contamination in Forensic Science,” Themis: Research Journal of Justice
Studies and Forensic Science, 3(12).
Betts, K. (2009). “Lost in Translation:
Importance of Effective Communication in Online Education,” Online Journal
of Distance Learning Administration, 12(2).
Butler, J. M. (2015). “The
future of forensic DNA analysis,” Philosophical Transactions of the Royal
Society B: Biological Sciences, 370(1674).
Erickson, I., K. Nilsson.
(2008).“Preconditions needed for establishing a trusting relationship during
health counselling - an interview study,” Journal of Clinical Nursing,
S.E., J. Reitsma, D. Spady, B. Wright, & K. Stobart. (2009). “The ‘fear
factor’ for surgical masks and face shields, as perceived by children and their
parents,” Pediatrics, 124(4).
Institute of Justice (NIJ). (1999). What Every Law Enforcement Officer
Should Know about DNA Evidence. Retrieved 14 Feb 2020: https://www.ncjrs.gov/nij/DNAbro/evi.html
National Institute of
Justice (NIJ). (2017). National Best Practices for Sexual Assault Kits: A
Multidisciplinary Approach. [PDF file] Retrieved 26 Mar 2020: https://www.ncjrs.gov/pdffiles1/nij/250384.pdf
National Institute of
Justice (NIJ). (2019) “Forensic DNA Research and Development. Retrieved 16 Feb 2020:
Otten, L., S. Banken, M.
Schürenkamp, K. Schulze-Johann, U. Sibbing, H. Pfeiffer, & M. Vennemann. (2019).
“Secondary DNA transfer by working gloves,” Forensic Science International:
Rudin N., K. Inman. (2002).
An Introduction to Forensic DNA Analysis (2nd Ed). Boca Raton: CRC
Scientific Working Group on
DNA Analysis Methods (SWGDAM). (2017). Contamination Prevention and
Detection Guidelines for Forensic DNA Laboratories. [PDF file]. Retrieved
26 Mar 2020: https://www.swgdam.org/publications
Speck, P., E.K. Hanson.
(2019) “Post-Coital DNA Recovery in Minority Proxy Couples.” Retrieved 26 Mar
Tupper, K., V. Feliciano, &
H.M. Coyle. (2019). An Engaging Lesson Model for Biological Evidence Collection
Training for DNA. The Journal of Forensic Science Education, 1(1).
Vandewoestyne, M., D. Van
Hoofstat, S. De Groote, N. Van Thuyne, S. Haerinck, F. Van Nieuwerburgh, & D.
Deforce. (2011). “Sources of DNA Contamination and Decontamination Procedures
in the Forensic Laboratory,” Journal of Forensic Research, S2(001).
van Oorschot, R.A.H., B. Szkuta,
G.E. Meakin, B. Kokshoorn & M. Goray. (2018). “DNA Transfer in Forensic Science:
A Review, Forensic Science International: Genetics, 38(140-166).