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Individual disability policies often provide both a total and a partial (residual or proportionate) definition of disability. As a result, things can get tricky at claim time. For instance, an OB/GYN physician might be considered totally disabled if he can no longer perform surgery or deliver babies, but if he can still work in his office, this might not be defined as a total disability.

For example, the insurance company may interpret the above claim as one in which the insured is merely partially disabled because the insured con-tinues to perform duties in the office and earn money. This is a very complicated area, and court decisions

have varied by state and local jurisdictions. Variations in policy language as to what con-stitutes total disability—or what constitutes “substantial and material”—can also affect decisions. A “specialty letter” that explicitly recognizes an insured’s occupation as a narrow specialty (such as an invasive cardiologist), WHEN the policy was purchased—and how the policy was marketed by the broker/agent/insurance company or how the claim was sub-mitted from a paperwork standpoint—can also have an influence on how the insurance company interprets the claim. One example of the “dual occupation” dilemma would be the case of an orthopedic surgeon whose duties include surgery, emergency surgery, “on calls” and an office practice seeing patients related to orthopedics. Let’s say that, because of past heart attacks, he reduces his hours and stops performing surgery and taking emergency calls. His reduced work schedule consists solely of clinical and non-surgery orthopedics. Should the insur-ance company consider this a total or a partial disability claim? The answer is that it could go either way, although there is a good deal of case law that might substantiate total disability. The insurance company will take into consideration how much surgery and on calls the orthopedic surgeon performed prior to the disability (by obtaining medical billing code numbers, etc.) and look at the pre-disability earnings compared to the post-disability earnings in various areas.

To further complicate matters, let’s assume this claimant taught once a week at a local university for a full day and was paid a salary for his efforts. Could this change the way the definition of disability was considered and determined? How old the claimant is and whether the benefit is paid to age 65 or life can also influence the decision. In the above example, if the orthopedic surgeon was age 58 with a lifetime benefit (if disabled prior to age 60), the insurance company may very well want to “push” the insured into a partial claim in order to only pay benefits to age 65 rather than for life (which could be for another 15-20 years or more). If you are beginning to think a disability can be complicated, let’s go even a step further. You are a practicing surgeon, but you were also involved with doing “Medical Reviews” and “Expert Witness Work.” Maybe you also do a number of IME’s (Independent/Qualified Medical Evaluations). If you cannot continue to do surgery but you can continue to do expert witness work, IME’s and QME’s, would that constitute a total disability? What if your broker/agent told you that you were covered in “your occupation”…would you be covered? Does the amount of work you performed other than surgery have a bearing on how the insurance company will interpret your claim? Are there any guidelines established that tell you what is permissible? Might an insurance company decide that you have 3 occupa-tions? These constitute the “grey” area related to disability claims, and often there are no clear answers. Nevertheless how you complete the claim forms and how your attending physician completes the claim forms, as well as how you react to the various weapons at an insurance company’s disposal, can determine the outcome of your claim.

Art FriesFellow, ACFEI

Disability Claim ConsultantNationwide, USA

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A CENTENNIAL CELEBRATION

FORENSIC PSYCHOLOGY:Moving Forward

GROWTH AND SUCCESS:A Timeline of The Forensic Examiner

The Forensic Examiner Timeline

TABLE OF CONTENTS

04 THE FORENSIC EXAMINER® Spring 2011

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VIOLENCE IN THE HOUSE OF HEALING:Recognition and Response to Violence in Health Care

SUDDEN IN-CUSTODY DEATHS:Exploring Causality and Prevention Strategies

TRAUMA AND CANCER:Case Reports and Literature Review

TRUE GRIT:A Special Edition Interview with a Living Legend

YOUR BODY IS NOTHING WITHOUT A BRAIN

THE PERILS OF FRAUD DETECTION AT WORK:Warning Signs and Solutions

IN THIS ISSUE

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EXPERIENCE BRANSON

STARS AND SCOUNDRELS OF THE OZARKS

2010 CONFERENCE RECAP

TSK, TSK

THE DETECTIVES’ CORNER:I Confess

THE THIN BLUE THREAD:Alice Stebbins Wells

FALSELY ACCUSED:Caramad Conley

NEW MEMBERS

BOOK REVIEWS

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Nicholas G. Apostolou, DBA, DABFA, CPA, Cr.FALarry Barksdale, BS, MA E. Robert Bertolli, OD, FACFEI, CHS-V, CMI-VKenneth E. Blackstone, BA, MS, CFC, DABFEDavid T. Boyd, DBA, CPA, Cr.FA, CMA Jules Brayman, CPA, CVA, DABFA, FACFEIJohn Brick, PhD, MA, DABFM, FACFEI Richard C. Brooks, PhD, CGFM, DABFEDennis L. Caputo, MS, DABFET, CHMM, FACFEI Dennis H. Chevalier, BS, MSM, DM, CMIDavid F. Ciampi, PhD, FACFEI, DABPSLarry Crumbley, PhD, CPA, DABFE, Cr.FAAndrew N. Dentino, MD, FACFEI, DABFE, DABFM James A. DiGabriele, PhD/DPS, CPA, Cr.FA, FACFEIJohn Shelby DuPont Jr., DDS, DABFD Scott Fairgrieve, Hons. BSc, MPhil, PhD, FAAFSEdmund D. Fenton, DBA, CPA, CMA, Cr.FA Per Freitag, PhD, MD, FACFEI, DABFML. Sue Gabriel, MSN, MFS, EdD, RNNicholas Giardino, ScD, FACFEI, DABFEDavid H. Glusman, CPA, DABFA, Cr.FA, FACFEIRon Grassi, DC, FACFEI, DABFM, DABFERichard C. W. Hall, MD, FACFEI, DABFM, DABFEJohn J. Haberströh, DC, CFC, CMI-V, FACFEIRaymond F. Hanbury, PhD, ABPP, FACFEI, DABFENelson Hendler, MD, DABFMDavid L. Holmes, EdD, FACFEI, DABFE, DABPSLeo L. Holzenthal Jr., PE, DABFET, FACFEILinda Hopkins, PhD, CFC, DABPS, DABRE Zafar M. Iqbal, PhDNursine S. Jackson, MSN, RN, DABFNRobert S. Kassoff, PhD, DABPS, DACFM, DABFEPhilip Kaushall, PhD, DABFE, DABPS, FACFEIEric Kreuter, PhD, CPA, DABFA, FACFEIRonald G. Lanfranchi, DC, PhD, CMI-IV, FACFEIRichard Levenson, Jr., PsyD, DABFE, DABPS, FACFEIMonique Levermore, PhD, FACFEI, DABPS

Jonathan Lipman, PhD, FACFEI, DABFE, DABPS Judith Logue, PhD, FACFEI, DABFSW, DABPSMike Meacham, PhD, LCSW, DABFSW, FACFEIDavid Miller, DDS, FACFEI, DABFE, DABFDLeonard I. Morgenbesser, PhD, FACFEIJacques Ama Okonji, PhD, FACFEI, DABFE, DABPSNorva E. Osborne, OD, CMI-IIIGeorge Palermo, MD, PhD, FACFEI, DABFMRonald J. Panunto, PE, CFC, CFEI, DABFETLarry H. Pastor, MD, FACFEI, DABFE, DABFMTheodore G. Phelps, CPA, DABFAMarc Rabinoff, EdD, FACFEI, DABFE, CFCJerald H. Ratner, MD, CFP, PAEdward W. Reese, PhD, BCFE, BCFM, CMI-VHarold F. Risk, PhD, DABPS, FACFEISusan P. Robbins, PhD, LCSW, DABFSWWalter A. Robbins, DBA, CPA/CFF, Cr.FAJane R. Rosen-Grandon, PhD, DABFC, FACFEIDouglas Ruben, PhD, FACFEI, DABFE, DABPSJ. Bradley Sargent, CPA, Cr.FA, DABFA, FACFEIWilliam Sawyer, PhD, FACFEI, DABFE, DABFMHoward A. Shaw, MD, DABFM, FACFEIIvan Sosa, MDHenry A. Spiller, MS, DABFE, FACFEIMarilyn J. Stagno, PsyD, RN, FACFEIRichard I. Sternberg, PhD, DABPSJames R. Stone, MD, MBA, CHS-III, CMI-IVGeorge S. Swan, JDWilliam A. Tobin, MA, DABFET, DABLEE, FACFEIRobert Tovar, BS, MA, DABFE, DABPS, CHS-IIIBrett C. Trowbridge, PhD, JD, DABPS, FACFEIRichard A. Vera II, PI, MBA, CPA, CFEJeff Victoroff, MD, DABFE, DABFMSandy Weiss, BS, BCEPPatricia A. Wallace, PhD, FACFEI, DABFE, DABFM, CFCRaymond Webster, PhD, FACFEI, DABFE, DABFMDean A. Wideman, MSc, MBA, CFC, CMI-III

*Note: For spacing and consistency considerations, the number of designations listed has been limited to four.

FOUNDER AND PUBLISHER:Robert L. O’Block, MDiv, PhD, PsyD, DMin ([email protected])

CHIEF ASSOCIATION OFFICER:Joey Fletcher ([email protected])

EDITOR IN CHIEF:Christopher Powers ([email protected])MEMBER SERVICES: Candice Sickman ([email protected])Summer O’Block ([email protected])EXECUTIVE ART DIRECTOR:Brandon Alms ([email protected])ANNALS® EDITOR:Laura Johnson ([email protected]) INSIDE HOMELAND SECURITY® EDITOR:Ed Peaco ([email protected])ADVERTISING:Christopher Powers ([email protected])(800) 592-1399, ext. 116

2011 EDITORIAL ADVISORY BOARD

CONTINUING EDUCATION

ACFEI provides continuing education credits for accountants, nurses, physicians, dentists, psychologists, counselors, social workers, and marriage and family therapists. Approvals for continuing education activities are subject to change. For the most up-to-date status, please check the course catalog on our Web site, www.acfei.com, or contact the Continuing Education staff toll-free at (800) 423-9737. ACFEI is an approved provider of Continuing Education by the following:Accreditation Council for Continuing Medical Education National Association of State Boards of Accountancy National Board for Certified Counselors California Board of Registering Nursing American Psychological Association California Board of Behavioral Sciences Association of Social Work Boards American Dental Association (ADA CERP) The Missouri Sheriff’s Association co-sponsors Police Officer Standards Training (POST) accreditation for the American College of Forensic Examiners Institute’s activities. The American College of Forensic Examiners Institute is a member of the National Certification Commission and the Alliance for Continuing Medical Education. The Ethics Course, Law Course, Evidence Course, Certified Medical Investigator®, Certified in Disaster PreparednessSM, Certified Forensic Accountant, Cr.FA®, and the Certified in Homeland Security, CHS® Levels I–V are all approved for the G.I. Bill benefits.

CHAIR Cyril H. Wecht, MD, JD, FACFEI, CFP; Chair, American Board of Forensic MedicineMEMBERSDouglas Wayne Beal, MD, MSHA, CMI-V, CFP; Chair, American Board of Forensic ExmainersAlexander Lamar Casparis, CPA, MBA, Cr.FA, FACFEI; Chair, American Board of Forensic AccountingSteven R. Conlon, Chair, American Board of Registered InvestigatorsDianne Ditmer, MS, RN, CFN, FACFEI; Chair, American Board of Forensic NursingDouglas E. Fountain, PhD, LCSW, DABFE, DABFSW; Chair, American Board of Forensic Social WorkersRaymond H. Hamden, PhD, FACFEI, CFC, CMI-V, Chair, Ameri-can Board of Psychological SpecialtiesJames H. Hutson, DDS, CMI-V; Chair, American Board of Forensic DentistryMarilyn J. Nolan, MS, FACFEI, DABFC; Chair, American Board of Forensic CounselorsGregg M. Stuchman; Chair, American Board of Recorded Evidence

ACFEI EXECUTIVE ADVISORY BOARD

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The American College of Forensic Examiners International (ACFEI) does not endorse, guarantee, or warrant the credentials, work, or opinions of any individual member. Membership in ACFEI does not constitute the grant of a license or other licensing authority by or on behalf of the organization as to a member’s qualifications, abilities, or expertise. The publications and activities of ACFEI are solely for informative and educational purposes with respect to its members. The opinions and views expressed by the authors, publishers, or presenters are their sole and separate views and opinions and do not nec-essarily reflect those of ACFEI, nor does ACFEI adopt such opinions or views as its own. The American College of Forensic Examiners International disclaims and does not assume any responsibility or liability with respect to the opinions, views, and factual statements of such authors, publishers, or presenters,

nor with respect to any actions, qualifications, or representations of its members or subscriber’s efforts in connection with the ap-plication or use of any information, suggestions, or recommendations made by ACFEI or any of its boards, committees, publications, resources, or activities thereof.

The Forensic Examiner® (ISSN 1084-5569) is published quarterly by The American College of Forensic Examiners International, Inc. (ACFEI). Annual membership for a year in the American College of Forensic Examiners International is $165. Abstracts of articles published in The Forensic Examiner® appear in National Criminal Justice Reference Service, Cambridge Scientific Abstracts, Criminal Justice Abstracts, Gale Group Publishing’s InfoTrac Database, e-psyche database, and psycINFO database. Periodicals Postage Paid at Springfield, Missouri, and additional mailing offices. © Copyright 2010 by the American College of Forensic Examiners Interna-tional. All rights reserved. No part of this work can be distributed or otherwise used without the express written permission of the American College of Forensic Examiners International. The views expressed in The Forensic Examiner® are those of the authors and may not reflect the official policies of the American College of Forensic Examiners International.

CONTACT US:Publication, editorial, and advertising offices of ACFEI, 2750 East Sunshine Street, Springfield, MO 65804. Phone: (800) 592-1399, Fax: (417) 881-4702, E-mail: [email protected]. Subscription changes should be sent to ACFEI, 2750 East Sunshine, Springfield, MO 65804.

POSTMASTER:Send address changes to American College of Forensic Examiners International, 2750 East Sunshine Street, Springfield, MO 65804.

BOARDS


AMERICAN BOARD OF FORENSIC ACCOUNTINGCHAIRAlexander Lamar Casparis, CPA, MBA, Cr. FA, FACFEI

MEMBERS Stewart L. Appelrouth, CPA, CFLM, Cr.FA, FACFEIGary Bloome, CPA, Cr.FAD. Larry Crumbley, PhD, CPA, DABFA, Cr.FAJames A. DiGabriele, PhD/DPS, CPA, Cr.FA, FACFEIMichael W. Feinberg, CPA, Cr.FAMichael G. Kessler, Cr.FA, CICA, FACFEI, DABFAEric A. Kreuter, PhD, CPA, FACFEI, DABFARobert K. Minniti, CPA, MBA, Cr.FAJ. Bradley Sargent, CPA, CFS, Cr.FA, FACFEIJoseph F. Wheeler, CPA, Cr.FA, CHS-III, CFF

AMERICAN BOARD OF FORENSIC COUNSELORSCHAIR Marilyn J. Nolan, MS, FACFEI, DABFC, DABCIPChair Emeritus: Dow R. Pursley, EdD, FACFEI, DABFC

MEMBERSGeorge Bishop, LPC, LAT, FACFEI, DABFELaura W. Kelley, PhD, LPC, DABFC, FACFEIWilliam M. Sloane, JD, LLM, FACFEI, CHS-III

AMERICAN BOARD OF FORENSIC DENTISTRYCHAIRJames H. Hutson, DDS, CMI-V, FACFEI Chair Emeritus: Brian L. Karasic, DMD, MBA, DABFD, CMI-III

MEMBERS Bill B. Akpinar, DDS, CMI-V, FACFEI, DABFDStephanie L. Anton-Bettey, DDS, CMI-VJeff D. Aronsohn, DDS, FACFEI, DABFD, CMI-VSusan Bollinger, DDS, CMI-IV, CHS-IVChester B. Kulak, DMD, CMI-V, CFC, DABFD

AMERICAN BOARD OF FORENSIC EXAMINERSCHAIRDouglas Wayne Beal, MD, MSHA, CMI-V, CFP

MEMBERS Jess P. Armine, DC, FACFEI, DABFE, DABFMRonna F. Dillon, PhD, DABFE, DABPS, CMI-V, CHS-IIIBruce H. Gross, PhD, JD, MBA, FACFEIDarrell C. Hawkins, MS, JD, FACFEI, CMI-VMichael W. Homick, PhD, DABCHS, CHS-VJohn L. Laseter, PhD, FACFEI, CMI-IV, CHS-IIILeonard K. Lucenko, PhD, FACFEI, DABFE, CPSIMarc A. Rabinoff, EdD, FACFEI, DABFE, CFCJanet M. Schwartz, PhD, FACFEI, DABFE, CHS-V

AMERICAN BOARD OF FORENSIC ENGINEERING AND TECHNOLOGYCHAIRBen Venktash, DABFET, DABFE, FRSPH(UK), FIET(UK)VICE CHAIRGeorge C. Frank, CFC, DABFE, FACFEIMEMBERS

Cam Cope, BS, DABFET, DABFERobert K. Kochan, BS, FACFEI, DABFET, DABFEJ.W. “Bill” Petrelli Jr., DABFET, CFC, AIA, FACFEI Max L. Porter, PhD, DABFET, CFC, FACFEI

AMERICAN BOARD OF FORENSIC MEDICINECHAIRCyril H. Wecht, MD, JD, FACFEI, CFP

MEMBERS Douglas Wayne Beal, MD, MSHA, CMI-V, CFPZhaoming Chen, MD, PhD, MS, CFPJohn A. Consalvo, MD, DABFE, DABFM, FACFEIVijay P. Gupta, PhD, DABFMLouis W. Irmisch III, MD, FACFEI, CMI-V, CFPE. Rackley Ivey, MD, FACFEI, CMI-V, CFPLawrence Lavine, DO, MPH, CHS-V, CMI-VKenneth A. Levin, MD, CFP, FACFEI, DABFME. Franklin Livingstone, MD, CFP, FACFEI, DABFMManijeh K. Nikakhtar, MD, CFP, MPH, CMI-VMatthias I. Okoye, MD, MSc, JD, FRCPJohn R. Parker, MD, FACFEI, DABFM, CFPJerald H. Ratner, MD, DABFE, DABFM, FACFEIS. Sandy Sanbar, MD, PhD, JD, FCLM

AMERICAN BOARD OF FORENSIC NURSINGCHAIR Dianne T. Ditmer, MS, RN, CFN, CHS-III

MEMBERSHeidi H. Bale, RN, BSN, CFNMarilyn A. Bello, RNC, MS, CFN, CMI-IVWanda S. Broner, MSN, RN, FNE, CENCynthia J. Curtsinger, RN, CFNLinda J. Doyle, RN, CLNC, CFN, CMI-IIIL. Sue Gabriel, EdD, MSN, RN, CFNDiane L. Reboy, MS, RN, CFN, FACFEIElizabeth N. Russell, RN, BSN, CCM, BCSharon L. Walker, MPH, PhD, RN, CFNCarol A. Wood, RN, CFN, BS, NHA

AMERICAN BOARD OF FORENSIC SOCIAL WORKERSCHAIR Douglas E. Fountain, PhD, LCSW, DABFE, DABFSW

MEMBERSPeter W. Choate, PhD, BA, MSW, DABFSW, DABFEMichael G. Meacham, PhD, LCSW, DCSW, DABFSWKathleen Monahan, DSW, MSW, CFC, DABFESusan P. Robbins, PhD, LCSW, DCSW, DABFSWSteven J. Sprengelmeyer, MSW, MA, FACFEI, DABFSW

AMERICAN BOARD OF PSYCHOLOGICAL SPECIALTIESCHAIRRaymond H. Hamden, PhD, FACFEI, CFC, CMI-VCHAIR EMERITUSRaymond F. Hanbury, PhD, FACFEI, DABPS, DABFE

MEMBERSCarol J. Armstrong, PhD, LPC, DABPSRobert J. Barth, PhD, DABPSMonica J. Beer, PhD, DABCIP

Ronna F. Dillon, PhD, DABPS, CMI-V, CHS-IIICarl N. Edwards, PhD, JD, FACFEI, DABPSPaula M. MacKenzie, PsyDHelen D. Pratt, PhD, FACFEI, DABPSDoublas H. Ruben, PhD, FACFEI, DABPS, DABFERichard M. Skaff, PsyD, DABPSCharles R. Stern, PhD, DABPS, FACFEI, CMI-VJoseph C. Yeager, PhD, DABFE, DABPS, FACFEI Donna M. Zook, PhD, DABPS, CFC

AMERICAN BOARD OF RECORDED EVIDENCECHAIRGregg M. StutchmanChair Emeritus:Thomas J. Owen, BA, FACFEI, DABRE, CHS-V

MEMBERSEddy B. Brixen, DABFETStephen C. BullerRyan O. Johnson, BA, DABFE, DABREMichael C. McDermott, JD, DABRE, DABFE, FACFEIJennifer E. Owen, BA, DABRE, DABFEJeff M. Smith

AMERICAN BOARD OF REGISTERED INVESTIGATORSCHAIRSteven R. Conlon, MS

MEMBERSKenneth E. Blackstone, MS, CFC, DABFEH. Scott Brown, MS, RS, RIRon Carroll, BSEric Lakes, CHS-III, CLWE, MCSELt. David Millsap, RI, CMI-IIIJoseph A. Juchniewicz, MA, SSI, CHS-III, RIGregory M. Vecchi, PhD, CFC, CHS-V, FACFEIRichard A. Vera, II, MBA, CPACyril H. Wecht, MD, JD, CFP, FACFEIClaude E. Wells, BA, RI

EXECUTIVE ADVISORY BOARDOF THE INTERNATIONAL COLLEGEOF THE BEHAVIORAL SCIENCES CHAIR Janet M. Schwartz, PhD, FACFEI, DABFE, CHS-V

MEMBERS Clifton D. Croan, MA, LPC, DAPA Duane L. Dobbert, PhD, FACFEISue Gabriel, EdD, RN, CFNMark L. Goldstein, PhDRaymond H. Hamden, PhD, FACFEI, CFC, CMI-V Janice L. Hargrave, MEd, CFCDavid L. Holmes, EdDTina Jaeckle, PhD, LCSW, MFSW, CFCGary Kesling, Ph.D., LMFT, LPC, DAPALon Kopit, PsyD, LPC, BCPCCarl J. Patrasso, PsyDJerald H. Ratner, MD, CFPRonald M. Ruff, PhDJanet M. Schwartz, PhD, FACFEI, DABFE, CHS-V

ACFEI EXECUTIVE ADVISORY BOARDS

WWW.ACFEI.COM • (800) 592-1399B

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Spring 2011 THE FORENSIC EXAMINER® 07

1-800-423-9737 www.ACFEI.com

ACHIEVE NEW GOALS. LEARN NEW JOB SKILLS. GROW YOUR PASSION.The American College of Forensic Examiners Institute® provides the latest in certi� ed training. We o� er a range of online forensic credentials from Certi� ed Forensic Nurse, CFN® to Certi� ed Forensic Accountant, CrFA®. Check out our online catalog for a complete list of the certi� cations we o� er from all our associations.

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EFROM THE DESK OF...

Christopher Powers, Editor in Chief

Members, thank you. It is your continued dedication to your respective fields that has fueled the impressive growth of the ACFEI, and its flagship journal, The Forensic Examiner®, has grown by the same leaps and bounds. The journal has grown from Dr. Robert O’Block’s dream, first embodied by a single-page typewritten newsletter, into a full-color, nationally distributed publication offering insights into new research, agencies, case studies, ways of thinking, and all manners of fascinating facts and information. Inside, you will find a visual timeline charting the journal’s evolution and expansion from its beginnings in the early ‘90s to the present.

All of our editors and graphic designers had hands in the development of this issue to engage you intellectually, creatively, and professionally. We all truly “stepped it up” to deliver the strongest issue to date. As we celebrate our 100th issue with senses of pride and duty, we are also thinking about the future. In 2011, expect further changes as we foray into new territories, including digital distribution through major e-reader platforms and new, stellar design concepts and styling. These are, of course, continued benefts provided courtesy of ACFEI to all of its members.

I would especially like to thank those members whose articles appear in this issue. The content and topics covered represent a full spectrum of the forensic arena, and the effort that was taken to write them is evident on every page. Thank you for your contributions to this very special issue; it is an honor to work with you—and all of the authors whose works have appeared in the pages of The Forensic Examiner®. I cannot emphasize enough that this publication is what it has become because of your continued efforts and your dedication to your pas-sions; academic and professional development; and science, integrity, and justice.

I trust you are as excited as I about the future of our esteemed publication as we push our boundaries, grow, and change for the continual better.

Respectful thanks,

Christopher PowersEditor in Chief



WWW.ACFEI.COM • (800) 592-1399FROM THE DESK OF...C

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Joey Fletcher, Chief Association Officer

Hello fellow members. I am eager to celebrate this landmark in the history of our organization and specifi-cally, The Forensic Examiner®. For those of you who have enjoyed membership with us for a number of years, you have witnessed first-hand the evolution of the journal from a one-page, black-and-white newsletter to the leading professional, peer-reviewed forensic journal it is today. I am very appreciative to those of you who submitted quotes, letters, or articles to help make this issue extraordinary!

The ACFEI has high ambitions for 2011, and I hope all of you will be pleased. We hope to increase the as-sociation’s visibility on an international scale, thereby bringing more direct benefits to each of you. Of course, having the top professionals from every forensic discipline in your membership makes that job many times easier and enjoyable. The melting pot of professionals we are fortunate enough to have comprising our mem-bership is a unique benefit no other association can claim. You are each a truly valuable asset to the ACFEI. You are the association and have been for nearly two decades.

This centennial issue celebrates the membership and the top-notch publication that you have the privilege of calling your own. I would also like to extend my thanks to the professional editorial and design team here at Headquarters; they do an excellent job daily, making The Forensic Examiner® the caliber it is when it ar-rives in your mailbox. This year, you can start looking for us on Kindle and Nook, and through other media in the not-so-distant future. Join us as we continue into the 21st century, paving the way into new arenas, in line with the advancements each of you make toward your respective fields each day. The people of ACFEI and The Forensic Examiner® are both excited to show you many positive changes this year, changes that will only improve your membership experience as we continue forward.

In moving forward, I am pleased to announce the remodeling of our 2011 National Conference into the 2011 Executive Summit (ES20). Our mission is to network together the top leaders in the forensic community, enhancing the quality of forensic programs everywhere. Please accept my invitation and join us in Branson on October 12–14th.

Sincerely,

Joey FletcherChief Association Officer, ACFEI

IMPROVEMENTS TO THE JOURNALCOMING IN 2011 As we continue to provide you with the latest research and cutting-edge content, we are brainstorming ways to get the journal to you faster. Expect some positive changes to the structure and format of the journal this year beginning with the next issue. Your feedback is always encouraged and welcomed, so be sure to call us at (800) 423-9737 or write the editor at [email protected]!

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I NEW

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ADVANCE EARLY BIRD REGISTRATION

To receive the Advance Early Bird rate for the Executive Summit, be sure to register before April 30th! The Executive Summit will be held October 12–14, 2011 at the Branson Convention Center in Branson, Missouri. This year’s event promises to be the most exciting, interactive to date.

EARN THE CREDENTIAL THAT COULD SAVE YOUR LIFE!

The newest release for ACFEI Members is a credential essential to surviving a violent encounter, Certified in Survival Mindset, CSM! Subject matter expert Lt. Col. Dave Grossman is an internationally recognized scholar, author, soldier, and speaker who is one of the world’s foremost experts in the

field of human aggression and the roots of violence and violent crime. The course materials cover each of his books, On Killing, On Combat, and Warrior Mindset and will prepare you for the physiological and psychological aspects of violent encounters and equip your body and mind to survive disastrous events.

Beginning later this year, The Forensic Examiner® will be working with its distributor to make the journal available across an array of digital formats! The infrastrucutre for this rollout is underway and will be in place in the coming months. Please join us as we enter this most modern of frontiers.

JOB SEARCH NOW FREE AT ACFEI.COM

Due to popular demand, the job search and job listing features on acfei.com are now free for all to benefit from. If you have a position you need filled or are yourself seeking employment, please visit www.acfei.com/forensic_services/jobsearch to get started!

WANTED: MODULES FOR THE REGISTERED INVESTIGATOR, RI CREDENTIAL

We are currently seeking authors for additional elective modules to add to the Registered Investigator®, RI® program. The RI is the world’s first open source credential, which means anyone can submit a relevant module to the field of investigation if it is peer reviewed and approved by the American Board of Registered Investigators. We currently pay $500 for a 4000-word, complete module submitted complete with an abstract, learning objectives, and exam questions. For more details about submitting a module, please refer to our course submission guidelines.

READ THE FORENSIC EXAMINER® ON YOUR PREFERRED E-READER IN 2011!

s Lt. Col. Dave Grossman


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By Dianne Ditmer, PhD, RN, CFN, DABFN, SANE, CMI-III, FACFEI

Workplace violence, in its most lethal form, is a substantial contributor to death and permanent impairment. An estimated 20 workers are murdered each week, and an additional 18,000 are assaulted. Untold numbers suffer psychological consequences from bul-lying, teasing, and verbal abuse. Documentation of injuries resulting from workplace violence is inconsistent, may fail to include nonfatal injuries, and/or may even fail to acknowledge a causal connection of injuries to the workplace. Failing to appreciate the extent and impact of workplace violence results in the failure to address the problem in a meaningful manner. Nurses, who comprise the largest group of health care providers, are assaulted more frequently than any other employment demographic in the United States. The majority of nonfatal assaults occur in patient care areas, where the abuse most commonly comes in the form of bullying be-havior, hostility, and open verbal assaults. Verbal abuse, however, is rarely reported, since many people may not recognize verbal abuse as a form of workplace violence; sadly, some nurses even consider it to be “part of the job.”

ABSTRACT


SCOPE OF VIOLENCE IN HEALTH CARESociety can no longer consider health care institutions as sacred ground, immune from dangerous acts of violence. Hospitals, once considered safe havens and revered as heal-ing institutions, have become battlefields fraught with disruptive behavior and crimi-nal activity. News headlines, horrifying tales of brutality, pictures of gun battles … all graphically document violent acts commit-ted in the health care sector. Health care workers face a substantial risk of becoming victims of nonfatal assaults at work. According to a groundbreaking re-port issued by the Bureau of Justice (1998), more than 160,000 health care workers are assaulted each year. These numbers are in-creasing steadily. Of the incidents reported by medical professionals between 1992 and 1996, an estimated 70,000 nurses, 24,000 technicians, and 10,000 physicians were victimized annually. Tragically, the number of workplace assaults on medical personnel averages 137,500 per year for simple assaults

without the intent to injure and 12,800 per year for aggravated assaults, which may include use of a weapon. In health care set-tings, nonfatal violent incidents in the work-place involve the use of a weapon only 7% of the time (Bureau of Justice, 1998). Approximately 40% of the victims of non-fatal violence report knowing their assailants, who had been their coworkers, patients, or supervisors (Bureau of Justice, 1998). Only 1% of the known perpetrators are identified as intimate partners (or ex-partners) who trespass, committing acts of violence in the victim’s place of employment (Bureau of Justice, 1998). According to the U.S. Bureau of Labor Statistics (American Nurses Association, 2009), this sobering trend of violence con-tinues as the health care sector leads all other industries in incidents of workplace violence.

THIS ARTICLE IS APPROVED BY THE FOLLOWING FOR CONTINUINGEDUCATION CREDIT:(ACFEI) The American College of Forensic Examiners International provides this continuing education credit for Diplomates and certified members.

AFTER STUDYING THIS ARTICLE, PARTICIPANTS SHOULD BE BETTER ABLETO DO THE FOLLOWING:

1. Review the scope of violence in health care.2. Explore the full continuum of acts of violence among nurses, to include horizontal

violence.3. Discuss the prevalence of fatal assaults and nonfatal assaults.4. Identify potential offenders within the health care setting.5. Evaluate the impact of bullying behavior and horizontal violence on clinical outcomes

and staff retention.6. Identify strategies to reduce violence in relationship to environmental design, adminis-

trative controls, and staff retention.

KEY WORDS: bullying, horizontal violence, physical assault, escalation curve TARGET AUDIENCE: nurses, health care providers, hospital administratorsPROGRAM LEVEL: BasicDISCLOSURE: The author has nothing to disclose.PREREQUISITES: None

EARN CONTINUING EDUCATION CREDITSTAKE THE CE TEST FOR THIS ARTICLE ON PAGE 151

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“Often, fear of repercussions for being viewed as incompetent, provocative, or unable to handle the job leads to a failure to disclose.”

health care workers are assaulted each year.”

“More than

160,000

FORENSIC NURSESLearn more about forensic nursing at

www.acfei.com/forensic_certifications/cfn

VIOLENCE IN THE HOUSE OF HEALING: Recognition & Response to Violence in Health Care


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To make matters worse, 45% of all report-ed nonfatal assaults against staff result in lost workdays. Assault, rape, and homicide are consistently among the top 10 types of sentinel events, as reported to The Joint Commission (TJC), with 256 incidents oc-curring since 1995. TJC received 33 reports in 2009 alone (TJC, 2010a). Although alarming, the available data are conservative at best, with an estimated 80% of assaults against health care workers still going unreported. Many believe violence is just “part of the job,” or that incidents should be reported only if they are severe or result in injury. Often, fear of repercussions for being viewed as incompetent, provoca-tive, or unable to handle the job leads to a failure to disclose. Many staff believe that reporting is time-consuming and a likely waste of time, since nothing will be done, or they simply do not know how to docu-ment events (Taylor, 2010; Geig, 2010; Hutchinson, Vickers, Jackson, & Wilkes, 2006; Gates & Kroger, 2002).

The following is a true story, too sad to be a fictional account: After being paged to the emergency de-partment, the evening supervisor wasn’t prepared for what she was about to see and hear. Her friend and colleague of 20 years had just had her arm broken by a violent patient. Horrified and feeling helpless, the

supervisor reassured her nursing colleague that once she was cared for, the two must document the incident and educate the staff how to be safer in these situations, not want-ing this to happen to anyone else! To which the injured nurse replied, “Why are you so upset? This is just nursing.”

Violence committed against nurses and other hospital staff is not limited to the U.S. Recent worldwide reports include:• In India, relatives of a patient who died during an emergency caesearan section clashed with nurses and security guards on Jan. 16. Police had to intervene.• In Australia, a veteran Geelong Hospital nurse was punched in the head six times by an emergency room visitor, also on Jan. 16. The hospital’s statistics show that 60 nurses are assaulted there each month.• In New Zealand, Tauranga Hospital‘s zero-tolerance policy now requires staffers to call police when a patient becomes violent.

of the victims of nonfatal violence report knowing their assailants, who had been their coworkers, patients, or supervisors.

160,00040%

>>> VIOLENCE IN HEATLH CARE: A GLOBAL ISSUE


Health care workers are at a significant risk for all types of violence, due in part to the very nature of the clients they serve, includ-ing substance abusers, mental health clients, and forensic patients under police arrest. A fast-paced, stressful environment, in which life-and-death decisions are commonplace, often leads to anxiety among health care providers as they strive for perfection and expect to heal all who enter their domain. Frustrations also run high among patients and family members when needs are not

met, service requests are delayed, limits are

set, or questions go unanswered. Frustration, anxiety, and stress may combine to form an environment filled with verbal assaults, bul-lying behavior, and physical threats. Myriad precipitating factors make health care a risky business, especially for nurses who are direct care providers. They are in the unenviable position to be the recipients of acts of violence from angry, confused pa-tients (Type II) and frustrated, overworked coworkers (Type III). Ironically, the over-whelming stressors encountered in health

care settings, which include long hours, fast-paced decisions, and increased patient assignments, often lead to incidents of verbal and physical violence from colleagues.

VIOLENCE AGAINST NURSESNurses are three times more likely to experi-ence violence than any other group of pro-fessionals, and among health care providers, they suffer the highest rate of physical assault (Hader, 2008; Keely, 2002). According to Hader, more than 73% experience occasional violence, and 80% report witnessing a nurs-ing colleague being victimized from multiple sources, including patients (53.2%), fellow nurses (51.9%), physicians (49%), and visi-tors (47%). Acts of aggression, harassment, and intimidation are experienced by 75% of nurses, verbal abuse is experienced every shift by 27% of nurses, and 80% of nurses experience bullying during their working careers (Hutchinson, Wilkes, Jackson, & Vickers, 2010; ENA, 2008; Hader, 2008; Keely, 2002).

One nurse conveyed the following story of a known aggressor: During hospital rounds, staff would whis-per, “Here comes ‘Dr. M. the Maniac,’” when the infamous physician would enter the nursing station. It was common knowl-edge and regular behavior that she would belittle the staff, insulting their professional knowledge and throwing charts, her pager, or pen when questions were not answered immediately.

MULTIDIMENSIONAL RISK FACTORSEach environment within the health care setting presents its own unique circum-stances that can expose the nursing staff to violence. Emergency departments are filled with victims of unexpected—and often life-threatening—injuries and ill-nesses. Patients and their family members hope for the best, but fear the worst. This

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>>> CONTINUUM OF VIOLENCE IN HEALTH CARE

Researchers and criminal justice specialists have divided workplace violence into four distinct, standardized categories in an effort to identify its root causes and correlate potential interventions. As noted in their final document, “Workplace Violence: A Report to the Nation” (Injury Prevention Research Center, 2001), violence is classified by the following types:

Criminal Intent (Type I)Violence erupts during the commission of a criminal activ-ity. Workers who are at greatest risk for this type of violence include employees who work alone, which often includes those who work the night shift, such as home health and hospice nurses. These workers often find themselves in secluded neighborhoods or working alone. Walk-in clin-

ics are open during late evening hours, creating a potential for risk of harm motivated by drug seekers.

Customer/Client (Type II)Client becomes violent while the employee is performing routine job responsibilities. The majority of this type of vio-lence occurs in health care settings, including emergency departments, extended care facilities, and psychiatric facilities. Aggressive acts may be viewed as “routine” or “normal” by nurses, mental health professionals, and other

hospital staff, who encounter varying levels of violence in their daily work lives.

Worker-on-Worker (Type III)Disgruntled current or former employee or supervisor verbally or physically assaults a fellow employee or su-pervisor. Violence escalates following a work-related or interpersonal dispute. Unresolved anger and constant stress contribute to frustrations, which then erupt into violence. Approximately 7% of all homicides that occur

in the workplace are a result of worker-on-worker violence (Injury Prevention Research Center, 2001).

Personal Relationship (Type IV)Current or former spouse, girlfriend, or boyfriend. Violence begins in the home setting and spills into the workplace.

tense environment often fuels feelings of helplessness and unmanageableness. Mental health units may serve patients who are in-voluntarily admitted or who suffer from de-lusional and homicidal thoughts. Patients’ very freedom may be restricted and requests denied, which can result in aggression and may further escalate into violent behavior. Surgery waiting areas are filled with fear-ful, exhausted family members; when news of unanticipated outcomes or unsuccessful surgical procedures arises, these individu-als may resort to grief-fueled violence, un-leashing their emotions on unsuspecting hospital staff.

The National Institute of Occupational Safety and Health (NIOSH) identifies com-mon risk factors for violence against nurses based upon the complexity of the health care environment (2002). The physical plant and emotional environment create many risks associated with violence. The diversity of people who provide services and of patients who receive care can individually contrib-ute to a hazardous workplace based on past experiences, personalities, and physical and emotional health. Although each facility’s size, patient population, and geographic location may vary, the risks for violence are universal. CERTAIN PATIENTS MAY POSE AN ELEVATED RISKDirect working relationships with volatile people, including patients and their fam-ily members, can lead to threats of physi-cal violence and physical assaults. Due to the great stress and lack of control in the hospital environment, abusive personalities become more violent because they have poor impulse control. Family members may make demands and at times can overwhelm and outnumber staff members. Aggressive or abusive behavior may result when patients or their family members do not believe their needs or requests are being met in a timely manner or at all. Verbal assaults, in the form of offensive and threatening language, are the result of stress and fear. Providing care for patients who have a history of violence or certain psychotic di-

agnoses predisposes staff to injuries from physical violence. Psychiatric or forensic patients may experience psychotic, violent episodes and present a serious safety risk to bedside nurses. Caring for patients who are under the in-fluence of drugs or alcohol creates a high risk for physical and verbal assaults. Substance abuse can lead to irrational behavior and violent outbursts. Assaults can result when patient demands are not met or when staff impose restrictions on tobacco, alcohol, or drug use. When patients, gang members, family members, or hospital security staff bring in or confiscate weapons in the hospital, there is a potential for physical assault and lethal outcomes. Although most occurrences of workplace violence are nonfatal assaults, le-thal forms of violence do occur in hospitals as 25% of patients and visitors carry a dan-gerous weapon into treatment areas (Bureau of Justice, 1998).

STAFFING SITUATIONS CAN ELEVATE RISKConversely, understaffing can lead to frus-trated and vulnerable staff. Tension among coworkers and feelings of unequal or un-manageable work assignments can lead to verbal abuse from colleagues. Disparaging comments, the use of profanity, and shouting create a hostile work environment. Without appropriate interventions, verbal assaults can escalate to physical aggression, such as throwing objects or a full-on physical assault of a fellow worker. Substance abuse by staff can lead to un-predictable, aggressive, and violent behavior. Irritability can lead to verbal assaults and progress to physical aggression.

POOR PHYSICAL SPACE DESIGN MAY CONTRIBUTECrowded and uncomfortable waiting rooms increase anxiety. Patients’ family members are under tremendous stress as they anxiously await news of surgical outcomes, results of diagnostic exams, or permission to visit a loved one. Bad news and restricted visita-tion can lead to verbal and physical assaults. Dysfunctional families may be drawn togeth-er in a medical crisis without possessing the coping skills needed to deal with individual and interpersonal stress. Working alone creates a significant risk for physical assault, not only in patient care ar-eas, but also in isolated restrooms and break

“Crowded and un-comfortable waiting rooms increase anxiety. Patients’ family mem-bers are under tre-mendous stress as they anxiously await news of surgical outcomes, results of diagnostic exams, or permission to visit a loved one.”

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rooms. An isolated environment may also limit availability of security staff or affect response time. Transporting patients in iso-lated hallways and elevators during evening hours, when nurses may be working alone, can predispose staff to physical assaults. Risks can be dramatically increased by poor physical design of the care environ-ment. Open access to departments, absence of security measures, and building layout and design all contribute to safety issues. Unlimited visitor access to patients may en-able the continuation of domestic violence in a health care setting. Unrestricted move-ment of the public can lead to unauthorized access to drugs, money, or medical supplies, which makes pharmacy areas, credit unions, gift shops, and other hospital areas potential targets of robberies.

INADEQUATE SECURITY, TRAINING, OR PLANNING

Lack of or inadequate security personnel can disrupt response to crisis situations. This can lead to critical injuries, hostage situations, or fatalities. Often, the presence of hospi-tal security staff can prevent verbal aggres-sion from escalating into a physical assault. Hospital security staff are specially trained to use nonviolent crisis intervention tech-niques, which are most appropriate when dealing with worker-on-worker or patient and family types of violence. Inadequate training of health care person-nel in recognizing and preventing crises can affect the safety and emergency response of working environments. Identification of behaviors that lie at the beginning of the es-calation curve of violence allows for early in-

tervention. Verbal as-saults, which include shouting, offensive language, conde-scending language or tone, and verbal threats of physical violence, must be recognized as acts of violence. Verbal as-saults can result in emotional scars that in turn may lead to stress, physical or psychological illness, decreased morale,

and job dissatisfaction. All of these factors can create an emotional state that contributes to future instances of health care violence. Failing to have policies designed to pre-vent, manage, and report workplace violence creates liability for the facility and increas-es the risk to patients and care providers. Formal policies provide evidence of admin-istrative support and commitment to a safe work environment. Nurses feel empowered and supported when policies identify risk factors and detail safety practices appropri-ately for the specific needs of the facility or organization. Clear policies and procedures serve to facilitate the documentation of events, educate staff, reduce risks, and pre-vent future occurrences of violence. When patients, gang members, family members, or hospital security staff bring in or confiscate weapons in the hospital, there is a potential for physical assault and lethal outcomes. Although most occurrences of workplace violence are nonfatal assaults, le-thal forms of violence do occur in hospitals as 25% of patients and visitors carry a dan-gerous weapon into treatment areas (Bureau of Justice, 1998). Prevention of emotional and physical inju-ries begins with an understanding of the fac-tors that make health care such a risky busi-ness. Nurses and other health care providers will not be safe until the true sources of this violence are identified and their prevalence acknowledged by hospital administrators and staff.

Some California lawmakers are urging signifi-cant changes in security at state hospitals after the slaying of psychiatric technician Donna Gross last October at Napa State Hospital. According to a Jan. 1 article in the Los Angeles Times, patients who have committed crimes now represent more than 90% of the popula-tion in the state’s mental hospitals. Attacks on staff at the Napa hospital doubled to about 200 compared with the same period in 2009, state data show—although patients themselves are victimized by other patients more often

than staff.

Often, the presence of hospital

security staff can prevent verbal

aggression from escalating into a physical assault.

>>> A CALL FOR REFORM



The Forensic Examiner (Sample) - Winter 2010/Spring 2011 Double Issue

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