resources for guidance. Forensic nursing is a specialty practice that encounters situations involving sexual assault, child abuse, homicide, torture, and other tragedies that are emotionally charged and involve medico-legal implications. The outcomes associated with these events may have lifelong negative effects for the patient, their families and loved ones, their community as well as for the accused, suspects and perpetrators of the violence and his/her family and loved ones. Issues related to clinical, professional, and organizational ethics within forensic nursing practice span the realms of clinical practice, research, education, administration, and policy. Forensic nurses find themselves at the intersection of healthcare and the law, yet there remains an absence of forensic nursing research on topics such as dual loyalty (e.g., to the patient and society; to nursing and the criminal justice system), professional values (e.g., value development, response to conflicting values), and ethical decision making processes. There is also a lack of published articles addressing conflicts of interest and conflicting interests, and where the two concepts overlap, in clinical forensic nursing practice. Interestingly, within the Scopes and Standards of Forensic Nursing Practice (2009), there are several references to the ethical 3 paradigms of forensic nursing practice although a literature search for such a paradigm or their application to practice was unsuccessful within the forensic nursing literature and textbooks. Discourse surrounding forensic medical services for unconscious patients serves as an exemplar of the concerns described above. During discussions of potential ethical conflicts, many forensic nurses become focused solely on the pelvic exam, specifically, the insertion of a speculum into the vagina of an unconscious female patient. Considerations are not given to other related invasive procedures (e.g., sample collection from anal or oral cavities), equivalent concerns for male or transgender patients, nor grounds for suspicion of assault itself. Individual decisions and even program policies have been based on what the forensic nurse would want if s/he were the patient or based on an assumed fear on the part of the forensic nurse of risking his/her professional nursing license(s). These decision processes are not consistently evidencebased nor patient centered and represent a weak ethical decision making process. A second exemplar, and the impetus behind the data generating section of my doctoral studies, involves the practice and policy surrounding photodocumentation, particularly digital photodocumentation. Concerns around the use of digital imaging technology for photodocumentation emerged through formal and informal discussions during an International Association of Forensic Nurses symposium on photodocumentation, posts on general and subspecialty discussion boards, articles exploring the use and purpose of digital imaging technology, and questions posed during forensic nurse training and presentations. Much of the formal and informal discourse appeared to be anecdotal at best and similar to the exemplar shared above. These conversations tended to focus primarily on female patients and their genitalia. Yet there was a lack of evidence-based or research-informed literature related to the use of digital imaging for photodocumentation among forensic nurses. The same held true for forensic nurses concerns 4 involving the practice of photodocumentation and use of digital imaging technology. This gap in the literature included both extra-genital and ano-genital photodocumentation practices. To develop best practices, policy statements or guidelines, and to address ethical concerns surrounding the use of digital imaging technology in clinical forensic nursing practice, it is critical to move beyond anecdotal accounts. A review of the current state of practice among forensic nurses across different populations, systems, and roles was needed. I returned to earn a PhD in nursing because I wanted to make a difference. My goal was to serve as a change agent by creating safe professional environments that promote informed conversations about difficult subjects. Informed dialog and questioning the “what is” is critical to enacting change within forensic nursing practice. Positive change can create a ripple effect across all domains of practice helping us achieve the “how it should be”. By doing so, we enhance our capacity to better serve populations affected by violence and mass disasters regardless of how they self-identify or how they may be labeled by society or the legal systems: victims and survivors; the accused, suspects and perpetrators; secondary survivors; individuals, families and communities. My hope is to collaborate with others in the future who wish to do the same for the populations they serve. I am dedicated to serving as a change agent and I understand the risks associated with raising my head above the crowd and objectively speaking out about emotionally charged and controversial subjects. Speaking up for those whose voices are not valued, or whose voices are actively silenced, carries risk. These goals were the impetus for this dissertation. Structure of the Dissertation In Chapter Two, I explore forensic nursing from the perspectives of role confusion, role conflict, dual