delivered 12 58 Secure portal or secure file sharing 9 43 Portable storage device via mail or courier 4 19 Images are never released 3 15 Other means not listed above 13 62 Don’t know 11 54 69 Discussion The results from this descriptive survey of a large sample of forensic nurses licensed predominately in the United States is the first report of current practice around forensic medical photodocumentation to our knowledge. As such, these findings represent crucial, guiding information for forensic clinicians, educators, scientists and policy makers. Three key findings are discussed below. The majority of nurses who participated in this study had 20 years or less forensic nursing experience. This was expected for two reasons. First, most nurses practice for several years in a general area of nursing before entering a specialty area such as forensic nursing. Second, forensic nursing is a relatively young specialty, only achieving formal recognition from the ANA in 1996, with many sub-specialties (e.g., sexual assault nurse examiners, medical death investigators). Additionally, over half of the nurses in this study reported a narrow clinical subspecialty practice - forensic medical exams related to sexual assault/abuse. This may be reflective of how forensic nursing came to exist. Unlike other nursing specialties where subspecialties emerge from the general specialty, forensic nursing subspecialties were established prior to the specialty itself and merged to form one specialty group. These findings also raise concerns about forensic nurses’ knowledge of and ability to provide an accurate estimate for their professional experience. This is an important issue because of the critical intersection between forensic nursing and the legal system. Forensic nurses are expected to be able to accurately represent their experience and expertise, particularly during judicial proceedings. This is similar to a nurse midwife who is expected to be able to provide an overall estimate of deliveries, including by presentation and complication. Yet these survey findings suggest that forensic nurses may not recognize this professional expectation. 70 Respondents were asked how many patients they had provided forensic nursing services to in the past 12 months, and in the role as a forensic nurse overall. While all participants responded regarding how many patients they have served in their role as a forensic nurse over the past 12 months, nearly a third did not respond when asked to estimate over their career. In addition to the lack of clarity regarding career expertise, there is concern across the forensic nursing community about overall lack of expertise among forensic nursing educators, trainers, and consultants. A little over a quarter of survey respondents (26%) reported providing services to 10 or fewer patients in the past year. Just over two-thirds reported providing services to 50 or fewer patients in the past year. This raises the question of what frequency of practice is necessary to maintain proficiency and expertise, and how to support competence in settings, such as rural communities, that are anticipated to be low-volume. Practicing a skill 1-4 times a month may not be adequate to maintain competence without a robust just-in-time consultation mechanism. Options that have been utilized in similar situations of low-frequency healthcare skills include telemedicine support, national expert consultation available by phone 24/7, or clinical guidelines available through professional societies. One current national project is exploring the use of telemedicine to address low-volume areas and a recent national RFP was released to fund a state-wide initiative (www.ovc.ncjrs.gov). Perhaps simulation labs, live patient-model labs, or virtual simulation programs should be explored for remote and lowvolume regions, programs or individuals. Anecdotal accounts by forensic nurses of photodocumentation practices related to sexual assault/abuse forensic medical examinations have suggested wide variations in practice based on the patient’s age. The results of this study suggest that while there are differences, there is great commonality. Photodocumentation of ano-genital structures is relatively consistent across all age 71 groups, suggesting that it is viewed as standard of practice by all forensic nurses, regardless of the age group they predominantly serve. These data showed a concerning exception however. Nearly 13% of the nurses in the survey reported not using any type of photodocumentation during a forensic medical exam regardless of type of violence reported. In addition, of the forensic nurses who do use photodocumentation, almost 5% who provide forensic medical examinations for young children take no images at all. Forensic nursing needs to identify the reasons behind these variations in care. Are these variations reflecting regional differences? Or variations related to source of education and training? Perhaps acquiring equipment is a barrier resulting in no photodocumentation? Most importantly, forensic nursing must address if this is a variation in practice or a breach in the standard of practice? How images are taken, transmitted and stored is critical and, with rapidly changing technology, often may be perceived as a moving target for procedures and policies. The findings from this study highlight the seriousness of the issues