loyalties and conflicting interests. Chapter Three introduces a dialogue highlighting 5 inequities related to forensic medical examinations for persons identified as suspects or the accused in sexual assault cases versus those identified as victims. Chapter Four explores photodocumentation practices among forensic nurses and begins discussions related to variations in practices in this important area of forensic nursing practice. In the final chapter, I offer reflections on implications of my doctoral work for forensic nursing practice, education and research. 6 References American Nurses Association. 2009. Forensic Nursing: Scope and Standards of Practice. Silver Spring, MD: American Nurses Association. 7 Chapter 2: Exploring Forensic Nursing in the Context of Roles, Loyalties, and Interests 8 Introduction Forensic nurses function at the crossroads of the healthcare and legal systems. Forensic nursing education starts from a foundation of nursing education and then adds basic and advanced tenets of forensic science, legal processes, and population health. Forensic nurses practice in diverse settings across a myriad of systems from acute healthcare institutions to correctional facilities to community-based service settings. Forensic nurses serve patients including individuals, families, groups, communities and populations affected by violence, both intentional and unintentional injury, and disasters caused by nature or humans. Multidisciplinary collaboration involving law enforcement professionals, advocates, social service providers, legal professionals, and forensic scientists is a central feature of the practice role (ANA, 2009). Given the unique and diverse practice for forensic nursing, where expectations emerge from both within and outside of the profession, it may not be surprising that forensic nurses have found themselves declaring, “We are nurses first!” Yet, these statements may contribute to greater confusion about the role of the forensic nurse, creating a false distinction among the many duties that are integrated into a single unique role. After all, if you are a nurse first, then you must be something else second, third, or fourth. This approach to clarifying one’s role and role expectations across a variety of stakeholders may have simply exacerbated confusion. As nurses, forensic specialty nurses continue to have a primary ethical commitment to the patient (ANA, 2015). Role conflict and role confusion are not unique to forensic nursing nor new to the nursing profession as a whole. Research exploring the prevalence of role conflict and confusion, subsequent effects on patient care, job satisfaction, and contribution to role stress or moral distress appear in the nursing literature dating as far back as the 1950s (Benne & Bennis, 1959). 9 Dual loyalty and dual roles are raised in discussions about healthcare provider roles in correctional, detainee and forensic psychiatric settings (Mason, 2002; Sekula et al, 2001). However, there is little discussion about the differences between dual loyalty (or dual roles) versus dual duties with a single role. For example, is there a dual loyalty or an obligation (loyalty) to a single entity (e.g., the patient) with multiple duties within that obligation? Does conflict stem from inconsistent role expectations or secondary to incongruence among expected duties of the role? Similarly, are concerns about healthcare provider conflicts of interest different than concerns about conflicting interests, or are these terms being used synonymously but perhaps incorrectly? Conflicts of interests and conflicting interests rest on the same conceptual continuum. Conflicting interests, on one end of the continuum, may cross a threshold to become conflicts of interest at the other end. Is one concept more applicable to forensic nursing than the other? Role clarity is essential for the forensic nursing community to effectively respond to questions about forensic nursing practice, from both within and outside of healthcare settings, and to address incongruence between expectations of the role and the enacted role. The aims of this paper are to (1) explore the concepts of role confusion and role conflict; (2) introduce the concept of dual duties within a single role as an alternative to dual roles or dual loyalties; (3) highlight the difference between conflicts of interest and conflicting interests, all within the context of forensic nursing practice. Current dialogues on listservs, at forensic nursing conferences and professional meetings, and between forensic nursing experts include these concepts. It is time to bring these discourses forward and set the foundation for future research on forensic nursing practice. 10 Background Role Conflict and Role Confusion Experiences of role conflict and role confusion among professional nurses in the United States dates back to the 1870s. Nurses found themselves in what was described as competing ethical loyalties to the patient and patient’s family, a known physician requesting their service, the registry employer, and self (ANA, 2008). With the shift of nursing to the hospital setting following World War II, nurses still faced role conflict with loyalties to the patient, an institution, a physician (who might not be known to them), and self. This also marked a time in nursing history when there was an explicit loyalty expectation to obey and serve the physician. This paradox between what should be based on nursing