“When we’ve had our say with the government — and maybe the adults have gotten used to saying ‘it is what it is,’ but if we students have learned anything, it’s that if you don’t study, you will fail. And in this case, if you actively do nothing, people continually end up dead,
so it’s time to start doing something.”

-  Emma Gonzalez, Marjory Stoneman Douglas High School Student and Gun Safety Activist, March 2018

INTENT

The intent of this position statement is to describe the impact of gun violence on society and to declare nurses’ role as advocates to minimize the adverse effects. Due to the tremendous rise in the incidence of active shooter incidents, NYSNA has a separate position statement on active shooter incidents specifically. 

POSITION

It is the position of the New York State Nurses Association that: 

• Gun violence or the threat of gun violence must not be tolerated under any circumstances, whatever the source.
• Registered professional nurses need to: (1) increase their understanding of the issue of gun violence; (2) develop skills to prevent, advocate, and intervene when necessary; and (3) report all, and contribute to the analysis of, violent events. 
• Registered professional nurses can play a critical role by educating the public and influencing policy about responsibilities associated with gun ownership and potential detrimental effects on society when guns are used irresponsibly.
• A central tenant of nurses’ ethical obligation is to serve as advocates for patient health; registered professional nurses can and should play a role in supporting the unfolding youth movement around gun violence.
• Nurses and nurses associations should demand that legislators ban assault weapons and enact other effective gun control reforms to protect the public and restore access to mental health services for individuals and families.

BACKGROUND

Gun violence in the U.S. is a public health crisis. Every day more than 89 Americans are killed by guns (Everytown for Gun Safety, Gun Violence by the Numbers, 2018). The latest Centers for Disease Control and Prevention Fatal Injury Reports show that guns were responsible for 164,821 civilian U.S. deaths from 2010 to 2014 — 33,315 of these were under the age of 25 (Centers for Disease Control, 2018). The rate of people killed by guns in the U.S., is almost 20 times higher compared to similar socio-economic countries in the world. The U.S. ranks first out of 178 countries in the number of firearms privately owned (Odom-Forren, 2016). Guns manufactured in the U.S. do not need to pass federal safety standards.

Gun violence affects all New Yorkers. People of color, women and children are particularly vulnerable. It plays a significant role in many cases of domestic violence, and this can spill over into other settings including healthcare facilities. 

Gun violence is intertwined with domestic abuse and violence against women. Women who are victims of domestic violence are five times more likely to be killed by their abuser if the abuser owns a gun. During an average month, 50 women are shot to death by intimate partners in the U.S. (Federal Bureau of Investigation, Supplementary Homicide Reports, 2010-2014. The extent of the risk is also evident by the fact that, in New York State, there are roughly 300,000 orders of protection issued per year. 

Screening and counseling for violence against women in primary care settings recommendations wer published in the May 2013 issue of Nursing Outlook urging health care providers to screen and counsel all women for interpersonal violence and domestic violence.  

Gun violence effects people of color disproportionately. The New York State Nurses Association (NYSNA) condemns any and all abhorrent racially-motivated shooting deaths. Black Americans killed by police are twice as likely to be unarmed as white people. While racial minorities make up about 37.4 percent of the general population in the US and 46.6 percent of armed and unarmed victims, they are 62.7 percent of unarmed people killed by police. (The Guardian, June 2, 2015).

Gun violence has a huge impact on children. Children are the victims of numerous shootings. They can also be involved in accidental shootings of other children, with three year olds one of the largest groups likely to be involved. On average, seven children and teens are killed with guns in the U.S. every day (Everytown for Gun Safety, Gun Violence by the Numbers, 2018). While just looking at school shootings, since the 2012 attack at Sandy Hook Elementary School, there have been 400 school shootings (Jugal K. Patel, New York Times, February 15, 2018).

According to a new federal study, guns are the third leading cause of death of those aged 1 to 17 years, outpaced only by unintentional injuries such as car crashes and drowning, and illnesses like cancer. Approximately 19 children are killed or injured from gunshot wounds each day in the United States, making guns the second leading cause of injury-related deaths of children in the U.S., exceeded only by car accidents. On average 1297 children under the age of 18 die from gunshot wounds each year (Fowler, Dahlberg, Haileyesus, Gutierrez, & Bacon, 2017).

The issue of gun violence is increasingly viewed as a public health issue and nurses have a role in discussing firearm related issues with their patients and communities. Families will ultimately decide what is best for their families, but health care practitioners can make sure that families understand the risks and know how to reduce those risks. 

The Costs of Gun Violence

Researchers conservatively estimate that gun violence costs the American economy at least $229 billion every year, including $8.6 billion in direct expenses for emergency response and medical care. The total bill includes legal costs, police costs for investigations, security improvements and needs, prison costs and mental health needs. (Giffords Law Center, 2018).

Many of these costs are shouldered by taxpayers, or transferred to the public in the form of higher prices for goods or services. The costs for medical care are an additional financial burden on hospitals, long term care facilities and the healthcare system overall. 

Non-monetary costs are also significant. The subsequent effects of trauma and PTSD related to gun violence are pronounced, particularly among children. Urban area studies have shown that 52% of urban youth exposed to violence have severe PTSD symptoms, while over 80% have at least some PTSD symptoms. Other studies have found that 27% of children living in violent urban areas met the official diagnostic criteria for PTSD (Giffords Law Center 2018). 

Regarding statistics related to gun violence it should be noted that the NRA and gun manufacturers have fought consistently to make it more difficult to collect accurate data. Therefore, statistics on incidents and costs are likely underestimated. More than 100 medical organizations asked Congress in 2016 to lift the Dickey Amendment, one of the measures that makes researching and collecting data on gun violence difficult. In 2018 the CDC announced that it would restart data collection, but continued vigilance will be needed to insure that research continues. The President’s Budget for Fiscal Year 2019 proposed a cut of $19.2 million, or 6.7%, from Fiscal Year 2017 levels for the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, responsible for leading research on violence prevention.

Hospitals as Targets for Gun Violence

While NYSNA addresses active shooter situations in a separate statement, there are a range of weapons-related incidents that occur in hospitals. Some of them involve an individual shooter and individual target, such as a family member or gang member. Others are akin to the mass shootings experienced in other settings. There are two major considerations regarding these incidents in healthcare facilities. First, healthcare facilities are already subject to routine violence directed at staff. While the reasons for this are too numerous to investigate here it should be pointed out that the many pressures on the delivery of quality care, such as inadequate RN staffing, play a significant role in increasing the risk of violence.

Hospitals are also often considered “soft” targets, as the majority of staff do not anticipate violent situations. Access can be easier, because hospitals are open 24/7, commonly have very liberal visitation policies and usually have little or no access control. Underreporting by doctors and nurses eager to please patients and improve patient satisfaction scores often exacerbates this problem; however, NYSNA believes that patient experience should never trump the staff’s safety.

The Role of the Nurse Regarding Gun Violence

The nurse’s role in prevention and mitigation of gun violence begins with recognizing risks both at the individual and community level. The nurse works with other health professionals to perform community needs assessments to ascertain the pre-existing prevalence of disease, the susceptibility of health facilities, and identification of vulnerable populations, such as those with chronic disease, mental health problems, or disability. This information provides valuable data that can be used in the development of disaster response plans (Alfred, et al., 2015; ICN, 2009).

The nurse collaborates in developing plans for alternative housing and other interventions designed to diminish the vulnerability of these populations. Participation in risk reduction activities in health care facilities to create safe and sustainable environments for care or identifying alternative sites for care following a disaster is another activity that necessitates the expertise of the nurse. The nurse helps to plan for the evacuation of health facilities and relocation of patients as required by working in collaboration with other health care providers and leaders in the community.

Another important role of the professional registered nurse is helping to shape public policy that will decrease the consequences or potential effects of a disaster. The nurse’s knowledge of the community and areas of vulnerability contribute to policy development. Working with policy-makers to identify hazards, the risk such threats pose to the population, and health organizational structure to develop solutions that decrease the risk are all part of nursing’s role. Nurses also bring expertise to ongoing community education related to identification and elimination of health and safety risks in the home or community (Alfred, et al., 2015; ICN, 2009).

Nurses have a key role to play in education and awareness – and more work is needed on this front. A Medscape Medical News poll reported that at least 65% of healthcare providers who responded view gun violence as a public health threat. (Medscape Medical News, December 2017). This number is higher than it would have been in the past, but more work is needed to insure that an overwhelming majority of healthcare providers recognize this public health threat.

At the same time, relatively few physicians and nurses are having conversations with their patients about gun hazards. Forty-five percent of physicians and 39% of nurses said they had never had those discussions with patients. That may be related to the low confidence both groups reported in their readiness to have such conversations. Fewer than half of physicians and nurses (38% vs 47%) said they felt “very prepared” to discuss gun safety with patients. The answer “not at all prepared” was selected by 26% of physicians and 29% of nurses. (Medscape Medical News, December 2017).

Nurses working in the school, community, and emergency and psychiatric mental health settings can play a key role in the prevention of violence by understanding the dynamics and profiles behind these types of homicides. The highly variable nature of specialty areas, such as behavioral health, operating rooms, neonatal intensive care units, and MRI suites, calls for special planning and drills to address specific threats. Engaging in reality-based training simulates the incident and addresses the cold, hard fact that the shooter has the tactical advantage. Nursing response and messaging can be simulated to replace panic with confidence.

Ethical Considerations

Healthcare professionals have a duty to care for the patients for which they are responsible. Since incidents such as an active shooter scenario are highly dynamic, some ethical decisions may need to be made to ensure the least loss of life possible. Every reasonable attempt to continue caring for patients must be made, but in the event this becomes impossible without putting others at risk for loss of life, certain decisions must be made (Healthcare and Public Health Sector Coordinating Council, 2015).

The following guidelines are meant to provide issues to consider when making difficult decisions, prompt meaningful discussions, and prepare those who might be involved in such an incident before it ever happens (Healthcare and Public Health Sector Coordinating Council, 2015; Maryniak, 2016):

• Allocate resources fairly with special consideration given to those most vulnerable
• Limit harm to the extent possible. With limited resources, healthcare professionals may not be able to meet the needs of all involved
• Treat all patients with respect and dignity, regardless of the level of care that can continue to be provided them
• Prepare to decide to discontinue care to those who may not be able to be brought to safety in consideration of those who can
• Realize some individuals who are able to avoid the incident will choose to remain in dangerous areas. Consider how to react to those situations

RECOMMENDATIONS

The New York State Nurses Association recommends:

1. Treating gun violence as the epidemic that it is, and supporting and advocating for full-scale research into its causes and prevention – whether by the CDC or other reputable organizations. We oppose the Dickey Amendment and support all efforts to expand gun violence data collection and analysis.

2. Establishing policies and security practices that can reduce the risk of active shooter incidents in healthcare facilities and schools.
3. Evaluating staffing patterns and other causes of delay in patient care, with the intent of reducing the potential incidence of conflict and subsequent violence.
4. Supporting education programs designed to educate nurses and the public on the most effective ways to reduce the risk of gun violence.
5. Supporting organizations that educate and advocate around the issue of preventing domestic violence.
6. Expanding licensure to encompass all gun owners, and requiring that all applicants must, as a condition of licensure:
   
   • Be at minimum 21 years of age.
   • Undergo both fingerprint and name-based background checks.
   • Complete a safety instruction course and prove competency.
   • Present proof of liability insurance coverage.

7. Supporting gun control measures, locally and nationally, that experts cite as effective, including banning assault weapons, semiautomatic guns, high capacity magazines barring sales to convicted stalkers and people deemed dangerous by mental health providers; and processing universal checks for gun and ammo buyers. 
8. Supporting the establishment of gun amnesty programs to encourage the voluntary relinquishment of guns, especially those programs resulting in the destruction of the gun.
9. Developing and promoting programs and policies that give healthcare providers the resources they need discuss gun safety and violence with their patients, and advocate around gun violence in general.
10. Increase access to mental health programs for individuals, families, and students from elementary school through college.
11. Include a gun safety assessment as part of routine health screenings for all patients.

References

Alfred, D., Chilton, J., Connor, D., Deal, B., Fountain, R., Hensarling, J., & Klotz, L. (2015). Preparing for disasters: Education and management strategies explored. Nurse Education in Practice, 15, 82-89.

The Guardian, June 2, 2015. Black Americans killed by police twice as likely to be unarmed as white people.

Centers for Disease Control. (2018). Retrieved from https://www.cdc.gov/injury/wisqars/facts.html.

Everytown for Gun Safety. (2018). Gun Violence by the Numbers. Retrieved from https://everytownresearch.org/gun-violence-by-the-numbers/.

Everytown for Gun Safety (2018). Mass Shootings in the United States: 2009 – 2016. Retrieved from https://everytownresearch.org/reports/mass-shootings-analysis/.

Federal Bureau of Investigation. (2010 – 2014). Supplementary Homicide Report.

Fitzpatrick, K. M., & Boldizar, J. P. (1993). The prevalence and consequences of exposure to violence among African-American youth. Journal of the American Academy of Child & Adolescent Psychiatry, 32(2), 424-430.

Fowler, K. A., Dahlberg, L., L., Haileyesus, T., Gutierrez, C., & Bacon, S. (June, 2017). Childhood firearm injuries in the United States. Pediatrics, 140(1), e20163486. http://dx.doi.org/10.1542/peds.2016-3486.

Frellic, M. (December 28, 2018).  Most healthcare providers see gun violence as public threat. Medscape Medical News. Retrieved from https://www.medscape.com/viewarticle/890677/.

Giffords Law Center to Prevent Gun Violence. (2018) Protecting the Parkland Generation, Strategies to keep America’s kids safe from gun violence. Retrieved from http://lawcenter.giffords.org/wp-content/uploads/2018/03/Protecting-Parkland-Generation_3.9.18.pdf.

Healthcare and Public Health Sector Coordinating Council. (2015). Active shooter planning and response in a healthcare setting. Retrieved from https://www.fbi.gov/about-us/office-of-partner-engagement/active-shooter

Kelen, G. D., Catlett, C. L., Kubit, J. G., & Hsieh, Y.H. (2012). Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine, 60(6), 790-798.

Lehman-Huskamp, K. (2015). Active shooter in the hospital setting: Are you prepared? Retrieved from http://www.cardinalglennon.com/Documents/continuingeducation/2015-pediatric-trauma-conference-active-shooter-in-the-hospital-setting.pdf

Marynik, K. (2016). The nurse’s role in active shooter and mass casualty incidents. Retreived from https://lms.rn.com/getpdf.php/2184.pdf

Odom — Forren. J. (2016). Gun violence: A public health and nursing concern. Journal of PeriAnesthesia Nursing, 31(4), 285 – 288.

Patel, Jugal, K. (February 15, 2018). After Sandy Hook, more than 400 people have been shot in over 200 school shootings. Retrieved from https://www.nytimes.com/interactive/2018/02/15/us/school-shootings-sandy-hook-parkland.html.

Pelto, C. (2010). Code black: Hospitals as terrorist targets. Journal of Counterterrorism & Homeland Security International, 16(1), 28-32.

Springer, C. & Padgett, D. K. (2000). Gender differences in young adolescents’ exposure to violence and rates of PTSD symptomatology. American Journal of Orthopsychiatry 70(3), 370.

Violent death rates: the U.S. compared with other high-income OECD countries, 2010. Am J Med. 2016;129(3):266-273 pmid: 26551975.

Zhang, S. (February 15, 2018). Why can't the U.S. treat gun violence as a public-health problem? The Atlantic. Retrieved from https://www.theatlantic.com/health/archive/2018/02/gun-violence-public-health/553430/.