While an official count is unavailable, at least one analysis suggests 2020 was one of the deadliest on record with respect to gun violence.1 Relying on data from the Gun Violence Archive (2012-2020) and the CDC (1999-2019), the Everytown for Gun Safety Support Fund reported firearms-related homicides and nonsuicide-related shootings resulted in more than 19,000 deaths in 2020, a 25% increase from 2019.1 Ultimately, the authors noted that when all the numbers are tallied it is likely the information will show that more 40,000 people died last year, a figure that, if confirmed, will represent the highest rate of gun deaths in 20 years.1

Pointing to such data, several healthcare organizations believe it is time for healthcare professionals to do what they can on the prevention front to identify patients at risk, leverage those encounters to promote safety, and address access to firearms when that is a concern. However, admitting there are knowledge gaps when it comes to firearms-related counseling, there are new efforts to shore up medical education in this area.

For instance, clinicians from the Johns Hopkins Center for Gun Violence Prevention and Policy have collaborated with experts across the United States to establish priorities on firearms education and to set standards for continuing medical education.2 In a similar vein, the Emergency Nurses Association (ENA) has unveiled new resources aimed at helping clinicians most effectively intervene when they have a patient who is at risk.3

“Our patients are dying of gun violence and gun injuries. We as clinicians of all types and of all disciplines are ill-equipped to address risk factors for violence and mechanisms for prevention because, to a large degree, we lack education and training,” explains Katherine Hoops, MD, MPH, an assistant professor of anesthesiology and critical care medicine at Johns Hopkins University.

Hoops says only about 20% of clinicians receive any kind of training on firearm injuries or injury prevention during their medical education. “When you consider that this is one of the leading causes of death in adults and children, that really doesn’t make a whole lot of sense, that our medical curricula don’t match what is a huge burden of disease and mortality in our patients,” she says.

Gun violence is a hot-button issue that can make clinicians reluctant to broach the subject with patients. Hoops suggests that for many clinicians, some of this discomfort likely is related to their lack of training. “If we encounter a gun-owning patient, we are worried about engaging in these conversations [if] we ourselves don’t have any technical familiarity with firearms,” she says.

Further, some clinicians are worried they will encounter resistance from patients, and possibly even fracture their relationship with some of them over counseling on the topic of firearms. Still, Hoops says that should not stop clinicians from addressing the issue. “We counsel on a lot of potentially divisive and inflammatory subjects. We approach all of those hard conversations with humility and with respect for all perspectives,” she says. “When we do that, coupled with good education and knowledge of what works and what doesn’t, then we can break down a lot of those barriers between us and our patients.”

Hoops observes the American Academy of Pediatrics has recommended screening and counseling about firearm access and safe storage.4 How each physician wants to approach screening and counseling is individualized. “I am a pediatric intensivist in my clinical life. The setting in which I will counsel patients looks very different from how my colleagues in general pediatrics will counsel their patients or how an emergency provider will counsel [his or her] patients,” Hoops shares. “We need to appreciate better who is at risk, what the risk factors are, what the contexts are in which people choose to own firearms, and then better understand each individual patient and where they are coming from in order to provide the best counseling that is tailored to their specific situation.”

To develop the curriculum, Hoops and colleagues assembled a group of subject matter experts from medicine, nursing, and public health.5 Combing through the literature, the group established categories of content identified in published research as highly relevant to firearm injury education, including intimate partner violence, peer violence, mass violence, suicide, and unintentional injury. The group also created another category that focuses on general content that is relevant to all types of gun injuries.

Training should enable clinicians to be able to describe fatal and nonfatal firearm injury epidemiology and to recognize the basic types of firearms and ammunition. The content also covers topics related to firearm access, ownership, transfer, and usage. Ultimately, clinicians should be able to provide effective counseling to their patients on firearm injury prevention, including topics such as safe gun storage. Additionally, regarding the issue of suicide, the curriculum covers the epidemiology of suicide and suicide attempts related to firearms, and offers guidance on how to assess for suicide risk and appropriately respond when patients are at risk.

“One of the most common scenarios that I see now for providing this type of counseling in my daily practice is for adolescents who present after a suicide attempt,” Hoops observes. “We know that firearms carry a very high case fatality rate — 80% to 90% or more. When youth can access firearms and attempt suicide by firearms, they are much more likely to die.”

Consequently, whenever Hoops encounters an adolescent who has made a suicide attempt by whatever means, it is a routine part of her practice to always screen for access to firearms. “We know that the majority of firearms used in suicide come from the home [of the adolescent] or the home of a close friend or family member,” she states. “If [the adolescent] does have access to a firearm, then I, with their permission, talk to their adult caregiver or one of their family members to try to come up with a solution for safe storage ... either storing it elsewhere away from the home or getting access to a safe storage/locking device.”

Regarding youth suicide, the issue is gun access, not ownership, according to Hoops. “Even if that youth is not the direct owner of the firearm, [in Maryland] we can still petition the court to remove firearms from the home if we believe they are at imminent risk of harming themselves,” she reports. “One of the things that we do highlight in the curriculum is how clinicians need to become more aware of state and local policies that they can leverage to protect their patients.”

Hoops stresses the curriculum is not just for physicians, but rather is intended to drive education for many medical disciplines and clinical practice settings. “I believe that if we are going to make a difference in this area, this requires an all-hands-on-deck approach,” she says. “If we think that this counseling and intervention would be best provided in a particular ED or other setting by a case manager, social worker, or an advanced practice provider, that is a very institution- or practice-specific question. Each one will know what is right for their setting, but all of us are responsible for knowing and understanding the material.”

Unfortunately, there is no consensus about what the role of emergency nurses should be in the realm of firearms safety, explains Lisa Wolf, PhD, RN, CEN, FAEN, director of the Institute of Emergency Nursing Research at ENA. “Like with other nationwide organizations, there is a wide variety of opinions on this ... but I think we may be getting closer to the idea of firearms safety as a public health issue,” she predicts.

The ENA’s Firearms Injury Prevention Education program includes a webinar, online learning modules, and a podcast series that delve into how to identify patients at risk, and what steps emergency nurses can take to reduce the chance such patients will encounter harm from firearms.3 “There is definitely an opening or a space where we can view gun safety as separate from owning guns,” Wolf says. “[We can] give people the tools to have firearms in a way that reserves them for their stated purpose of sports shooting or hunting ... and provide the parameters so that they can make sure that the people around them are not injured by the firearm.”

Wolf stresses there are large swaths of people who come to the ED who are at high risk of injury if firearms are accessible. These include patients with suicidal ideation, victims of intimate partner violence, the geriatric population, and children. “These are four very specific groups that we need to assess [for access to lethal means],” Wolf observes.

However, in research on the subject, Wolf and colleagues discovered nurses are fearful that bringing up the subject of firearms may result in anger or even violence.6 To circumvent this problem, Wolf advises nurses begin any such discussion in the context of safety as opposed to asking patients first whether they own firearms. “If you assume the patient has a gun, then it becomes less of an inquisition and more of a collaborative planning situation,” she says. “This is a real threat to safety, especially for children.”

When parents understand clinicians ask everyone about firearms access, it becomes less of a divisive issue, particularly if providers explain firearms are a significant cause of injury in young children. “In the case of a suicidal patient or a patient presenting with concerns around intimate partner violence, this is a calculus. We have to know where it is safe for this patient to go. It is a critical piece of information for discharge planning,” Wolf says.

Wolf advises EDs to designate a person who can delve more deeply into firearms safety/access issues with patients who are at high risk. This may be a role for a social worker or case manager who works in the emergency environment or a behavioral health professional who can respond to the ED when the need arises.

REFERENCES

  1. Everytown for Gun Safety Support Fund. Gun violence and COVID-19 in 2020. May 7, 2021.
  2. The Johns Hopkins Center for Gun Violence Prevention and Policy. About us.
  3. Emergency Nurses Association. Emergency Nurses Association debuts Firearms Injury Prevention Education program. April 14, 2021.
  4. Naureckas Li C, Sacks CA, McGregor KA, et al. Screening for access to firearms by pediatric trainees in high-risk patients. Acad Pediatr 2019;19:659-664.
  5. Hoops K, Fahimi J, Khoeur L, et al. Consensus-driven priorities for firearm injury education among medical professionals. Acad Med 2021; Jul 6. doi: 10.1097/ACM.0000000000004226. [Online ahead of print].
  6. Wolf LA, Delao AM, Perhats C, et al. Emergency nurses’ perceptions of risk for firearm injury and its effect on assessment practices: A mixed methods study. J Emerg Nurs 2019;45:54-66.e2.