AACN Position Statement: Raising the Standard of Care for the Disease of Firearm Injury

Aug 14, 2024

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Background:

"RUN, HIDE, FIGHT" is the text message commonly sent to U.S. students during an active shooter event, and many children are taught this tactic in primary school.1 "RUN, HIDE, FIGHT" has been the U.S. government's most consistent message to students regarding firearm violence since 2013.2 Yet, in 2021 firearms became the leading cause of death for children and adolescents.3,4 This terse advice is helpful for all age groups in a crisis situation. However, widespread use of evidence-based practice to define firearm injury as a disease and create prevention protocols for both children and adults has been tragically lacking.

Media reports of mass shootings create public trauma, but result in few significant changes. The number of mass shootings in 2023 totaled 655, compared with a total of 335 in 2018.5 Sadly, the vast majority of firearm injuries and death take place daily, in many neighborhoods across the United States, and more than half are the result of suicide.6,7 There were estimated to be 43,137 all-cause firearm deaths in 2023.5Whether public or private, self-inflicted or interpersonal, the disease of firearm injury is a leading cause of mortality and long-term physical and psychological suffering.

Legislative or policy proposals to curb firearm use polarize U.S. communities.8 This polarization has hindered public health officials, scientific researchers, and healthcare professionals from treating firearm injury and death as the widespread, preventable disease that it is. There is consensus among leading national professional associations that firearm injury is a major public health crisis that damages the health of individuals, families, and both rural and urban communities.9

Acute and critical care nurses frequently care for patients with firearm injury and their families — and nurses are excellent communicators who can lead research, implement evidence-based interventions, and foster interdisciplinary dialogue to confront this challenge.10 The holistic perspective provided by nursing can help unravel the many intricate threads that lead to firearm violence. These factors include hate, racism, and misogyny, and also inequity, poverty, fear, and hopelessness. Nurses are highly skilled in teaching patients how to prevent diabetes or cardiac events, and can take a similar role in the prevention of firearm injury. If we are to prevent this disease, we must identify and disseminate approaches that move beyond "RUN, HIDE, FIGHT."

AACN's Position

Healthcare institutions and clinical providers must raise the standard of care for firearm injury. Preventive measures, treatment, and follow-up care should be done in a manner similar to that of other widespread deadly diseases. Action should include incorporation of trauma-informed care, collaboration with local community organizations, mental health support, and non-judgmental conversations about preventive practices. Nurses can be effective leaders in changing the dialogue surrounding this issue and must be provided the time, training, and resources to do so.

Recommended Actions for Healthcare Institutions:

  • Fully embrace the fact that healthcare systems deal with the effects of firearm violence every day and use institutional data and resources to create evidence-based responses.11
  • Treat firearm injury as a widespread and preventable disease, and take responsibility for screening and prevention — as is done with of other deadly diseases such as heart disease and cancer.
  • Recognize that prevention of firearm injury and associated admissions and readmissions can have a beneficial effect on institutions' financial status and community standing.12
  • Establish a firearm injury prevention committee to set priorities using institutional data, create policies, allocate resources, and deploy staff education. Ensure the committee is intentionally diverse and contains healthcare workers from many disciplines as well as residents of the surrounding community.
  • Develop protocols and provide training on how to dialogue with patients to evaluate social and emotional determinants of health, including a history of traumatic events.13
  • Maintain adequate staffing levels that enable nurses and other health professionals to obtain firearm injury prevention training and to spend time providing preventive and trauma informed care and education for patients.
  • Build healthcare providers' skills in routinely discussing firearm ownership and safety practices with patients and family members (similar to smoking or infant car seat assessment and education) before discharge.
  • Partner with community organizations to provide firearm owners with easy-to-use firearm safety locks, especially for homes with children and adolescents, or those with family members dealing with cognitive impairment or dementia.
  • Support community and school-based interventions such as mental health support in your area to address public health risk factors of violence.
  • Institute systemwide collaboration, work with other healthcare organizations including those promoting mental health, and reach out to sectors beyond healthcare to help prevent firearm injury.
  • Provide healthy and supportive work environments for healthcare professionals dealing daily with gunshot wound patients, and in the wake of mass shooter events or other emotionally charged situations related to firearm injury. Offer easily accessible mental health services and debriefing sessions to engage staff in implementing lessons learned.

Recommended Actions for Nurses:

  • Keep up-to-date on how best to provide clinical care and psychosocial support for patients with firearm injury and their families.
  • Learn more on how to treat the long-term morbidity associated with firearm injury since readmissions for complications related to gunshot wounds are quite high.
  • Provide trauma informed care and help obtain mental health assistance for patients and families when needed. In addition to the severe physical injuries related to firearm use, these injuries often have a negative psychological impact on patients, their families, and the nurses providing care.
  • Seek emotional support for yourself in the wake of mass casualty events or repeated exposure to the emotional burden connected with firearm injury.
  • Consider participation in gun violence research and apply for funding.14
  • Seek out or create clinical resources and content on how to talk with families and patients about firearm injury, provide trauma-informed care, and discuss preventive measures.
  • Use carefully crafted language and statistics based on public health messaging to talk about firearm injury with patients, families, and others — and make sure that polarizing "gun control" terminology does not color the public health message.15
  • Monitor and support legislative actions you believe are appropriate to reduce violence and firearm injury. AACN supports legislation to fund firearm injury research.16
  • Understand that the purchase of firearms and ammunition may mean a person feels unsafe. This may help support non-judgmental discussions with patients and others about firearm safety and injury prevention, particularly with those who may feel threatened due to gender identity, race, ethnicity, income, or geographic location.17
  • Investigate whether your state has secure storage laws to prevent child access to firearms in the home, or extreme risk protection order ("red flag") laws that enable law enforcement to confiscate firearms from individuals deemed a risk to themselves or others. Learn how to use these laws if you think a patient, family member, or child is in jeopardy.

References

  1. Bisset V, Hassan J. Shock, concern over text that encouraged MSU students to 'Run, Hide, Fight.' The Washington Post. February 14, 2023. Accessed April 24, 2024. https://www.washingtonpost.com/nation/2023/02/14/msu-shooting-run-hide-fight-sms/
  2. Guide for Developing High-Quality School Emergency Operations Plans. U.S. Department of Education, Office of Elementary and Secondary Education, Office of Safe and Healthy Students; 2013. Accessed April 24, 2024. https://www.dhs.gov/sites/default/files/publications/REMS%20K-12%20Guide%20508_0.pdf
  3. Goldstick JE, Cunningham RM, Carter PM. Current causes of death in children and adolescents in the United States. Letter. N Engl J Med. 2022;386(20):1955-1956. Accessed April 24, 2024. https://www.nejm.org/doi/full/10.1056/NEJMc2201761
  4. Kaufman EJ, Richmond TS, Hoskins K. Youth firearm injury: a review for pediatric critical care clinicians. Crit Care Clin. 2023;39(2):357-371. Accessed April 24, 2024. https://doi.org/10.1016/j.ccc.2022.09.010
  5. Past summary ledgers. Gun Violence Archive. 2024. Accessed April 24, 2024. https://www.gunviolencearchive.org/past-tolls
  6. Means matter. Harvard T.H. Chan School of Public Health. Accessed April 24, 2024. https://www.hsph.harvard.edu/means-matter/
  7. Gramlich J. What the data says about gun deaths in the U.S. Pew Research Center. February 3, 2022. Accessed April 24, 2024. https://www.pewresearch.org/fact-tank/2022/02/03/what-the-data-says-about-gun-deaths-in-the-u-s/
  8. Amid a series of mass shootings in the U.S., gun policy remains deeply divisive. Pew Research Center. April 20, 2021. Accessed April 24, 2024. https://www.pewresearch.org/politics/2021/04/20/amid-a-series-of-mass-shootings-in-the-u-s-gun-policy-remains-deeply-divisive/
  9. Kaufman EJ, Richmond TS. Beyond Band-Aids for bullet holes: firearm violence as a public health priority. Crit Care Med. 2020;48(3):391-397. https://doi.org/10.1097/CCM.0000000000004147
  10. Richmond TS, Foman M. Firearm Violence: A Global Priority for Nursing Science. J Nurs Scholarsh. 2019;51(3):229-240. https://doi.org/10.1111/jnu.12421 PMID: 30215887
  11. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice, Wojtowicz A, French M, Alper J, eds. Health Systems Interventions to Prevent Firearm Injuries and Death: Proceedings of a Workshop. National Academies; 2019. https://doi.org/10.17226/25354
  12. Spitzer SA, Vail D, Tennakoon L, Rajasingh C, Spain DA, Weiser TG. Readmission risk and costs of firearm injuries in the United States, 2010-2015. PLoS One. 2019;14(1):e0209896.doi:10.1371/journal.pone.0209896
  13. Hope AA, Munro CL. Dialogue as a disruptive discourse oriented toward justice. Am J Crit Care. 2020;29 (6):415-417. https://doi.org/10.4037/ajcc2020334
  14. National Institute of Nursing Research. Research funding opportunities. National Institutes of Health. Accessed August 10, 2023. https://www.ninr.nih.gov/researchandfunding/fundingopportunities
  15. Betz ME, Harkavy-Friedman J, Dreier FL, Pincus R, Ranney ML. Talking about "firearm injury" and "gun violence": words matter. Am J Public Health. 2021;111(12):2105-2110. doi:10.2105/AJPH.2021.306525
  16. Gun violence research. American Association of Critical-Care Nurses. Accessed August 10, 2023. https://www.aacn.org/policy-and-advocacy/~/media/aacn-website/policy-and-advocacy/legislation-regulatory/gun-research.pdf?la=en
  17. Wu TY, Hsieh HF, Chow CM, Yang X, Resnicow K, Zimmerman M. Examining racism and firearm-related risks among Asian Americans in the United States during the COVID-19 pandemic. Prev Med Rep. 2022;27:101800. https://doi.org/10.1016/j.pmedr.2022.101800
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