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Original Research: Nurses' Knowledge and Comfort with Assessing Inpatients' Firearm Access and Providing Education on Safe Gun Storage

Sheppard, Kimberly Smith BSN, RN; Hall, Kathryn MS, RN, ANP-BC, NE-BC; Carney, Julia MS; Griffith, Catherine PhD, RN; Rudolph, Meaghan MS, RN, PMHCNS-BC; Zelinsky, Megan MPA, MSW; Gettings, Elise MPH, BSN, RN

Author Information
AJN, American Journal of Nursing: September 2020 - Volume 120 - Issue 9 - p 26-35
doi: 10.1097/01.NAJ.0000697636.34423.45
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Gun violence is a complex public health issue that may affect anyone at any time. In 2018 (the most current year for which data are available), 39,740 people were killed by firearms in the United States.1 Of these deaths, 24,432 were due to suicide, 14,497 were due to homicide and legal intervention, and 458 were unintentional.1 The following scenarios can happen in any community: a child finds an unlocked loaded gun and accidentally shoots themselves or someone nearby, a despondent teenager makes a rash decision to end their life with the family gun, a homeowner mistakes a family member for an intruder. The immediate and ripple effects of these incidents are staggering: the loss of life, the lasting impact of nonfatal injuries, grief and bereavement among family members and friends, psychological and emotional trauma among surviving victims and their loved ones. Yet such tragedies are preventable.

Nurses are particularly well positioned to lead patient-directed educational initiatives aimed at increasing awareness of safe gun storage. National nursing associations have initiated discussion regarding nursing policy on this important topic, including the American Academy of Nursing, which recently urged congressional leadership to launch a bipartisan National Commission on Mass Shootings, with recommendations to support “enriched training of health care professionals to assume a greater role in preventing firearm injuries by health screening.”2 But more research is needed in order to better understand clinicians' current comfort levels in this area and improve the training curricula on how to educate patients.

Nurses spend more dedicated in-person time with hospitalized patients than many other providers, allowing them to develop significant, trusting relationships with their patients. Thus, nurses have unparalleled opportunities to educate patients on safe gun storage and help patients and families to create safer home environments. Yet hospital-based policies and protocols designed to support nurses' ability to do so are generally lacking.3, 4 Furthermore, nurse-specific barriers to assessing firearm access and providing education on safe gun storage are poorly understood.

Study purpose. This study sought to examine hospital nurses' knowledge about firearm safety and current state law, as well as their comfort with assessing their patients' access to firearms and providing education on firearm safety and storage. Facilitators and barriers to such assessment, as well as best educational practices, were also explored. The specific research questions were:

  • What are nurses' knowledge and education levels regarding firearm safety and current state law?
  • What are nurses' comfort levels with asking patients about firearm access and providing education on safe gun storage?
  • What are facilitators and barriers to asking patients about firearm access and safe gun storage?
  • What are best methods for nurse and patient education on this topic?

BACKGROUND

Several earlier studies have shown that, in clinic and ED settings, educating patients and parents or primary caregivers on safe gun storage is effective in changing behavior toward limiting access to firearms, thereby promoting a safer home environment.5-12 But to our knowledge, studies exploring the effectiveness of providing such education to hospital inpatients are lacking. An important first step is to ascertain what hospital nurses currently know and how comfortable they feel in assessing their patients' access to firearms and providing education on safe gun storage.

Two studies have specifically explored ED nurses' perceptions and knowledge in these areas. Wolf and colleagues evaluated more than 1,400 ED nurses' perceptions of patient risk for firearm injury and considered how these perceptions influenced patient screening, assessment, and counseling.4 Primary findings suggested that fear of potential violence from patients limited consistent screening of firearm access. The findings also supported the need for more nursing education and resources on this topic. Grossman and colleagues surveyed 527 ED nurses about their experiences with suicidal adolescents, as well as their knowledge of, training in, and attitudes toward means restriction and their practice in providing relevant education to parents.3Means restriction was defined as “a risk-reduction strategy designed to prevent suicide by modifying the environment through restricting access to common means of suicide completion or attempts.”3 The study results demonstrated that, although most nurse respondents had had recent experiences with suicidal adolescent patients, only 24% had received training on means restriction and only 28% had educated parents about limiting access to lethal means of suicide. Only 18% of the respondents reported that providing means restriction education to parents was standard unit practice.

In another study, Khubchandani and colleagues surveyed 64 directors of graduate psychiatric nursing programs, and found that 87% had not considered providing students with training on firearm injury prevention.13 Nearly half (48%) reported that they didn't routinely screen their patients for firearm ownership, and 66% felt that curriculum guidelines on firearm injury prevention should be provided by the American Psychiatric Nurses Association.

Although the relevant research specific to nurses is scant, these studies highlight the need for more nursing education and training in assessing patients' access to firearms and providing essential education. Moreover, the available research exposes knowledge gaps in these areas across nursing specialties and work environments, notably in the hospital setting.

METHODS

Study design and sample. The study used a cross-sectional design. All staff nurses working on an inpatient adult general medical unit and an inpatient adult psychiatric unit at an academic medical center in the northeastern United States were invited to participate. The study included a survey as well as optional participation in a private, semistructured interview. This article covers the survey findings only; results from the private interviews will be shared elsewhere.

At present, questions pertaining to firearm access and safe gun storage are not included in the nursing assessment intake for adult inpatients at this institution, with the exception of those admitted to the psychiatric unit. The psychiatric unit was selected for this study because we wanted to elicit the perspectives of nurses who have experience asking questions in these areas. The medical unit was selected to elicit the perspectives of nurses who don't routinely ask such questions.

After approval was obtained from the study site's institutional review board (IRB), the principal investigator (one of us, KSS) met with nursing leadership from both units to discuss the study in detail and confirm unit participation. A total of 89 nurses (42 on the medical unit and 47 on the psychiatric unit) received an e-mail that included a study overview and a link to the online survey, which was conducted via Research Electronic Data Capture (REDCap) software. Flyers about the study were also posted on both units. Per the IRB, completion of the survey implied consent. Participants received a $10 gift card for completing the survey.

Instrument. For this study, we created a 22-item survey that was based on a review of the literature, existing questionnaires that have been used in mixed clinician cohorts, and current clinical practice. The content was revised several times until the team reached agreement on the final version. The survey was not tested for face validity or reliability. Future psychometric evaluation of the survey is planned.

At the time of study development, no survey designed to assess nurses' knowledge and comfort with asking inpatients about firearm access and safe gun storage had been published. For the purpose of this study, we tailored the survey such that it covered five domains. Domain 1, demographics, included questions pertaining to age, education, and employment. Domain 2, firearm knowledge and education, included items pertaining to state law on safe gun storage, as well as education and training in firearm safety and storage. Domain 3, current practice, included questions about current assessment practice regarding patients' access to guns. Domain 4, nursing comfort with assessing firearm safety and storage, included questions about nurses' comfort with asking patients about their firearm access and with educating patients on safe gun storage. Items in this domain also explored perceived facilitators and barriers to such assessment and education, as well as attitudes toward learning strategies that might help nurses feel more comfortable in these areas. Domain 5, patient education on safe gun storage, included questions pertaining to providing patient education on this topic. Most items were answerable as yes–no or multiple choice with several prepopulated response options. Some included an “other” option that allowed participants to write another response. No data that would make respondents identifiable were collected. For the survey itself, see the Survey Instrument at https://links.lww.com/AJN/A174.

Data analysis. The survey data were exported from REDCap to JMP Pro 12 statistical software for analysis. Descriptive statistics were computed to analyze responses for each survey item and reported as percentages. Data were analyzed for the entire study cohort and also by unit in order to determine differences and similarities in nurse responses by unit.

RESULTS

Sample. A total of 42 nurses completed the survey, with 21 from each unit, for an overall response rate of 47%. Of all participants, 71% were between the ages of 20 and 40 years, and 93% were female. Seventy-nine percent reported their highest educational degree was a bachelor's degree, and 38% had four or fewer years of experience as a nurse. For more details on participant demographics, see Table 1.

Table 1.
Table 1.:
Demographic Characteristics of Study Participants

Nurses' knowledge and training regarding firearm safety and safe gun storage. More than half of the nurses from each unit (52% from the medical unit and 76% from the psychiatric unit) were unfamiliar with Massachusetts state law on safe gun storage. Nearly all participants had never participated in a class or training in firearm safety or safe gun storage, and none of those who answered this question had ever taken a class on how to educate others in these areas. For more details, see Table 2.14

Table 2.
Table 2.:
Nurses' Knowledge and Prior Training on Firearm Safety and Safe Gun Storage (N = 42)

Nurses' comfort level with assessing firearm access and providing education on safe gun storage. Results differed between the two units. Response options for three questions on comfort were “uncomfortable,” “somewhat uncomfortable,” “somewhat comfortable,” and “comfortable.” Among the nurses from the medical unit, 52% were uncomfortable or somewhat uncomfortable asking patients about gun ownership or accessibility, and 52% felt uncomfortable or somewhat uncomfortable asking about safe gun storage. Yet 57% were comfortable or somewhat comfortable with providing patient education on safe gun storage. In contrast, among the nurses from the psychiatric unit, 100% were comfortable or somewhat comfortable asking patients about gun ownership or accessibility, and 90% were comfortable or somewhat comfortable asking about safe gun storage. But just 48% were comfortable or somewhat comfortable providing patient education on safe gun storage. Eighty-six percent of nurses from the medical unit and 100% of those from the psychiatric unit agreed that if patient education information on safe gun storage were available, they would feel comfortable providing this to patients.

Participants were also asked whether they felt nurses should ask patients about gun ownership and then provide education on safe gun storage only to those who owned or had access to a gun; or whether they felt nurses should not ask patients about gun ownership and instead provide education to all patients. Responses differed by unit. Among medical unit nurses, 52% supported not asking all patients about gun ownership and instead providing education to all patients. Among psychiatric unit nurses, 86% supported asking all patients about gun ownership and providing information only to those who owned or had access to a gun. For more details, see Table 3.

Table 3.
Table 3.:
Nurses' Comfort Level with Assessing Firearm Access and Providing Education on Safe Gun Storage (N = 42)

Facilitators to assessing firearm ownership and safe gun storage. Nurses could select one or more options from a provided list and could also write in others. Results differed somewhat between the two units. The top facilitators endorsed by the medical unit nurses were “having a policy in place to document this information” (20 responses) and “receiving education about firearm safety and safe gun storage” (18 responses). Two options—“having educational information I can hand to the patient for them to read themselves” and “having a safety protocol in place in case the situation becomes uncomfortable”—received 17 responses each. The least-endorsed facilitator was “having educational information I can hand to the patient and review with the patient” (16 responses). One write-in response was “All of these options would put me a lot more at ease asking these questions [of] my patients.”

Among the psychiatric unit nurses, the top three facilitators were endorsed equally, with 16 responses each: “having educational information I can review with the patient,” “having educational information I can hand to the patient for them to read themselves,” and “receiving education about firearm safety and safe gun storage.” “Having a safety protocol in place in case the situation becomes uncomfortable” and “having a policy in place to document this information” each received just 11 responses. Write-in responses included “Being able to tell patients what will be done with their info” and “If [the box indicating] access to gun or firearms is checked, it should prompt the state/federal protocol or policies.”

Barriers to assessing firearm ownership and safe gun storage. Nurses could choose one or more options from a provided list and could also write in others. The top barriers endorsed by nurses on both units were similar. “Lack of knowledge about firearm safety and safe gun storage” was endorsed by 18 medical and 17 psychiatric unit nurses; “I don't have educational information to share with patients” was endorsed by 18 medical and 14 psychiatric unit nurses.

Differences emerged between the units with regard to other options. Nurses on the medical unit selected “I don't know what to do with the information I collect” (14 responses), “I don't have time” (11 responses), and “I feel unsafe” (2 responses). In contrast, fewer psychiatric unit nurses selected “I don't know what to do with the information I collect” (5 responses). “I don't have time” received just one response, and “I feel unsafe” received none. Write-in responses from the medical unit nurses included “Knowing from report already that a patient has a violent history or maybe is a prisoner, I may feel . . . awkward or uncomfortable broaching this subject” and “It is none of my business. It will not affect the care I provide.” Write-in responses from the psychiatric unit nurses included “I am comfortable asking about gun ownership but am not knowledgeable to guide or recommend about safe gun storage.”

Nurse education strategies. A majority of nurses from both units—81% of medical and 90% of psychiatric unit nurses—indicated that a class on firearm safety and safe gun storage would help them feel more comfortable both in asking patients about and in providing education on this topic. Nurses were asked, “What type of learning strategy would be most helpful to you?” and could select one or more from the following list: “a one-hour class involving security and other disciplines, including nursing”; “a half-day training course involving security and other disciplines, including nursing”; “a HealthStream training module”; and “other.” The top strategies endorsed by the medical unit nurses were the one-hour class and the half-day training course. The top strategies endorsed by the psychiatric unit nurses were the one-hour class and the HealthStream training module. Write-in responses from medical unit nurses included “none of the above” and “I do not think nurses should be asked to educate or discuss gun safety with patients.” One psychiatric unit nurse wrote this response: “a basic overview/article . . . perhaps on HealthStream. Not a lot of detail.”

Patient education strategies. Nurses were also asked, “What type of patient learning strategy do you think would be most effective?” and could select one or more from the following list: “a pamphlet on firearm safety and safe gun storage for patients and families,” “a brief video for patients to watch on firearm safety and safe gun storage,” and “other.” A pamphlet on firearm safety and safe gun storage was highly endorsed by nurses on both units. A hospital committee at the study site had recently developed a patient education pamphlet on these topics. Asked whether they were familiar with this pamphlet, 95% of all the participating nurses said they were not.

More medical than psychiatric unit nurses endorsed a brief video for patients as an effective education strategy. Write-in responses from medical unit nurses included “brief instruction and ensuring patient engagement.” Write-in responses from psychiatric unit nurses included “video only isn't enough, as patients will decline to watch . . . tangible education items may be more beneficial as [patients are] more apt to read it at bedside at some point during hospitalization” and “meeting with police/security on gun safety.”

Regarding the timing of inpatient education, unit-specific differences were evident. Nurses were asked to choose from three options—at admission, during hospitalization, or at discharge—in naming the best time to provide patient education on safe gun storage. Fifty-two percent of medical unit nurses favored educating patients during hospitalization, while 45% of psychiatric unit nurses favored doing so at admission. Only a few nurses from each unit identified discharge as the best time.

DISCUSSION

To our knowledge, this investigation is among the first to evaluate hospital staff nurses' knowledge and comfort with assessing firearm accessibility and educating patients on safe gun storage. The results, based on responses from nurses on the two units involved in the study, demonstrated that most were unfamiliar with state gun law, had no prior training on firearm safety or storage, and had no prior training on how to educate others in this area. Furthermore, nurses on both units identified their own lack of knowledge regarding firearm safety and storage, as well as a lack of patient education information, as top barriers to assessing and educating patients. Unit differences were seen in how nurses responded to some survey questions. These discrepancies helped bring to light certain factors, including nursing specialty and patient population, that might influence nursing assessment and subsequent development of relevant hospital policies and educational initiatives.

More specifically, there were unit differences in nurses' reported comfort with firearm assessment and education, as well as in their identification of certain facilitators and barriers to these tasks. Most nurses from the medical unit felt uncomfortable or somewhat uncomfortable assessing patients with regard to firearm access and safe gun storage. Further, two write-in comments from medical unit nurses were: “It is none of my business. It will not affect the care I provide” and “I do not think nurses should be asked to educate or discuss gun safety with patients.” In contrast, most nurses from the psychiatric unit felt comfortable or somewhat comfortable with both assessments.

One factor that may have contributed to this difference is that the psychiatric unit nurses had more experience asking firearm-related questions of patients who were suicidal or were at elevated risk for harming themselves or others. Our findings here are similar to those from the aforementioned study by Wolf and colleagues, conducted among a nationwide sample of ED nurses.4 In the quantitative portion of that study, about 64% of nurses strongly agreed or somewhat agreed that they were “comfortable discussing firearm safety with patients and families.” Given that most EDs serve acute psychiatric illness and trauma patients, the ED nurses' comfort levels may result from their frequent exposure to and familiarity with treating high-risk patients. It's also important to note that in the qualitative portion of that study, the ED nurses described challenges with broaching firearm-related topics to patients in a manner that wasn't “confrontational.”4 This underscores the need to consider the nature of the assessment questions asked, as well as the influence their wording might have on both nurses and patients. As our findings indicate, a nurse's perspectives on and comfort with firearm assessment may differ by nursing specialty, unit, or inpatient population. These differences should be considered when establishing policy and educational trainings for nurses.

Facilitators that were endorsed by nurses on both units included having a safety protocol for uncomfortable situations and having a documentation policy in place. Regarding barriers, more medical than psychiatric unit nurses cited “I feel unsafe” and “I don't know what to do with the information I collect” as barriers to assessment. These results are similar to qualitative findings from the study by Wolf and colleagues.4 In that study, barriers to firearm-related assessment included fear of potentially violent patients and fear of “holding on to potentially harmful information relevant to a given patient's safety [without] guidance for action.” Taken together, findings from both studies demonstrate the need for appropriate, standardized hospital-based policies and procedures regarding nursing assessment of patients' firearm access. Such policies should be in place before an institution implements nurse assessment of patients' access to firearms. Adequate training for nurses should also be implemented, so that nurses feel safer in this regard.

Nurse education was endorsed by nurses from both units as a top facilitator to patient assessment of firearm access and safe gun storage. This suggests that establishing educational and training initiatives tailored to staff nurses may be essential to raising awareness and enhancing gun violence prevention strategies in hospital settings. As in the study by Wolf and colleagues,4 the majority of nurses in our study had never participated in a training on firearm safety and storage; and none reported being trained in how to educate others on this topic. Nearly all of the nurses from both units felt that a class on firearm safety and safe gun storage would enhance their comfort with both inpatient assessment and education. Indeed, prior participation in firearm violence prevention and safety training has been associated with increased likelihood of relevant assessment and follow-up by nurses.4

In our study, nurses from both units endorsed a one-hour class with hospital security and other disciplines as a learning strategy; a half-day training received greater endorsement from the medical unit nurses. The latter finding highlights potential differences in the training needs of various nursing specialties. Compared with psychiatric unit nurses, nurses on other units may feel less prepared to conduct firearm assessment and patient education, especially in potentially volatile situations.

Almost all nurses on each unit reported that they would feel comfortable giving information on safe gun storage to patients if it were available. A pamphlet was the most endorsed patient education strategy. Furthermore, nurses from both units identified the lack of relevant patient education materials as a barrier to assessing and educating patients. A surprising finding was that 95% of the study participants were not familiar with the hospital's existing patient education pamphlet on firearm safety and storage. Further exploration regarding clinicians' access to and the distribution of such resources is needed to improve communication and materials dissemination in the hospital setting.

Nearly 40% of the ED nurses in the study by Wolf and colleagues felt strongly that they had insufficient time to discuss firearm safety with patients.4 Similarly, in our study, about half of the medical unit nurses referenced lack of time as a barrier to asking patients about firearm ownership and safe gun storage. A critical factor influencing such discussion in Wolf and colleagues' study was whether other colleagues were available to provide further risk assessment.4 While this factor wasn't addressed in our survey, it stands to reason that having additional staff who could serve as designated firearm safety “experts” and were readily available for consultation would be an invaluable resource.

Limitations. Our study was conducted with a small sample size and was limited to nurses from two units at a single large urban academic medical center. Furthermore, the study took place in Massachusetts, and state gun laws and practices differ from state to state. Nurses living and working in urban areas may have different knowledge of firearms than those in more rural areas. For all these reasons, the generalizability of our findings is limited, and results should be interpreted with caution. The survey tool was created by the study investigators, and its reliability and validity have yet to be established. The study was exploratory, using relatively general survey questions pertaining to nurses' individual experiences with the topics of interest. Many of the survey questions included prepopulated response options. Although nurses could write in “other” responses for some items, it's possible that the provided options were limiting and didn't reflect the true scope of relevant facilitators, barriers, and educational strategies.

Practice implications and future research. This study found that while many medical unit nurses felt uncomfortable asking patients about firearm access and discussing safe gun storage, they wanted to learn more about how to have the conversation. We recommend the development of comprehensive hospital-based educational initiatives for nurses that not only address firearm-related knowledge gaps but also consider nurses' comfort, nurses' safety, and hospital policy. Nurses from both units in our study specifically endorsed the prospect of a one-hour class involving hospital security and other disciplines. A class curriculum could include review of national gun violence statistics; review of pertinent literature and evidence-based practices; information on at-risk populations; and most important, guidance for nurses on how to talk to patients about firearm safety and storage. A video in which a nurse talks with a patient in a nonjudgmental and supportive way about these topics, as well as the implications for the general public's health and safety, could be a useful tool. Moreover, hospital administrators should collaborate with inpatient nurses to establish a hospital policy for asking patients firearm-related questions and documenting answers, such that all parties in the conversation feel safe.

We further recommend the creation of institution-based, multidisciplinary committees that can discuss and address ways clinicians and others can work together to reduce gun violence. Several years ago, the study site did just that. The committee comprises nurses, physicians, social workers, security staff, and other hospital employees interested in gun violence prevention. It is dedicated to reducing firearm-related morbidity and mortality, and to promoting safety in the homes and communities of the patients served through education, community engagement, and research. Such committees foster interprofessional dialogue and support for hospital-based initiatives aimed at raising awareness and promoting gun violence prevention. (For more, see Creating MGH's Gun Violence Prevention Coalition.)

Box 1
Box 1:
Creating MGH's Gun Violence Prevention Coalition

Future research should include studies involving larger sample sizes and more diverse geographical settings. Studies conducted among nurses working on other units (such as pediatric, ambulatory care, and surgical) would enhance knowledge and help in the development of unit- or patient population–specific policies and educational materials. We did not ask nurses whether they themselves owned or were familiar with guns; such information could add further insights. (In February, we sent a revised survey to nearly 700 nurses that included questions about prior military service, prior law enforcement employment, prior gun use for sport, and prior training in firearm use. But data collection and analysis has been postponed because of the COVID-19 pandemic.) Follow-up studies should also include diverse methodological approaches. The effectiveness of both nursing and patient education should be evaluated.

Lastly, it's important to note that some states have laws addressing how health care providers acquire firearm-related information from patients. A “gag law” is one that prohibits providers from talking to patients about firearms. That said, at the time of this writing, there is no current state or federal gag law that prohibits a provider from discussing firearms with patients when such information is pertinent to the health of the patient or others.15, 16 Future nurse-led, policy-centric research could help inform nursing practice and care delivery in this area.

CONCLUSIONS

Gun violence in this country is pervasive—and preventable. Innovative and multimodal strategies to improve awareness and foster safer practices are greatly needed to address this public health issue. Nurses have a critical role to play in helping to curtail gun violence. Assessing inpatients' access to firearms and educating them about safe gun storage can help increase awareness, and might prevent accidental shootings, suicides, and homicides in our homes and communities. The findings from this study offer a window into the experiences and views of medical and psychiatric unit nurses. These perspectives can help inform the development of vital nurse trainings and hospital-based policies that may influence firearm safety and storage practices of patients and families and save many lives.

Resources on Safe Gun Storage

American Academy of Pediatrics Parenting Website

www.healthychildren.org

Guns in the Home

www.healthychildren.org/English/safety-prevention/at-home/Pages/Handguns-in-the-Home.aspx

Recommendations regarding storing guns at home where children reside

Everytown for Gun Safety/Moms Demand Action for Gun Sense in America

https://everytown.org/moms

Unload, Lock, and Separate: Secure Storage Practices to Reduce Gun Violence

http://besmartforkids.org/wp-content/uploads/2019/09/BeSmart-Secure-Storage-Fact-Sheet-Print-091119C.pdf

Recommendations on how to store guns safely

Massachusetts Medical Society/Massachusetts Office of the Attorney General

Gun Safety and Your Health

www.massmed.org/firearmguidanceforpatients

Recommendations on safe gun storage and ways to dispose of an unwanted gun

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Keywords:

firearm safety; gun violence; nurse education; preventable death; safe gun storage

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