Francis Joseph “Joe” Desjardins, RN-BC, BSN, MEd, is director of nursing practice and education at Valley Regional Hospital in Claremont, N.H., a rural town where, he said, many consider guns as essential as household tools. He said the best way to prevent gun violence is not to ban assault weapons but rather to increase mental health services. “The core of the problem is not the weapon,” he said. “Its the individual who needs help and cant get it.”
Rose Gonzalez, RN, MPS, director of government affairs for the American Nurses Association, grew up in New York City and never has owned a gun. She agrees with Desjardins about increasing mental health services, but does not understand the need for civilians to have lethal weapons that can fire many rounds of ammunition. “Its not logical or practical,” she said.
Spurred by a series of mass shootings, most prominently the horrific attack on a Newtown, Conn., elementary school in December, the national debate about guns has intensified. On its website, the CDC says gun violence is a public health issue, but nurses opinions about gun violence and how to reduce it are as varied as those expressed by the American public. However, nurses who research firearm safety and were interviewed by Nurse.com said as healthcare providers and trusted members of society, RNs are in a position to emphasize safety, public health and education in place of polarizing political arguments.
“Heres the bottom line,” said Therese S. Richmond, RN, PhD, CRNP, FAAN, professor at the University of Pennsylvania School of Nursing in Philadelphia and research director at the universitys Firearm and Injury Center. “[Based on the Second Amendment], as a U.S. society we have chosen to live in a world that has guns. How do we decrease death and injury from guns?”
An everyday occurrence
Although mass shootings make headlines and inspire public outcry, they are responsible for a very small percentage of firearm fatalities and injuries in the U.S., said Mary E. Muscari, RN, PhD, CPNP, APRN-BC, associate professor and director of the OConnor Office of Rural Studies at the Decker School of Nursing at Binghamton (N.Y.) University, and a pediatric nurse practitioner and psychiatric and forensic clinical specialist who lives in rural Pennsylvania.
Rather than racing to action because of a single horrible incident, Muscari said policymakers should set politics and agendas aside and look at existing research on firearm injuries, gather more data to fill in gaps and educate people how to best protect themselves and their families from gun injuries and death, whether they own guns or not.
According to an article in the Jan. 31 issue of the New England Journal of Medicine, in 2011 an average of 88 Americans per day died from firearm violence and another 202 per day were seriously injured.
In response to the shootings in Newtown, the White House proposed a series of reforms, including increased access to mental health services, improved universal background checks, bans on military-style weapons and high-capacity magazines, and limits on selling guns to those with a history of criminal behavior, mental illness or substance abuse. The National Rifle Association and some lawmakers oppose many of the newly proposed regulations related to guns, saying they violate Second Amendment rights.
Healthcare organizations have reacted in various ways. More than 30 nursing organizations, including the ANA, the American Psychiatric Nurses Association and the National League for Nursing, signed a call-to-action letter to national, state and local officials asking for better access to mental health services for individuals, families and students, a ban on assault weapons and “other meaningful gun control reforms.” The Emergency Nurses Association, while not taking a position on the weapons ban, issued a statement supporting the Obama administrations efforts to respond to injuries and deaths related to guns, especially improving access to mental health services.
A public health issue
An excellent public health model already exists that could be applied to improving gun safety, Richmond said. Traffic fatality rates are at their lowest since 1966, when the government passed laws mandating national highway safety standards, according to the U.S. Department of Transportation. “How did we decrease death and injury from cars?” Richmond asked. “We studied it; we got data; we had a policy agency that made recommendations. We changed how we built cars. We worked on peoples behaviors. We changed the design of roads.”
The task of improving gun safety is similar, she said. It would take a combination of efforts, including regulations to strengthen universal background checks; new technology, such as improved mental health and gun ownership databases, better safety locks and “smart guns” that can be fired only by the registered owner; increased education about keeping guns away from household members who would not safely use them; and community programs for mental health assessment, violence prevention, anger management and suicide prevention.
However, few of these things are happening because discussion about guns can elicit high emotions, accusations and suspicions, Richmond said.
Many nurses interviewed by Nurse.com agreed on the need for more research on firearm injuries and prevention. Until January, when the White House lifted a congressional ban, the CDC and the National Institutes of Health could not fund any research that might lead to gun control, even if it only involved gathering safety statistics, Richmond said. As a result, researchers point to a huge gap in data about firearm deaths and injuries occurring in the U.S.
“We have lots of research on seat belts, but we dont have the evidence-based research to support what should be done to prevent gun violence,” said JoAnn Lazarus, RN, MSN, CEN, president of the ENA.
Should we talk about it?
Muscari said one of the most obvious ways for healthcare providers to help reduce firearm injuries and deaths is to routinely educate patients about gun safety. She and Richmond believe asking patients whether they have guns in the house — and whether guns are inaccessible to children, people with dementia or others who should not have access to them — should be part of routine health screenings for all patients, just as questions about seat belt use and smoke detectors often are asked during a patient assessment.
However, some nurses do not think they should ask about gun ownership or discuss gun safety except in special circumstances, such as if a patient mentions suicide.
“I think thats a really touchy subject,” Desjardins said. “Patients may feel its an invasion of their privacy. It might be seen as overstepping our bounds.” Firearm safety education should be left to gun experts, such as those who teach courses for hunters or law enforcement, rather than being brought into nursing, he said.
Nurses should know how to educate patients about firearm safety, including how to keep children safe from gun injuries, Lazarus said, but the ENA has not taken a stand on talking about firearm safety to everyone or making questions about guns part of a screening. “Some people wouldnt care, but some people are very protective” about their gun ownership, she said.
But nurses often ask about sensitive topics such as sex habits or illegal drug use, Richmond said. “If we dont have these conversations, if we dont look at the risk, I think thats unethical,” she said.
A closer look
Many nurses say looking just at gun violence is too narrow. “I think all violence is a public safety issue,” Desjardins said. He thinks part of the answer to addressing violence in the U.S. is to create more evidence-based violence prevention and intervention programs, including anti-bullying programs, resources for spousal abuse and anger management programs. Reducing the stigma of mental health problems, making it easier for those with mental health issues to get help, and providing insurance coverage for mental health services will help prevent gun violence, Gonzalez said, because those who might use a gun to harm themselves or others will be more likely to get the help they need.
Muscari supports improved access to mental health services, but she said more evidence is needed to direct limited research funds if the goal is to decrease mental health-related gun violence. Are they best spent on early intervention or later? In EDs or community settings? For screening or treatment? “Lets not just throw more money at it,” she said. “Lets plan first.”
Richmond said she sees universal background checks and denying gun sales to people with histories of criminal activity, domestic violence and substance abuse as the most effective measures against gun violence in the U.S. Laws on who can sell and buy guns vary from state to state, and many private sellers are not required to conduct background checks. In December 2012, the New England Journal of Medicine reported public-opinion polls showed 75% to 85% of gun owners supported comprehensive background checks and denying sales to those with records of misdemeanor violence.
Perhaps the greatest effect nurses can have on gun violence is to help change the dialogue from pro-gun versus anti-gun into a conversation about health and safety, Richmond said. “I think we should speak out about gun violence. Were not asking to take away guns. We want to let people know how they can keep their families safe and decrease injury and death.”
When the issue is put in this light, she said, “usually you can get people to agree.” •
Editors note: For information on mental healthcare, go to www.Nurse.com/Article/Mental-Health-First-Aid and www.Nurse.com/ Article/Mental-Illness.