By Melinda Young
EXECUTIVE SUMMARY
Mass shootings cause physical and mental health injuries to patients. Case managers can improve care transitions by adding gun violence to the list of social determinants of health. Clinicians can make mental health referrals.
- Research shows healthcare settings experience a disproportionate amount of workplace violence and gun assaults.
- The Joint Commission requires accredited hospitals to implement new workplace violence prevention requirements.
- From 2008 to 2017, the percent of physicians who were victims in hospital-based shootings tripled.
Violence in healthcare has increased, and mass shootings remain a danger even in settings that would have been unimaginable a few decades ago.
One new study revealed physician injuries and deaths from acute care hospital shootings has more than tripled during the past two decades. Some of the shootings were even carried out by physicians.1
“The percentage of physicians as victims has tripled from 3% to 9% of hospital-based shooting victims from 2008 to 2017,” says Joseph R. Wax, MD, an attending physician and professor of obstetrics and gynecology in the division of maternal-fetal medicine at Maine Medical Center.
Workplace violence — especially mass shootings and fatalities — also affect nurses and other hospital employees. “It’s always a concern — not just for us as physicians,” Wax adds. “Based on recent trends, we’re unfortunately seeing gun violence every day in the news. It’s a concern for everybody in their daily lives.”
There are more guns than people in the United States.2 It is little wonder the nation experiences 10 times the rate of gun homicides as Canada or 100 times the gun homicides of the United Kingdom and Australia, says Wendy Cukier, MA, MBA, PhD, founder and academic director of Diversity Institute and professor of entrepreneurship and strategy at Toronto Metropolitan University.
Violence in Healthcare Is Increasing
Researchers studied the rate of all non-gun murders and found the United States had twice the rate of homicides as Canada, the United Kingdom, and Australia. But add in gun homicides, and everyone — including healthcare professionals — is at risk. The U.S. Bureau of Labor Statistics reported healthcare and social service workers were five times more likely to experience workplace violence than all other workers.3,4
From the perspective of case managers, gun violence may affect their workplace — but even more commonly, it affects their patients. Victims of gun violence are at increased risk of mental health problems, according to new research.5,6
Case managers could screen patients for past gun violence, considering it a social determinant of health.
“There’s a lot of need for mental health support among victims of violence — and especially gunshot victims,” says Rafael Tamargo, MD, MBA, fourth-year resident in the department of psychiatry at Western Psychiatric Hospital and University of Pittsburgh Medical Center. “Large population studies on people who experienced gun violence find that about half of them will develop PTSD. Up to 44% of people who had a gunshot injury may develop substance use disorder.”5 (See story on gun violence and mental health in this issue.)
Victims also struggle with social involvement and often experience physical function issues that lead to lower rates of employment, Tamargo adds.
Violence in healthcare settings has been rising over the past decade. Healthcare workers experience three-quarters of all workplace assaults every year.7
In January 2022, The Joint Commission (TJC) implemented new workplace violence prevention requirements. All TJC-accredited hospitals must create strong workplace violence prevention programs, following a framework that includes defining workplace violence, establishing leadership oversight, conducting worksite analysis, developing policies and procedures, collecting data, training staff, and creating post-incident tactics.3
Healthcare Facilities Remain Unprepared
Despite active shooter drills, well-armed and fast police forces, and decades of Americans becoming accustomed to mass shootings, hospitals and other healthcare facilities are not well prepared for a possible mass shooter event.
“We remain unprepared,” says Mary Scott-Herring, DNP, MS, CRNA, an assistant professor in the doctor of nursing anesthesia practice program at Georgetown University in Washington, DC. “It’s a highly unlikely event, and it gets prioritized way down the list. When something happens, people wonder what went wrong and what we could have done better.”
In May 2022, two mass shootings shocked the nation. The first was a suspected hate crime massacre of 10 Black people in a Buffalo, NY, grocery store.8 The next occurred at an elementary school in Uvalde, TX, where a teenager killed two teachers and 19 students.9 Soon after those shootings, an angry patient shot and killed two surgeons, a nurse, and a patient’s spouse at a surgery center in Tulsa, OK.10 These high-profile shootings led healthcare organizations to once again raised the need to do more to protect their staff.
But that sort of reaction to high-profile shootings has become more of a ritual than a spur to action. Shootings have become so common it is not unheard of for someone to have experienced more than one incident. Scott-Herring is a case in point: “The first shooting event that I experienced was in college,” she recalls. “I was walking home from classes and about to cross a street, and the officer said for me to get out of there or he’d shoot me himself. There was a shooter on an apartment building. One bullet struck a police car, so they locked down the area until the shooter killed himself.”
This occurred before the Columbine High School massacre in 1999, when the focus changed in how police responded to active shooter events, Scott-Herring notes. “After Columbine, I was at Johns Hopkins Hospital [in September 2010] and had transported to the seventh floor to the recovery room for pediatrics,” she says. “The elevator was recalled to the first floor, and a security officer entered the elevator.”
Scott-Herring’s pager buzzed with a message for all staff to shelter in place. She waited with colleagues and patients in a large recovery room with 15 bays and curtains between them. A TV in the room was tuned to the news.
“CNN started covering this shooting, and this is how we figured out what was going on — a shooting at Johns Hopkins Hospital,” Scott-Herring says. “I had students in various operating rooms, so I was paging them through the computer and said, ‘Stay where you are — don’t leave the OR.’”
The nurses and physicians in ORs did not know anything about the shooter and shelter in place order, so her text messages helped them stay safe.
Later, she learned a disgruntled family member shot a surgeon and then shot his own mother, who was the surgeon’s patient. Then he shot himself. The surgeon survived after emergency surgery.11
“The surgeon was brought to the OR a floor down, as an emergency case. That was the first time some of those people knew there was anything going on because a surgeon they worked with daily was brought in with a gunshot wound to the abdomen,” Scott-Herring explains.
Each healthcare provider should think about their personal tactics for dealing with an active shooter situation, about whether they will stay in the danger zone with patients or seek safe shelter.
“You should know what your facility’s plan is, and be aware of where you can run, where you can hide, and what items are at your disposal,” Scott-Herring says. “Some healthcare providers say they could never leave their patient. But it’s a very personal decision, and it depends on a lot of different factors.”
REFERENCES
- Wax JR, Cartin A, Craig WY, Pinette MG. U.S. acute care hospital shootings, 2012-2016: A content analysis study. Work 2019;64:77-83.
- Institute for Health Metrics and Evaluation. On gun violence, the United States is an outlier. May 31, 2022.
- Jacobs Jr LM. New workplace violence prevention standards take effect January 2022. Bulletin of the American College of Surgeons. Oct. 1, 2021.
- U.S. Bureau of Labor Statistics. Workplace violence in healthcare, 2018. April 2020.
- Tamargo R, Moschenross D, Clark T, et al. Consultation-liaison case conference: Psychiatric evaluation and management following gunshot injury. J Acad Consult Liaison Psychiatry 2022;S2667-2960(22)00022-2.
- Magee LA, Fortenberry JD, Aalsma MC, et al. Healthcare utilization and mental health outcomes among nonfatal shooting assault victims. Prev Med Rep 2022;27:101824.
- Stephens W. Violence against healthcare workers: A rising epidemic. American Journal of Managed Care. May 12, 2019.
- Bowman E, Chappell B, Sullivan B. What we know so far about the Buffalo mass shooting. NPR. May 16, 2022.
- Romo V. Texas community struggles with second-deadliest school shooting in U.S. history. NPR. May 25, 2022.
- Bella T, Knowles H, Bever L, Kornfield M. Tulsa gunman angry over pain after back surgery, police say. The Washington Post. June 2, 2022.
- Johns Hopkins Medicine. Update on shooting at The Johns Hopkins Hospital. Sept. 17, 2010.
Mass shootings cause physical and mental health injuries to patients. Case managers can improve care transitions by adding gun violence to the list of social determinants of health. Clinicians can make mental health referrals.
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