Firearm Safety & Mental Health: A Call to ARMS (Assess and Reduce Means to Suicide)

Firearm violence is a significant public health problem. There is growing data that most Americans support evidence-based policies that can help reduce firearm violence (John Hopkins, 2023). Nonetheless, there have been few recent changes to our national policies and practices. Deaths continue to rise, families and friends bury and mourn loved ones, and watching, listening to, or reading the news becomes almost unbearable (Postman, 2010), highlighting the latest loss of life to firearms. Mass shootings have increased in recent years and have received the most media attention; however, these headline-grabbing events make up a small percentage of all deaths due to firearms. In fact, of the 44,367 deaths due to firearm violence in 2022, mass shootings make up less than 2% (Gun Violence Archive, 2023). Public conversations about firearm violence directed towards others quickly turn to mental health, perpetuating stereotypes and processes of scapegoating (Girard, 1989; Riordan, 2021) without making meaningful changes. Even without the aid of national policy changes (John Hopkins, 2023), nurses can act now and promote a culture of health and safety. This article aims to recognize the strategic space nurses occupy and encourage nurses to assess/screen patients and provide education that can help decrease firearms-related deaths. Guided by the context and attributes of cultural humility, specific action steps will be presented to help empower nurses to educate patients about the safe storage of firearms.

Public conversations about firearm violence directed towards others quickly turn to mental health...

“Misrecognition” of the Problem

In 2021, the most recent year with complete data, the Centers for Disease Control and Prevention (CDC) documented a new record high: 48,830 people died of firearm-related injuries in the United States (Simon et al., 2022). Over half (54%) of these firearm-related deaths were suicides (26,328); 43% were homicides (20, 958); and 3% (1544) were deaths due to accidents, law enforcement involvement, or undetermined circumstances (Simon et al., 2022). Homicides with firearms have increased since and during the pandemic. Of particular concern is gun deaths in our population of ages 18 years or younger, with a 50% increase from 2020 (1,732) to 2021 (2,590) (Simon et al., 2022). Death by suicide, however, has remained tragically high and has remained the consistent leader for all firearm deaths for decades (Simon et al., 2022). Despite this fact, rarely do we hear it mentioned in public conversations.

Firearm violence is a public health concern that raises many complex questions. The response frequently provided by politicians and lobbyists and repeated by the media is the message that we have a firearm violence problem because we have a mental health problem. However, the data consistently tells us a different story. Firearm violence directed towards others is not causally linked to mental illness (Swanson et al., 2015a). Individuals with serious mental illness (SMI) are three times more likely to be the victim of violence rather than the perpetrator (Rozel & Mulvey, 2017), and individuals with SMI were found to be the minority of violent firearm offenders (Kivisti, 2017). Nevertheless, the typical public retort is, "This is not a gun problem—this is a mental health problem.” The concern with this typical rhetorical and scapegoating public response (Riordan, 2021) is that little evidence supports it. Meanwhile, by misrecognizing (Girard, 1989) the problem and encouraging stigmatization, we are not addressing complex public health concerns involving firearm violence.

Individuals with serious mental illness (SMI) are three times more likely to be the victim of violence rather than the perpetrator

In 2022, approximately 53 million people (20% of the adult population) met the criteria for a psychiatric condition (National Institutes of Mental Health [NIMH], 2023). In other words, a diagnosis for any mental health condition is common in the U.S. (1 in 5 adults). The numbers for the most impairing and severe mental illness (SMI) are significantly lower, associated with approximately 14 million, or 6%, of the adult population in the U.S. (NIMH, 2023).

While our mental health system is underfunded and fragmented in numerous ways, a simple benefit-cost analysis (Carol & Hayes, 2023) reveals that completely fixing our delivery system would have little impact on occurrences of violence directed toward others. How does mental illness relate to mass shootings and firearm violence directed toward others? Studies suggest that at the time of a shooting, one in five mass shooters had experienced SMI (Skeem & Mulvey, 2020). Individuals with serious mental illness are rarely violent. When these uncommon incidences of violence occur, it is typically during a known high-risk period, such as a first episode of psychosis or a period around an involuntary inpatient psychiatric hospitalization (Gold & Simon, 2016). Additional estimates state that 3% of firearm violence toward others is associated with individuals with SMI. In fact, if we somehow cured our nation’s mental health problems, we would only reduce firearm violence in our country by 4% (Swanson et al., 2015). Studies indicate that the best predictor of violent behavior is not a history of mental illness but rather past violent behavior.

According to Girard (1989), we are in danger of falling into the common cultural trap of “scapegoating” (i.e., individuals with mental illness) and the associated “misrecognition” of how to solve the problem (i.e., fix the broken mental health system). Perhaps instead of hyper-focusing on mass shootings (< 2% of all firearm violence) and the association between firearm homicide and individuals with mental illness (< 4%), we can focus on impactful solutions to reduce the problem.

Suicide

As previously stated, most firearm-related violence toward others is not associated with serious mental illness. However, the story changes when we focus on the interaction between firearms, mental illness, and suicide. The evidence overwhelmingly indicates that suicide, not homicide, holds the most significant association between firearms and mental illness (Gold & Simon, 2016). In 2021, a near-record 48,183 individuals died by suicide, making suicide the 11^th leading cause of death in the United States (CDC, 2022). Of these 48,183 deaths, over half (26,328; 54.6%) resulted from firearms (CDC, 2022). Decades of data have shown that 90% of suicidal acts involving a firearm result in death, making firearms responsible for more suicide deaths than all other methods combined (John Hopkins, 2022).

One of our nation’s leading researchers on suicide and firearms, Michael D. Anestis, stated: “Every American should know that most American gun deaths are suicides, and most suicides are gun deaths” (2018, p. 139). Unfortunately, a suicidal crisis is often short-lived, hard to predict, and can escalate quickly. The best time to act is before a suicidal crisis begins, and nurses are situated to intervene as frontline healthcare providers. With nearly 4.2 million registered nurses (RNs) nationwide, nursing is our nation's largest healthcare profession and has been ranked as the most trusted profession for over 20 years (Brenan, 2023). Nurses can provide a critical link to promoting a culture of health and safety around firearms.

Public Health, Autonomy, and Role of the Nurse

Victims of firearm violence (both suicide and homicide) have died from preventable injuries. Our goal and focus is not to remove or eliminate firearms but to educate about inherent risks and opportunities to increase safety. Ownership of a firearm, a constitutional right, has sharply risen since the COVID-19 pandemic, and we now have more guns than citizens in our nation (Anestis et al., 2021; Roess et al., 2023). Among the most commonly reported reasons for owning firearms are protection (72%) and hunting/sport shooting (62%) (Pew Research Center, 2023). Regardless of the reasons for legal gun ownership, nurses have an opportunity to promote a culture of safety around the proper storage of firearms.

Keeping a firearm in the home is associated with a five-fold risk of suicide and a three-fold risk of homicide (Ye et al., 2022). Despite these mortality risks, the goal is not the removal of firearms from the home; instead, the goal is to assess and promote the safe storage of firearms. Nurses can promote a culture of firearm safety that reduces access to lethal means during a crisis and can save lives. Over 90% of people who attempt suicide and survive do NOT die by suicide through a later attempt (Anestis, 2021). Reducing access to inappropriately stored firearms before patients experience an acute suicidal crisis can save lives.

Nurses can promote a culture of firearm safety that reduces access to lethal means...

For nurses, this is our call to ARMS – Assess & Reduce Means to Suicide. The best time to act is before a suicidal crisis begins. Nurses are strategically positioned throughout our healthcare systems to respond to the risk of firearm violence and take up a call to ARMS. The value of obtaining competency in suicide assessment has been addressed elsewhere (American Psychiatric Nurses Association [APNA], 2015; Brodsky et al., 2018; CDC, 2022; Melhem et al., 2023). Integral to ARMS is safe storage practices to help reduce firearm deaths.

Storage of Firearms

The most significant correlation between mortality from death by suicide and homicide is access to firearms. Unsafe (i.e., unlocked, loaded) firearm storage is associated with an increased risk of death by suicide (Anestis et al., 2023). Nurses have been entrusted with the care of patients and are uniquely positioned to assess firearm safety and promote a culture of health.

Housed and operated through the Harvard University T.H. Chan School of Public Health, the Means Matter Campaign provides evidence-based steps that nurses can share with firearm owners to store their firearms (Harvard University, 2023) safely. First, firearms in the home should be stored locked and unloaded securely (i.e., locked cabinet or gun safe). Second, the use of trigger locks/and or cable locks is recommended in conjunction with a locked cabinet or safe. Finally, ammunition should be stored in a locked and secured location separate from the firearm(s). Safely storing a firearm requires an individual to unlock one or more safes, load the firearm with ammunition, and release a trigger and/or cable lock. These crucial steps provide time for an individual to consider their actions carefully.

The safest storage for a firearm is out of the home. Many firearm owners with children and adolescents in the home choose to do this. Alternate locations may include self-storage facilities, a shooting range, a shop with friends or family, or a participating law enforcement department. Additionally, when an individual is in a psychiatric crisis, firearms should be removed (not hidden!) and stored outside the home (Gold & Simon, 2016).

Seek First to Understand: The Power of Cultural Humility

The practice of cultural humility provides nurses with the opportunity and tools to understand the value and place of firearms in the lives of their patients. The concept of cultural humility was first introduced by Tervalon and Murray-Garcia (1998) as an alternative to (the goal of) cultural competence. They summarized that cultural humility involves “a lifelong commitment to self-evaluation and critique, to redressing power imbalances…and developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations" (1998, p.123). Nurses must understand the value cultural humility can provide when working with firearm owners and those who dwell in households with firearms.

The opposite of cultural humility can be described with the following identified antonyms: “prejudice, oppression, intolerance, discrimination, stereotyping, exclusion, stigma, inequity, marginalization, labeling, mistrust, hostility, misunderstandings, cultural impositions, judgmental, undermining, and bullying” (Forrantanoda et al., 2016, p. 213), all of which describe what nurses want to avoid when discussing the safe storage of firearms. Cultural humility provides nurses with a critical approach and context to better engage with patients to understand their relationship with firearms and assess, screen, and educate for health and safety. According to Hook et al., cultural humility includes "the ability to maintain an interpersonal stance that is other-oriented (or open to the other) concerning aspects of cultural identity that are most important to the client" (Hook et al., 2013, p. 354). We must recognize and respect individuals’ values concerning ownership while building and promoting a health and safety culture around firearms.

Specific Action Steps to Empower Nurses

Cultural humility is a lifelong process involving several important attributes identified by Foronda and her colleagues (2016), including openness, self-awareness, egoless, supportive interactions, and self-reflection and critique. These five attributes provide nurses with a context and outline for action steps to utilize when assessing, screening, and counseling/educating for the safe storage of firearms:

• Openness. Be open to learning more about firearm culture and this population of patients for whom nurses are already providing care.
• Self-Awareness. Identify and recognize personal views and biases regarding firearms and individuals who value firearm ownership.
• Egoless. Adopt an open, humble approach when engaging with patients on firearms. Learn to embrace a “not knowing approach” (Anderson & Goolishian, 1992; Proctor et al., 2021) that is focused and allows the patient to be the expert. Remember to seek first to understand.
• Supportive Interactions. In a supportive and open manner, ask patients about their firearms access early. Do this in a supportive, open, interested, and conversational manner. Ask them about what kinds of firearms they own, and be genuinely interested in how and why this is important to them. Remember, the goal is not removing firearms but improving patient safety through promoting a culture of safety around firearm storage.
• Self-Reflection and Critique. Lastly, reflect on what the patient has shared and ask about firearm storage. Following assessment and screening, ask about sharing information about firearms and safety. Invite and encourage self-reflection and critique – on a continuum of safely storing firearms, where does their current practice fit? What changes would be required to make things safer? Is this something they have ever considered before? If they decided to engage in safer storage of firearms, what changes would be required, and what would the following steps be?

Nurses are strategically positioned throughout our healthcare systems to respond to the risk of firearm violence and take up a call to ARMS – Assess & Reduce Means to Suicide. Steps 1 (Openness), 2 (Self-awareness), and 3 (Egoless) involve steps nurses can take before the actual patient encounter. Steps 4 (Supportive Interactions) and 5 (Self-Reflection and Critique) outline a strategy for patient engagement and education regarding safe firearm storage. These attributes give nurses a context and outline for five action steps to utilize when assessing, screening, and counseling/educating patients to store firearms safely. Additionally, nurses must be updated with state and local laws, and seeking further training and education may be helpful. Through proactive knowledge and care practices, nurses can act now to promote a culture of health and safety that can help decrease deaths related to firearms.

Conclusion

Firearm violence (homicide and suicide) is a serious public health problem in the United States, and further research is needed to identify how to reduce associated deaths (Metzl et al., 2021; Richmond & Foman, 2019). Blaming our fragmented and broken health system and searching for a scapegoat is a “misrecognition” of how to effectively and efficiently address the problem (Girard, 1989; Riordan, 2021). Nurses can refocus the conversation and make a lasting impact on firearm safety. The evidence overwhelmingly indicates that suicide, and not homicide, holds the most significant association between firearms and mental illness. Unsafe firearm storage is associated with a higher risk for suicide, and 90% of suicide attempts involving a firearm are fatal (Anestis, 2018). Even without any changes to our national laws and policies, nurses can respond to firearm violence by taking up a call to ARMS – Assess & Reduce Means to Suicide. Nurses are uniquely positioned to promote a safety culture around firearms and safe storage practices. The identified attributes of cultural humility provide an outline and framework for nurses to engage in assessment, screening, and education. Nurse interventions may allow individuals to review firearm safety plans and help prevent death.

Author

James K. Tudhope, DNP, APRN, PMHNP-BC, NPD-BC
Email: jtudhope@kent.edu
ORCID ID: 0000-0002-2910-6410

James K. Tudhope has been a registered nurse since 2001, a licensed professional counselor since 2008, and a Psychiatric Mental Health Nurse Practitioner since 2013. He currently serves as an Assistant Professor at the College of Nursing, Kent State University where he also coordinates the Psychiatric Mental Health NP Concentration. Additionally, he is the Medication Clinic Coordinator and Program Director for the Integrated Community Psychiatry Nurse Practitioner Fellowship Program at Portage Path Behavioral Health in Akron, Ohio. Dr. Tudhope’s practice-based research focuses on professional development for nurses and the design and development of advanced practice registered nurse (APRN) post-graduate education programs.