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American Academy of Nursing on policy: Recommendations in response to mass shootings

      Background

      When Americans gather in public places, schools, work, places of worship, and at home, they should feel safe and not afraid. The recent massacre at Marjory Stoneman Douglas High School in Parkland, Florida, where 17 individuals were murdered, has led to a public outcry for action by policymakers to address mass shootings. This call to action is similar to those made in response to the mass shootings in Columbine, Sandy Hook, Orlando, and Las Vegas, making a case for a lack of progress and apathy in addressing mass shootings. With the leadership and guidance from the Expert Panel on Violence, the American Academy of Nursing (Academy) calls for a public health approach to address mass shootings, including distinguishing key factors that contribute to mass shootings and identifying actionable solutions. The Academy also calls for the establishment of a nonpartisan National Commission on Mass Shootings, the funding for gun violence research, and the development and monitoring of policies to ensure gun safety, including restricting access to firearms by those known to pose a danger to others. Lastly, we call for support for programs and policies that identify and respond to individual, family, and community risk factors for mass shootings—intimate partner violence (IPV), toxic stress, bullying, and mental health problems—and address missed opportunities for individuals and systems to prevent this type of violence.
      We use the definition of mass shooting used by the FBI and by other academic researchers: the murder of four or more people other than the shooter within one event, and in one or more locations in close proximity to each other (
      • Krouse W.J.
      • Richardson D.J.
      Mass murder with firearms: Incidents and victims.
      ). Mass public shootings can take place both in public spaces such as schools or shopping malls, and private spaces such as homes and workplaces. While mass public shootings attract substantial public notice, it is important to recognize that our best data on these cases suggest that more than 60% of mass shootings take place in or near a home (
      • Everytown for Gun Safety
      Mass Shootings in the United States: 2009–2016.
      ). Women and children are disproportionately represented in mass shootings (75%) as compared to other types of gun violence. In fact, while women perpetrators account for about 15% of total firearm homicides, they are 50% of mass shooting victims. Children account for 8% of overall firearm homicides but 25% of mass shooting victims.

      Access to Firearms

      The most effective policies to reduce mortality from firearm homicide are laws that do not allow dangerous individuals to purchase firearms and laws that restrict access to the most dangerous kinds of firearms. Evaluation of existing laws show that limiting the sale of certain firearms and reducing access to firearms for high-risk individuals appear to have the most significant effects on reducing number of deaths and casualties from mass shootings (
      • Koper C.S.
      • Johnson W.D.
      • Nichols J.L.
      • Ayers A.
      • Mullins N.
      Criminal use of assault weapons and high-capacity semiautomatic firearms: An updated examination of local and national sources.
      ,
      • Lee L.K.
      • Fleegler E.W.
      • Farrell C.
      • Avakame E.
      • Srinivasan S.
      • Hemenway D.
      • Monuteaux M.C.
      Firearm laws and firearm homicides: A systematic review.
      ). However, emerging research also suggests that the use of hand guns, shot guns, and high-capacity magazines may also play an important role in mass shootings (
      • Blau B.M.
      • Gorry D.H.
      • Wade C.
      Guns, laws and public shootings in the United States.
      ). Furthermore, 34% of individuals responsible for mass shootings were prohibited from possessing firearms (
      • Everytown for Gun Safety
      Mass Shootings in the United States: 2009–2016.
      ), underscoring the need for policies such as universal background checks and affirmative removal laws requiring prohibited possessors to relinquish firearms. Funding for firearms-related research has been limited in the U.S. by Congress for the past 20 years, as a result of an amendment to the 1996 Omnibus Consolidated Appropriations Bill largely known as the Dickey amendment (
      • 104th Congress
      Omnibus Consolidated Appropriations Act, 1997.
      ). This ban on use of Centers for Disease Control and Prevention monies to “advocate or promote gun control” has limited the knowledge base, and therefore has also limited the ability to create and implement research-informed policies aimed at preventing mass shootings and other forms of gun violence.

      Risk Factors

      Identification of and interventions for factors that increase the risk for violence must be addressed when discussing mass shooting prevention. Individual and family risk factors, including IPV, toxic stress, bullying, and mental health, appear to be among the most relevant in addressing this public health problem.

      Intimate Partner Violence

      IPV, also known as domestic violence, includes physical, sexual, or psychological harm committed by a current or previous intimate partner (
      • Institue of Medicine
      Clinical preventive services for women: Closing the gaps.
      ). IPV accounts for only about 10% of all gun violence but was a factor in 54% of mass shootings between 2009 and 2016 (
      • Everytown for Gun Safety
      Mass Shootings in the United States: 2009–2016.
      ). The Academy has previously provided recommendations regarding development of healthy families (
      • Pearson G.S.
      • Evans L.K.
      • Hines-Martin V.P.
      • Yearwood E.L.
      • York J.A.
      • Kane C.F.
      Promoting the mental health of families.
      ) and supporting screening and counseling for violence against women in primary care settings (
      • Amar A.
      • Laughon K.
      • Sharps P.
      • Campbell J.
      Screening and counseling for violence against women in primary care settings.
      ). However, considering IPV is so largely involved in mass shootings, attention to identifying and addressing dangerousness of IPV is also warranted.

      Toxic Stress

      Children who have persistent exposure to adverse childhood experiences (ACEs), such as abuse, neglect, death of a parent, family dysfunction (e.g., violence among parents), or living with someone who abuses alcohol or drugs, are at greater risk for committing acts of violence (
      • National Center for Injury Prevention and Control, Division of Violence Prevention
      About Adverse Childhood Experiences.
      ). Toxic stress is the compounded effect of ACEs throughout early childhood with a recent U.S. study reporting one in five children ages birth to 17 experienced two or more ACEs and were significantly more likely to be at higher risk for developmental, behavioral, or social delays compared with children who had no exposures (
      • Bethell C.D.
      • Newacheck P.
      • Hawes E.
      • Halfon N.
      Adverse childhood experiences: Assessing the impact on health and school engagement and the mitigating role of resilience.
      ).

      Bullying

      Bullying has been associated with harmful short- and long-term consequences and is a risk factor for violence. Individuals who commit bullying and are targets of bullying both appear to be at greater risk for poor psychological and social outcomes as children and adults (
      • National Academies of Science
      Preventing bullying through science, policy, and practice.
      ). Given that experiences of bullying and rejection of peers have been noted to contribute to mass shootings, addressing bullying in schools has been identified as a key strategy to prevention (
      • Bjelopera J.P.
      • Bagalman E.
      • Caldwell S.W.
      • Finklea K.M.
      • McCallion G.
      Public mass shootings in the United States: Selected implications for federal public health and safety policy.
      ).

      Mental Health

      Mental health is an important part of wellness that is challenged by exposure to toxic stress, bullying, and IPV. These experiences induce a stress response among individuals and may contribute to traumatic symptoms, depression, substance abuse, antisocial behavior, and other negative mental and physical health consequences (e.g., changes in neuroplasticity and brain function) that can serve as risk factors for future violence (
      • Campbell J.
      • Jones A.S.
      • Dienemann J.
      • Kub J.
      • Schollenberger J.
      • O'Campo P.
      • Wynne C.
      Intimate partner violence and physical health consequences.
      ,
      • Cook A.
      • Spinazzola J.
      • Ford J.
      • Lanktree C.
      • Blaustein M.
      • Cloitre M.
      • van der Kolk B.
      Complex trauma in children and adolescents.
      ). Research on the psychology of mass shooters has described how exposure to adverse experiences, in combination with minimal bonding to people, not being involved in school, work or a community, and isolation, contribute to an internal psychological world filled with bitterness, resentment, rage, paranoia, and vengeance seeking (
      • Dutton D.G.
      • White K.R.
      • Fogarty D.
      Paranoid thinking in mass shooters.
      ,
      • Reid Meloy J.
      • Hoffmann J.
      • Guldimann A.
      The role of warning behaviors in threat assessment: An exploration and suggested typology.
      ). Repeated interpersonal failures, conflict, or frustration, accompanied by the inability to handle or resolve such situations, can precipitate violent events and lead to explosive behaviors. It is important to note, however, that although mental illness may be more likely in those who commit mass shootings, the vast majority of individuals diagnosed with a mental health disorder do not commit mass shootings (
      • Metzl J.M.
      • MacLeish K.T.
      Mental illness, mass shootings, and the politics of American firearms.
      ). Additionally, mass shootings themselves can contribute to poor mental health outcomes, particularly for the growing numbers of survivors of these incidents (
      • Lowe S.R.
      • Galea S.
      The mental health consequences of mass shootings.
      ).

      Missed Opportunities to Intervene

      As observed in the recent school mass shooting in Parkland, Florida, the shooter appeared to have had many “red flags.” Investigations to date indicate that systems surrounding this child may have missed various opportunities to proactively intervene. Reports are that this young shooter had interactions with Child Protective Services, and was the subject of various 911 calls and tips to the Federal Bureau of Investigation. Additionally, he lost both parents, may have engaged in self-harm behaviors such as cutting, had a propensity to abuse animals, posted disturbing messages on social media that were at times concerning for his peers, and had been expelled from his high school for disciplinary reasons (
      • Rose J.
      • Booker B.
      Parkland shooting suspect: A story of red flags, ignored. All things considered.
      ). If these initial findings are corroborated, multiple support systems around the shooter failed to take advantage of opportunities to identify his pain and stressors, to recognize his risk for committing violence, and to provide interventions that may have possibly prevented the mass shooting.
      Safe, stable, and nurturing relationships and environments are needed to prevent, identify, and address violence (
      • Centers for Disease Control and Prevention
      Essentials for childhood: steps to create safe, stable, nurturing relationships and environments.
      ). Social supports, which can include informal and formal interactions with individuals and organizations such as peers, family, schools, parish or religious communities, health-care providers, social services, and law enforcement, among others, all have a responsibility in establishing healthy environments for children and families. There are several evidence-based strategies demonstrated to improve social supports and environments that promote wellness and prevent violence. These include Family-Nurse Partnerships, parenting programs, IPV prevention, access to school nurses, support for parents, mental health and substance abuse treatment, high-quality child care, and income support for low income families (
      • Centers for Disease Control and Prevention
      Essentials for childhood: steps to create safe, stable, nurturing relationships and environments.
      ,
      • Maughan E.D.
      • Cowell J.
      • Engelke M.K.
      • McCarthy A.M.
      • Bergren M.D.
      • Murphy M.K.
      • Vessey J.A.
      The vital role of school nurses in ensuring the health of our nation's youth.
      ). As we address mass shootings, it is important to support the implementation of family-, school-, and community-based programs with demonstrated success in preventing and addressing the toxic stress, bullying, mental health, and violence cascades that are often underlying mass shootings and other forms of violence.

      Responses and Policy Options

      The cycle of public outcry followed by legislative inaction must end. At the state level, successes have been made in improving background check and permitting policies, removal of firearms from individuals at risk for perpetrating violence against themselves or others, and limiting access to the most dangerous types of weapons (
      • Chapman S.
      • Alpers P.
      • Agho K.
      • Jones M.
      Australia's 1996 gun law reforms: Faster falls in firearm deaths, firearm suicides, and a decade without mass shootings.
      ,
      • Koper C.S.
      • Johnson W.D.
      • Nichols J.L.
      • Ayers A.
      • Mullins N.
      Criminal use of assault weapons and high-capacity semiautomatic firearms: An updated examination of local and national sources.
      ,
      • Lee L.K.
      • Fleegler E.W.
      • Farrell C.
      • Avakame E.
      • Srinivasan S.
      • Hemenway D.
      • Monuteaux M.C.
      Firearm laws and firearm homicides: A systematic review.
      ,
      • Pierce G.L.
      • Braga A.A.
      • Wintemute G.J.
      Impact of California firearms sales laws and dealer regulations on the illegal diversion of guns.
      ,
      • Wintemute G.J.
      • Frattaroli S.
      • Claire B.E.
      • Vittes K.A.
      • Webster D.W.
      Identifying armed respondents to domestic violence restraining orders and recovering their firearms: Process evaluation of an initiative in California.
      ). The Academy has previously supported legislative efforts to address gun violence and its causes, including the Assault Weapons Ban of 2013, and the Protecting Domestic Violence and Stalking Victims Act. However both bills were unsuccessful and have been reintroduced for consideration in the 115th Congress.
      On February 22, 2018 the governors of New York, New Jersey, Connecticut, and Rhode Island announced the formation of the States for Gun Safety Coalition to address the federal inaction regarding gun policy (
      • New York State Governor's Office
      Governors Cuomo, Malloy, Murphy and Raimondo Announce “States for Gun Safety” Coalition to Combat the Gun Violence Epidemic [press release].
      ). They aim to share data essential to completing comprehensive background checks as part of gun purchasing, registration, and licensing processes, to establish a regional gun violence research consortium, and to develop policy options to address access to firearms and cross-state law enforcement cooperation to enforce firearms policies. This partnership is applauded by the Academy, and may serve as a model for a federal commission and legislation.

      The Academy's Position

      The Academy has a history of supporting efforts to shape healthy behaviors and environments and has championed policy-related initiatives to keep children, parents, families, and the public safe. The Academy calls for the establishment of a nonpartisan National Commission on Mass Shootings (
      • American Academy of Nursing
      American Academy of Nursing Calls for National Commission on Mass Shootings [press release].
      ). This commission should be charged with distinguishing key factors that contribute to mass shootings and identify actionable solutions that can be employed by public health and governmental agencies, health-care organizations, individuals, and the general public. The Academy also supports an increase in federal funding for gun violence research and advocates for the development of evidence-based firearms laws. Lastly, the Academy supports public health initiatives addressing individual, family, and community risk factors for mass shootings, including toxic stress, bullying, domestic violence, mental health problems, and missed opportunities for individuals and systems to prevent this type of violence.

      Recommendations

      After considering the multidimensional influences on mass shootings and potential solutions, the American Academy of Nursing recommends the following:
      • The establishment of a nonpartisan National Commission on Mass Shootings to distinguish key factors contributing to mass shootings and to identify actionable solutions.
      • Expansion of funding for research to examine root causes of gun violence (including mass shootings), and supporting the development, implementation, and evaluation of strategies aimed at preventing gun violence and its consequence.
      • Along with a ban on high-capacity ammunition magazines and assault weapons, the Academy urges policymakers to implement our recommendations for reducing firearm violence, including universal background checks and closing the loopholes that exempt nonmarital partners and stalkers from firearms prohibitions (
        • Amar A.
        • Beeber L.
        • Laughon K.
        • Rice M.J.
        Reducing firearm violence.
        ).
      • Support for ongoing evaluation of universal and targeted family-, school-, and community-based violence prevention programs addressing IPV, toxic stress, bullying, mental health, and other contributing factors. In particular, universal access to a school nurse is one promising intervention to identify and address mental health concerns among youth (
        • Maughan E.D.
        • Cowell J.
        • Engelke M.K.
        • McCarthy A.M.
        • Bergren M.D.
        • Murphy M.K.
        • Vessey J.A.
        The vital role of school nurses in ensuring the health of our nation's youth.
        ).
      • Development and evaluation of payment models to support the implementation of evidence-based programs addressing mental health promotion, maintenance, and treatment—including building resilience for individuals, families, and communities experiencing toxic stress, bullying, and IPV (
        • Amar A.
        • Laughon K.
        • Sharps P.
        • Campbell J.
        Screening and counseling for violence against women in primary care settings.
        ,
        • Pearson G.S.
        • Evans L.K.
        • Hines-Martin V.P.
        • Yearwood E.L.
        • York J.A.
        • Kane C.F.
        Promoting the mental health of families.
        ).
      • Development of policies to strengthen and fund screening for dangerousness and collaboration between community crisis management teams and federal teams. When an individual threatens or demonstrates high risk of perpetrating, a mass shooting a standardized local and national risk assessment and intervention response should follow. The multidisciplinary team should provide direction for law enforcement and support for the individual, family, and community. Membership on crisis management teams must include representation from nursing, public health, law enforcement, and social services.

      Acknowledgments

      The authors would like to acknowledge the contributions of Gordon Lee Gillespie, PhD, DNP, RN, CEN, CNE, CPEN, PHCNS-BC, FAEN, FAAN, Rachell A. Ekroos, PhD, APRN, FNP-BC, AFN-BC, FAAN, Annie Lewis O'Connor, PhD, NP-BC, MPH, FAAN, Eileen M. Sullivan-Marx, PhD, RN, FAAN, and the members of the American Academy of Nursing Violence Expert Panel for reviewing and providing suggestions for this policy brief.

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