Position

The American Academy of Nursing (Academy) has long supported policies to reduce firearm violence.^1,2,3 Firearm violence, from suicides to mass shootings, is an epidemic in the United States, and as such, a public health approach to addressing the causes and risk factors leading to violence is necessary to safeguard the health of the nation.

Background

Firearm violence remains a serious American public health crisis that has been exacerbated in recent years. According to a Pew Research Center survey, around half of Americans see firearm violence as a very big problem in the country today.⁴ Firearm-related violence is highest among teens and young adults fifteen to thirty-four, including those from underserved populations due to systemic and social factors.⁵ More than 45,000 Americans were killed in firearm-related deaths, resulting in over 120 people dying each day.⁵ Firearms are also the leading cause of death for American children and teens.⁶ Given the sobering rise in injury and death, current policies may be expanded and a greater investment must be made to save lives and promote safer communities.

Public Health Research

A public health approach to increasing firearm safety and reducing firearm-related injuries and deaths is vital to address this crisis. The foundation of a public health approach through rigorous evidence-based research can identify opportunities for reducing morbidity and mortality. Federally funded public health research has a proven track record of reducing public health-related deaths. Examples of this type of health research include related issues such as smoking, Sudden Infant Death Syndrome, and many others. For the past three years, the Department of Health and Human Services funding for firearm morbidity and mortality prevention research has been provided to the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). The CDC has funded awards for two- and three-year projects to improve the scientific understanding of firearm-related violence and to rigorously evaluate the effectiveness of prevention strategies.⁷ These projects provide valuable information on how to reduce suicide risk in U.S. Army soldiers and veterans and how to improve efforts to reduce urban firearm injuries, among other topics. The NIH is funding research on the determinants of firearm injury, the identification of those at risk, and the evaluation of innovative interventions.^8,9 Other federal agencies have also been researching this issue. More research continues to be needed in this area.

Universal Background Checks

Firearm ownership should require a universal background check that can identify those legally precluded from owning a firearm and be uniformly mandated across all states. The Brady Handgun Violence Prevention Act (Public Law 103-159) requires federally licensed dealers to perform background checks for firearm purchasers.¹⁰ When individuals are seeking to purchase a firearm in person or online from an unlicensed dealer, they should be required to complete a background check. States that require unlicensed dealers to perform background checks, such as those from online sales and at gun shows, have a 10 percent lower homicide rate compared to states that do not require purchasers to undergo a background check from unlicensed dealers.¹¹ Additionally, policies should be developed and enforced to prevent the ability to avoid a background check to obtain a firearm.   

Semi-automatic Assault Weapons

Mass shooting fatalities were 70 percent less likely to occur during the ten years that the Public Safety and Recreational Firearms Use Protection Act, Title IX, Subtitle A of the Violent Crime Control and Law Enforcement Act (Public Law 103-322),¹² banned the “manufacture, transfer, and possession of certain semiautomatic firearms designated as assault weapons and ‘large capacity ammunition magazines’”, including weapons holding more than five rounds of ammunition.¹³ While there are currently limitations on purchasing automated weapons, there is no universal definition for “semi-automatic” assault weapons. A clear definition of semi-automatic assault weapons and high-capacity ammunition magazines that are restricted for use by civilians should be developed. Additionally, with the capability to manufacture firearms at home, and produce firearms through 3-D printing technology, as well as modifications to small firearms to convert them into automatic weapons, policies should be developed to prevent firearm violence with this largely unregulated production.

Violence Prevention

Risk laws vary state by state and should be implemented nationally to protect individuals who are married and/or dating someone who may inflict harm to them or others using a firearm. There are restrictions for married spouses with a history of domestic abuse that prevents these offenders from purchasing guns.¹⁴ However, this restriction does not currently apply to partners, boyfriends/girlfriends, and other non-married individuals. This “boyfriend loophole” is significant, given that an average of 70 women are shot and killed each month and access to a gun in settings with domestic abuse makes it five times more likely that a woman will be killed.^15,16 Extreme risk laws, or red flag laws, allow loved ones or law enforcement to petition a court for an order to temporarily prevent a person in crisis from harming themselves or others by removing access to guns and prohibiting the purchase of firearms.^17,18 These risk laws vary state by state and should be implemented nationally to protect individuals who are married and/or dating someone who may inflict harm to them or others using a firearm.

Although firearms are the leading cause of death for children under age 18 in the United States,⁶ researchers say 4.6 million children are living in homes with at least one unlocked and loaded firearm, leading to unintentional deaths and shootings.¹⁹ Firearm safety and violence prevention training is a step in the right direction to reduce children’s access to firearms in their own homes, leading to a reduced rate of unintentional deaths, school shootings, and suicides.²⁰ Educating firearm owners about safe storage practices are necessary to protect lives. While Federal law requires firearm dealers to provide a secure firearm storage or safety device with the sale of every firearm, it does not require firearm owners to utilize them.²¹ Clinician intervention using well-informed interventions for firearm injury prevention helps reduce injuries and deaths by educating patients about firearm ownership and safe storage.²² Nurses have a professional and ethical duty and play a key role in educating the public on the importance of firearm safety and violence prevention.

Mental Health Services

Children and adults with persistent exposure to adverse childhood experiences (ACEs) are at a greater risk of trauma and developing mental health conditions at all stages of life.²³ These experiences could contribute to the risk of firearm-related violence in communities. However, it must be noted that only a minority of individuals who commit acts of violence or mass shootings have mental health issues. Research has shown that only four percent of interpersonal violence can be attributed solely to a mental illness.²⁴ Increased access to mental health services is imperative to provide tools, resources, and support systems to individuals who may commit acts of violence.

Suicide Prevention

While the U.S. Department of Health and Human Services has introduced the 988 Suicide & Crisis Lifeline²⁵ ensuring all Americans have access to help during mental health crises, this is only one strategy to prevent suicides from being a leading cause of death by firearms. In the United States, gun violence conversations center around homicides, but six out of every ten deaths by guns are suicides.²⁶ Studies show that the ability to access firearms as well as firearm suicide risk varies by geographic location.²⁷ Firearm ownership in rural communities is twice the rate of ownership in urban communities.²⁸ Firearm-related suicides are highest amongst senior adults and populations that live in rural America.^5,26

Moreover, one-third of adolescents live in homes where one or more firearms are accessible increasing the risk of death by suicide.²⁹ Suicide prevention is enhanced by creating environments that reduce risk and enhance protective factors where individuals live, work, and play.³⁰ Successfully combatting firearm-related suicides should involve a robust proactive response. This includes petitioning for extreme risk laws to prevent someone with suicidal thoughts from accessing guns as well as to secure unloaded firearms and ammunition to prevent shootings and suicides. Access to and funding for mental health support services similar to the Family Violence Prevention and Services program³¹ and other violence prevention and intervention programs³² are also beneficial for adults and adolescents who may appear to have a crisis or are considering harming themselves or others.

The Academy calls for a wide-reaching, evidence-based public health approach to address and prevent firearm-related violence and promote firearm safety, including distinguishing key factors that contribute to all types of firearm-related violence while identifying actionable solutions.

1. Strengthen the nursing and health workforce to conduct and lead health screenings, patient counseling, and family-, school-, and community-based violence prevention training and programs to address risk factors such as unintentional shootings, intimate partner violence, toxic stress, bullying, and mental health.

2. Increase funding for all federal health agencies to conduct public health research.

3. Strengthen laws and federally mandate extreme risk protection laws to assure firearm purchases are temporarily prohibited for individuals at high risk for harming themselves or others as well as those with restraining orders or convictions of family violence, domestic violence, and stalking.

4. Require universal background checks for all gun sales, from licensed and unlicensed dealers.

5. Establish a comprehensive definition for “semi-automatic assault weapons” and high-capacity magazines and create policies to regulate firearms being manufactured or converted at home to automatic weapons.

6. Reenact provisions of the Public Safety and Recreational Firearms Use Protection Act, specifically Title IX, Subtitle A of the Violent Crime Control and Law Enforcement Act (Public Law 103-322)¹³

7. Increase the age limit for all firearm purchases to 21 years of age.

8. Expand mental health services for all, including individuals at risk of committing acts of violence.

9. Increase funding for and create evidence-based violence prevention and intervention programs such as the Family Violence Prevention and Services Program³¹ that are rigorously evaluated.

[1] Gonzalez-Guarda, R. M., Dowdell, E. B., Marino, M. A., Anderson, J. C., & Laughon, K. (2018). American Academy of Nursing on policy: Recommendations in response to mass shootings. Nursing Outlook, 66(3), 333-336. https://doi.org/10.1016/j.outlook.2018.04.003

[2] Amar, A., Beeber, L., Laughon, K., & Rice, M. J. (2013, May). Reducing firearm violence. Nursing Outlook, 61(3), 184. https://doi.org/10.1016/j.outlook.2013.04.003   

[3] American Academy of Nursing. (2022, May 17). Gun Violence and Racism are Public Health Crises in America. https://aannet.org/page/gun-violence-and-racism

[4] Schaeffer, K. (2021, September 13). Key facts about Americans and guns. Pew Research Center. https://www.pewresearch.org/fact-tank/2021/09/13/key-facts-about-americans-and-guns/

[5] Fast facts: Firearm violence prevention. (2022, May 4). Centers for Disease Control and Prevention. https://www.cdc.gov/firearm-violence/data-research/facts-stats/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/firearms/fastfact.html

[6] Centers for Disease Control and Prevention, National Center for Health Statistics, WONDER Online Database, Underlying Cause of Death. Data from 2020. Children and teenagers aged 1 to 19, number of deaths by known intent (homicide, suicide, unintentional deaths). Age 0 to 1 calculated separately by the CDC because leading causes of death for newborns and infants are specific to the age group.

[7] Firearm Violence Prevention: Funded Research. (n.d.). Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. https://www.cdc.gov/firearm-violence/php/funded-research/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/firearms/funded-research.html

[8] National Institutes of Health, Office of Behavioral and Social Sciences Research. (2020, September 30). NIH awards grants for firearm injury and mortality prevention research. https://obssr.od.nih.gov/nih-awards-grants-for-firearm-injury-and-mortality-prevention-research/

[9] National Institutes of Health, Office of Behavioral and Social Sciences Research. (2021, September 17). NIH awards 10 grants addressing firearm violence prevention. https://obssr.od.nih.gov/news-and-events/news/director-voice/nih-awards-10-grants-addressing-firearm-violence-prevention

[10] Brady Handgun Violence Prevention Act, Pub. L. No. 103-159 (1993).

[11] Siegel M., and Boine, C. (2019, March 29). What Are the Most Effective Policies in Reducing Gun Homicides?. Rockefeller Institute of Government. https://rockinst.org/wp-content/uploads/2019/03/3-28-19-Firearm-Laws-Homicide-Deaths-Brief.pdf

[12] Subcommittee on Crime, Terrorism, and Homeland Security of the Committee on the Judiciary. (2019, September 25). Protecting America From Assault Weapons. https://www.govinfo.gov/content/pkg/CHRG-116hhrg44091/html/CHRG-116hhrg44091.htm

[13] Violent Crime Control and Law Enforcement Act of 1994. Pub. L. No. 103-322 (1994).

[14] The Educational Fund to Stop Gun Violence/John Hopkins Center for Gun Violence Solutions. (2021, September 13). Domestic violence and firearms. The Educational Fund to Stop Gun Violence. https://efsgv.org/learn/type-of-gun-violence/domestic-violence-and-firearms/

[15] Guns and Violence Against Women: America’s Uniquely Lethal Intimate Partner Violence Problem. (2019, October 17). Everytown for Gun Safety. https://everytownresearch.org/report/guns-and-violence-against-women-americas-uniquely-lethal-intimate-partner-violence-problem/

[16] Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, M. A., Gary, F., Glass, N., McFarlane, J., Sachs, C., Sharps, P., Ulrich, Y., Wilt, S. A., Manganello, J., Xu, X., Schollenberger, J., Frye, V., & Laughon, K. (2003). Risk Factors for Femicide in Abusive Relationships: Results From a Multisite Case Control Study. American Journal of Public Health, 93(7), 1089–1097. https://doi.org/10.2105/ajph.93.7.1089

[17] Extreme Risk Laws. (n.d.). Everytown for Gun Safety. https://www.everytown.org/solutions/extreme-risk-laws/

[18] Extreme Risk Laws. (n.d.). Brady: United Against Gun Violence. https://www.bradyunited.org/fact-sheets/what-are-extreme-risk-laws

[19] Miller, M., & Azrael, D. (2022). Firearm storage in US households with children: Findings from the 2021 national firearm survey. JAMA Network Open, 5(2), e2148823. https://doi.org/10.1001/jamanetworkopen.2021.48823    

[20] Gun Violence, Prevention of (Position Paper). (2019, December 11). American Academy of Family Physicians (AAFP). https://www.aafp.org/about/policies/all/gun-violence.html

[21] Preventable Tragedies: Unintentional Shootings by Children. (2021, August 30). Everytown for Gun Safety. https://everytownresearch.org/report/notanaccident/

[22] Abrams, Z. (2022, April 1). Talking to patients about firearm safety. Monitor on Psychology. https://www.apa.org/monitor/2022/04/ce-firearm-safety

[23] Gun Deaths, Violence and Mental Health. (n.d.). Mental Health America. https://www.mhanational.org/gun-deaths-violence-and-mental-health

[24] Swanson, J. W., McGinty, E. E., Fazel, S., & Mays, V. M. (2015, May). Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Annals of Epidemiology, 25(5), 366–376. https://doi.org/10.1016/j.annepidem.2014.03.004

[25] U.S. transition to 988 suicide & crisis lifeline begins Saturday. (2022, July 15). U.S. Department of Health and Human Services (HHS). https://www.hhs.gov/about/news/2022/07/15/us-transition-988-suicide-crisis-lifeline-begins-saturday.html

[26] Gun Suicide. (n.d.). Everytown for Gun Safety. https://www.everytown.org/issues/gun-suicide/

[27] Spark, T. L., Wright-Kelly, E., Ma, M., James, K. A., Reid, C. E., & Brooks-Russell, A. (2021, October 8). Assessment of Rural-Urban and Geospatial Differences in Perceived Handgun Access and Reported Suicidality Among Youth in Colorado. JAMA Network Open, 4(10), e2127816. https://doi.org/10.1001/jamanetworkopen.2021.27816

[28] Fontanella, C. A., Hiance-Steelesmith, D. L., Phillips, G. S., Bridge, J. A., Lester, N., Sweeney, H. A., & Campo, J. V. (2015). Widening Rural-Urban Disparities in Youth Suicides, United States, 1996-2010. JAMA Pediatrics, 169(5), 466. https://doi.org/10.1001/jamapediatrics.2014.3561

[29] Swanson, S. A., Eyllon, M., Sheu, Y.-H., & Miller, M. (2021). Firearm access and adolescent suicide risk: Toward a clearer understanding of effect size. Injury Prevention, 27(3), 264–270. https://doi.org/10.1136/injuryprev-2019-043605

[30] Reducing Military and Veteran Suicide: Advancing a Comprehensive, Cross-Sector, Evidence-Informed Public Health Strategy. (2021, November). The White House. https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf

[31] Family Violence Prevention & Services Program Fact Sheet. (2020, October). Administration for Children and Families, U.S. Department of Health and Human Services (HHS). https://www.acf.hhs.gov/ofvps/fact-sheet/family-violence-prevention-and-services-program-fact-sheet

[32] Fact Sheet: The Biden Administration's 21 Executive Actions to Reduce Gun Violence. (2022, July 11). The White House. https://www.whitehouse.gov/briefing-room/statements-releases/2022/07/11/fact-sheet-the-biden-administrations-21-executive-actions-to-reduce-gun-violence/