Firearm violence is a significant public health issue in the United States (U.S.) (The U.S. Surgeon General’s Advisory 2024). In 2022, more than 48,000 total people died from firearm-related injuries, including intentional self-inflicted, unintentional, interpersonal, legal intervention, and undetermined causes (CDC, 2024). In a more recent study conducted by Schumacher and colleagues, a majority (54%) of U.S. adults or their family members reported experiencing a firearm-related incident, and nearly six in ten adults said that they worry “sometimes,” “almost every day,” or “every day,” about a loved one being a victim of firearm violence (Schumacher et al., 2023). The pediatric population, in particular, is at risk of firearm-related deaths as most of the firearms used are obtained from the home of a child (Osborne et al., 2024). Firearm-related injury has been the leading cause of death for U.S. children and adolescents ages 1-19 (Goldstick et al., 2022). This paper discusses a recommendation for firearm screening and firearm safety to be integrated into home healthcare visits in the State of New York.
Communities in the State of New York, participating in gun violence elimination initiatives, reported their lowest levels of gun violence in 2024. According to data, shooting incidents with injury decreased 28% in 2024 compared to 2023, while 238 fewer individuals were harmed by gunfire. Gun violence elimination initiatives support individuals and families and are strengthening communities for many New Yorkers. However, continued and expanded initiatives that prevent acts of gun violence and expand support for victims and survivors of gun violence are needed (New York State website, January 29, 2025).
It is the position of the New York State Nurses Association (n.d.) that nurses “increase their understanding of the issue of gun violence, and develop skills to prevent, advocate, and intervene when necessary” (p.1) and recommends including a gun safety assessment as part of routine health screenings for all patients. Home healthcare nurses provide services and care to patients and families in their home environment. Patients and families may experience gun violence or may be at risk for being a victim of gun violence. Given this, home healthcare nurses are in a uniquely vulnerable position, as their practice environment lacks the security measures often provided in acute care settings. Studies have found that violence toward home healthcare workers is common and underreported (Phoo & Reid, 2020; Zhong & Shorey, 2022).
In addition to concerns about home healthcare workers safety, screening for the safe storage of a firearm in the home provides an opportunity to offer firearm safety education. Nurses can assess for risk factors that could lead to the unsafe use of the firearm including self-harm or harm to others. Safe handling and firearm storage education decreases the potential for any unintentional injury. Screening identifies any potential safety issues and captures what is going on in the patient’s life, especially when firearms are used irresponsibly. Assessing firearm safety and for an experience of firearm violence is an important intervention to incorporate when providing home healthcare.
Hallowell and Cogan (2023) described nurses as healthcare professionals who are trusted and strategically positioned in communities to increase awareness, provide education, and develop and lead intervention efforts to address the complex factors contributing to firearm violence. Nurses possess the academic preparation and clinical skills that allow them to effectively screen patients and families for risk factors, educate and counsel patients and families, and provide resources and referrals to address safety concerns (Drake et al., 2023). However, education on firearm safety is lacking in nursing curriculum and in continuing education programs. Nurses must often address situations involving firearm violence with limited knowledge, training, and experience. Furthermore, there is a lack of standardized and universal firearm violence screening guidelines, knowledge about community resources, and nurses lack the confidence to discuss firearm safety with patients and families (Drake et al., 2023). Therefore, the authors of this commentary support a systems-based approach toward educating all nurses, especially home healthcare nurses, about firearm safety.
Finally, we recommend the inclusion of screening questions regarding firearm safety and violence prevention in home healthcare agency-specific electronic health records. In the 1990s, Centers for Medicare and Medicaid Service (CMS) (at the time named the Health Care Financing Administration) and the Robert Wood Johnson Foundation funded research to develop, test, and refine a system of outcome quality measures that Medicare and home health agencies could use to continuously improve the effectiveness of home health care (Shaughnessy et al., 1994). This data set is now titled the ‘Outcome and Assessment Information Set’ (OASIS) and is used to evaluate quality measures and outcomes-based quality improvements. The OASIS data is collected by Medicare-certified home health agencies and Medicaid home health providers in states, including New York, where the law requires agencies to meet the Medicare Home Health Conditions of Participation. OASIS is not intended to represent the comprehensive assessment, but it is expected to be incorporated into a home health agency’s comprehensive assessment documentation in accordance with their own policies and procedures. The guidance manual lists the time points for collecting the OASIS items based on a patient-centered assessment in addition to required assessment timeframes. Most OASIS data collection time points (e.g. Start of Care, Resumption of Care, Follow-up, and Discharge) require the clinician to have an in-person patient encounter during a home visit. Completing the OASIS data collection is the responsibility of the registered nurse or therapists (e.g. physical therapy, speech language pathology/speech therapy, or occupational therapy). The authors of this commentary support improvements to the Centers for Medicare and Medicaid OASIS Version E1 (OASIS-E1) Instrument (Centers for Medicare and Medicaid, n.d.) to include firearm screening and assessing for an experience of firearm violence. Exploring simple questions about firearm safety is necessary when addressing firearm safety. Asking questions such as, “If you have firearms in your home, do you keep them unloaded and locked?,” “If you have firearms in your home, do you keep the ammunition stored in a locked area away from the firearm?,” and “Have you experienced firearm/gun violence in your lifetime?” may initiate a discussion about safe storage and handling as well as interventions to reduce trauma and suffering related firearms. Offering firearm prevention strategies including tips about gun safety (safely securing weapons, safely securing ammunition, firearm safety devices such as trigger locks and cable locks) in the home and how to dispose of unwanted weapons in the community may be included in the steps to reduce firearm-related incidents. With the rising urgency and relative ease this recommendation provides, there is a need to normalize firearm safety and violence prevention measures in our healthcare systems and the home healthcare setting. Firearm screening may lower the risk of a future firearm injury and assessing for an experience of firearm violence may provide an opportunity to support victims and survivors of gun violence.
References
Centers of Disease Control and Prevention. (2024, July 5). About Firearm Injury and Death. Firearm Injury and Death Prevention. https://www.cdc.gov/firearmviolence/about/index.html
Centers for Medicare and Medicaid Services. (n.d.). Outcome and Assessment Information Set OASIS-E1 Manual (Effective January 1, 2025). https://www.cms.gov/files/document/oasis-e1-manualfinal12-9-2024.pdf
Drake, S. A., McDaniel, M., & Pepper, C. (2023). A scoping review of nursing education for firearm safety. Nurse Education Today, 121, Article 105713. https://doi.org/10.1016/j.nedt.2023.105713
Goldstick, J. E., Cunningham, R. M., & Carter, P. M. (2022). Current causes of death in children and adolescents in the United States. The New England Journal of Medicine, 386(20), 1955-1956. https://doi.org/10.1056/NEJMc2201761
Hallowell, S., & Cogan, R. (2023). Nursing’s role in firearm violence prevention. OJIN:The Online Journal of Issues in Nursing, 28(3). https://doi.org/10.3912/ojin.vol28no03man01
New York State Nurses Association. (n.d.). Position statement: On gun violence. https://www.nysna.org/position-statement-gun-violence
New York State Website. (January 29, 2025). Governor Kathy Hochul. Accessed at https://www.governor.ny.gov/news/governor-hochul-announces-safer-streets-gun-violence-communities-participating-states-gun
Osborne, M. C., Guastaferro, K., Banks, S., Vedantam, H., & Self-Brown, S. (2024). Firearm screening and secure storage counseling among home visiting providers: A cross-sectional study of SafeCare® providers in the U.S. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1324656
Phoo, N. N. N., & Reid, A. (2022). Determinants of violence towards care workers working in the home setting: A systematic review. American Journal of Industrial Medicine, 65(6), 447–467. https://doi.org/10.1002/ajim.23351
The U.S. Surgeon General’s Advisory. (2024). Firearm Violence: A Public Health Crisis in America. https://www.hhs.gov/sites/default/files/firearm-violence-advisory.pdf
Schumacher, S., Kirzinger, A., Presiado, M., Valdes, I., & Brodie, M. (2023). Americans’ experiences with gun-related violence, injuries, and deaths. KFF. https://www.kff.org/other/pollfinding/americans-experiences-with-gun-related-violence-injuries-and-deaths/
Zhong, X. F., & Shorey, S. (2022). Experiences of workplace violence among healthcare workers in home care settings: A qualitative systematic review. International Nursing Review, 70(4), 596–605. https://doi.org/10.1111/inr.12822
