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Active Shooting Event: How Should Nurses Respond?

Responding to Extreme Violence

Nurses General Nursing Article   posted

Specializes in Clinical Leadership, Staff Development, Education.

Once thought as the “unthinkable”, active shooter events can happen anytime and in any healthcare setting. There are unique challenges in preparing and responding to an active shooter in inpatient and outpatient facilities. However, nurses can develop personal protective skills and habits that will prepare them to respond when faced with extreme violence.

Active Shooting Event:  How Should Nurses Respond?
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The number of hospital-related shootings has consistently increased over the past 10 years. Once thought of as “the unthinkable”, active shooter events can happen anytime, anywhere in any healthcare setting in today’s world. In 2016, OSHA updated healthcare safety Rule 3148, "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers", in response to rising active shooter threats. Every healthcare facility is now required to incorporate an active shooter incident plan into its emergency medical response plan; taking into account the facility’s size, different departments, geographical setting, patient access, available security and exits.

Healthcare’s Unique Challenges

There are unique challenges in preparing and responding to active shooter events in healthcare settings. A hospital may have hundreds to thousands of patients every day and in many different departments. In addition to high patient volumes, other challenges include:

  • Potentially large and vulnerable patient populations (i.e. immobile, elderly)
  • Increased number of entrances and exits
  • Nurses and staff feel compelled to stay with patients
  • Hazardous materials and locked units

The large magnets in MRI machines can cause issues with firearms or even remove it from the hands of law enforcement. Christina Catlett, MD, associate director of Johns Hopkins Office of Critical Event Preparedness and Response, reports hospital shootings tend to be more targeted, “where the motive was grudge, or suicide, or euthanizing an ill relative”.

3 Protective Skills You Need to Develop

David W. McRoberts, CPP, is a retired police captain,, a security consultant and co-author of the course “Active Shooter Event in a Healthcare Environment”. McRoberts shares three personal protection skills nurses need to develop into habits for responding to an active shooting event.

Situational Awareness

Be in tune with your surroundings, knowing exactly where you are, where you are moving to or from, and what exists around you in terms of your realistic ability to react to what is taking place.

It Can Happen Anywhere

As nurses, we must acknowledge the “unthinkable” and bad things can happen. Nurses should not work through each day paranoid, but just know, it can happen anywhere and without warning.

See the Threat

Nurses need to develop the habit of looking for threats. And, when they see a threat, have the ability to suspend disbelief. McRoberts emphasizes the importance of nurses not “becoming paralyzed with shock and fear and fall victim simply because they never once even considered the fact they would need to function in a moment of the gravest extreme”.

Life Saving Questions Asked

In an article published in MedPage , McRoberts answered 3 common questions nurses ask when raising awareness about active shooting events.

What Do I Do When Shots Are Fired?

Nurses have an ethical and moral responsibility to care for others. Therefore, the answer to this question is not always easy to answer. Active shooting events last about 2 minutes (on average) and victims can be specifically targeted or random. McRoberts believes it is essential to create or increase the “reactionary gap”. There are several things that nurses need to understand when creating distance or cover from the threat:

  • You may need to leave the immediate area of patient care and return to patients when the threat is over
  • Shooter’s objective is to kill people and nurses remaining immovable will likely become victims
  • It is better to move away and return to patients when the event is over

Do I Interact?

As professional caregivers, a nurse’s first reaction in a shooting event is to help the injured. However, in many reported events, nothing stops the killing until the shooter stops or is stopped. Therefore, it is unlikely that a nurse could effectively plead or reason with the shooter.

How Do I Keep a Clear Head?

Developing your personal protective skills is the best way to prepare for an active shooter. Each skill provides action items for the nurse, providing the best chance to survive. Also, consider the body’s response to high stress, such as altered perception of time, temporary loss of hearing and loss of fine motor skills. Our physical reaction diminishes the ability to cope under duress. However, it is possible to develop our ability to function through the high stress of an active shooter event with practice. McRoberts suggests activities to practice under simulated stress, such as finding and climbing nearby stairs, then calling someone and clearly describing your location. Practicing these simple actions will help nurses build the skills needed to protect themselves and others.

Important Take-aways

Here are a few summary pearls about what nurses should and shouldn’t do in an active shooter event.

  • Look for and acknowledge the threat and then react to it
  • Don’t panic and freeze
  • Although the event’s timeframe will be perceived as very long, remember it will take only about 2 minutes.
  • Be confident, knowing you can function through the event
  • Know your surroundings and where to move for safety.
  • Know what information needs to be communicated to others
    • Including what is required by your facility’s policies and procedures
  • Know you may need to move more than once
  • Don’t try to negotiate or plead with an active shooter

What training has your facility provided to prepare you to respond in an active shooting?

Did any of the training include simulation?

Additional Resources

FBI Publication- Active Shooter Planning and Response in a Healthcare Setting

Article- Why is it Difficult for Hospitals to Address Active Shooter Threats

National Center for Biotechnology Information - Stat-Pearls: Active Shooter Response

J. Adderton MSN has over 20 years experience in clinical leadership, staff development, project management and nursing education. Her years of experience provide the expertise needed to write on a variety of topics, however, promoting student success is a favorite topic.

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Snatchedwig, ADN, CNA, LPN, RN

Specializes in Medsurg.

Very unsettling that we have to have this conversation. Similar that children have to wear bullet proof backpacks. With all that said, if a shooting starts I would be the first one out this motha.

Serhilda, ADN, RN

Specializes in Cardiac Telemetry, ICU.

When we had a mass shooter enter our hospital, most of our employees didn't take it seriously when it was announced. They assumed it was a drill. Others hid behind locked doors while the shooter hid in our chapel. Personally, I'd be running out of there in a heartbeat, license and "patient abandonment" claims be damned. He was apprehended before anyone was injured, but in the time it took police to get there, he could've shot dozens on our first floor.

I'm not going into hero mode. I'm saving my own behind. Nurses have enough unrealistic expectations put upon them, I'm not sacrificing my life too.

Pixie.RN, MSN, RN, EMT-P

Specializes in EMS, ED, Trauma, CNE, CEN, CPEN, TCRN.

I kept an expired 28 fr thoracic trochar in my office for self-defense. Very pointy. I am perfectly serious. I learned while deployed that I face situations head-on, so if I got to the "fight" part of the "run-hide-fight" triad, I would defend myself and my peeps with extreme prejudice.

My Army hospital had a situation with a behavioral health patient arriving with a bag of guns. Luckily no one was injured, but I know some of the people at gunpoint ended up with post-traumatic stress.


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