Improving Active Shooter Response Guidelines: Mobilizing Nurse Leaders for Action
Since 2020, a notable increase in mass shooting incidents throughout the United States has occurred. According to data from The Joint Commission covering the period from 2010 to 2020, 39 reports involving shootings occurred in a health care facility, resulting in 39 fatalities. Health care staff made up more than half of those fatalities. Active shooter events exhibit a wide range of variables, much like the health care settings where they unfold. Each incident presents unique challenges influenced by factors such as facility design, its location, communication processes and the specific circumstances of the event. As a health care improvement company serving 60% of the nation’s acute care providers, which includes 97% of the nation’s academic medical centers, Vizient Inc., based in Irving, Texas, is in a position to assist health care organizations in their efforts to respond to and prevent acts of violence.
In 2022, at the prompting of a clinical executive, Vizient initiated a survey of its national clinical network members to assess health care facility active shooter response and preparedness. As the data collected during the survey on active shooter preparedness and response was aggregated and analyzed, memories of my days as a critical care nurse came flooding back. I vividly remembered caring for a patient who was being sustained for the purpose of organ donation. The recipient of his life-saving heart was on the way to the hospital. What would happen if there were an active shooter incident at that moment? How would I know there was an active shooter in the hospital? Would I run, hide or fight? Would I stay with my patient? Would I try to move him to safety? How would I even open the doors while performing manual ventilation?
Addressing this situation would necessitate careful consideration, intention and the involvement of at least two additional individuals to guarantee the patient’s safety. Yet, in that circumstance, most nurses would be alone, without pre-existing plans to address the patient’s intricate clinical requirements. To effectively respond as a nurse, I would concentrate my attention on the patient’s needs and attempt to envision a comprehensive communication and response plan based on the patient’s perspective.
The gaps identified in the Vizient active shooter response and preparedness survey offer insights on the needed work to ensure the well-being of patients, visitors and staff.
Action plan gaps
The survey results from 60 organizations validated that nearly all health care facilities have active shooter response plans. However, the analysis exposed significant inconsistencies and gaps in these plans. One discovery from the survey was the variability in communication practices, highlighting the need for more standardized, effective and direct communication guidelines to ensure a coordinated response.
Another common observation among respondents was the absence of robust plans for managing care for the most critically ill and immobilized patients during such events. These patients often require specialized equipment and continuous attention, and pose a significant challenge to health care facilities during active shooter incidents.
Many organizations also lacked robust post-event response plans to address the long-standing effects of such traumatic incidents. Addressing these issues is imperative to bolster the overall preparedness and response capabilities of health care facilities in ensuring the safety and well-being of patients, visitors and staff during and after active shooter event.
Key survey findings include:
• Active shooter protocol and emergency preparedness: More than 98% of hospital systems surveyed have enacted an active shooter protocol.
• Communication alerts: Clear, concise communication in an emergency can be the difference between life and death. Hospitals historically have relied on codes as a simple way to alert staff to an actual or potential emergency. The survey revealed that reliance on these codes can send an ambiguous message and cause confusion.
• Care for vulnerable patients: Nearly a quarter of surveyed hospital systems have discussed a dedicated plan to ensure continuity of care for patients who are critically ill or otherwise immobile (such as those in active labor, in the operating room, receiving hemodialysis treatment or ventilator dependent).
• Real-time preparedness: Health care organizations that experienced an active shooter event in the past were more likely to practice active shooter response, through drills and simulations, than those health systems that had never experienced an active shooter event.
• Preparedness for the impact and aftermath of active shooter events: In regard to the psychological aftermath, it is noteworthy that 75% of health care organizations have established plans to address the mental well-being of both patients and staff following an active shooter event. Among those with formalized psychological wellness plans, a substantial 90% outlined comprehensive strategies for connecting staff with dedicated employee
assistance programs, trauma counselors and chaplain services. The absence of a comprehensive and robust post-event response plan could have repercussions not only on the immediate recovery and well-being of those directly affected, but also on the long-term resilience and readiness of the health care facility.
Developing guidelines
Vizient hosted a national call to share the survey results with its network members in December 2022. Hundreds of individuals from hospitals and health systems across the nation participated during a closing call to action to join Vizient in developing industry active shooter guidelines specifically to address the gaps and inconsistencies identified in the survey results.
During the following weeks, Vizient developed a member-driven Active Shooter Hospital Preparedness Task Force comprised of a variety of providers, administrators and security staff – including front-line nurses, nurse leaders, surgeons and patient safety officers. The task force met sometimes multiple times per month over the next nine of months.
Though there was limited evidence-based literature, the task force – which consisted of 40 individuals from 27 member hospitals and health systems – reviewed protocols from federal and private organizations to identify and develop focused leading practices, which will be available to the public on Vizient’s website in 2024. These guidelines are meant to point hospitals to evidence-based literature and guide hospitals in addressing the gaps and inconsistencies in communications, response plans, drills and post-event responses. Because an active shooter situation can occur anywhere within a health care facility, the guidelines are appropriate in diverse settings, including large and small organizations, inpatient and ambulatory, as well as those in rural and urban settings. Included in the practices are recommendations such as using plain language and sample resources that have been successfully deployed in health care organizations.
The hope is that every health care organization will access and use these resources in its planning. Doing so will help ensure that when the next active shooter incident occurs, every provider – whether they are bedside with an ambulatory patient, providing care to infants in the neonatal intensive care unit (NICU), or in a surgical suite about to begin a life-saving procedure – knows exactly what to do for their patient and for themselves.
The primary objective of the dissemination of national consensus-based guidelines and resources is to accelerate the recognition of knowledge gaps, bolster the effectiveness of response protocols and sustain this crucial conversation to drive meaningful change. By providing comprehensive, up-to-date information, these resources act as a diagnostic tool for pinpointing areas where health care leaders’ understanding may be incomplete or in need of refinement. This awareness is essential because it allows health care stakeholders to prioritize safety.
However, this collaborative effort is not limited to health care practitioners alone; it extends to the engagement of the broader community. By making these resources widely accessible, Vizient is empowering individuals at all levels to play a pivotal role in fostering a safer environment for patients, visitors and staff.
Engaging nurse leaders for change
To enact substantial change within hospitals and health care systems nationwide, the dialogue must begin at the unit level. Nurse leaders are responsible for care at the front line and can provide valuable input.
The voice of the nurse leader is a critical component in the development of all phases of the emergency response plan including communications, physical security, drills and simulations, and post-event plans and responses. Of note, post-event plans and responses are crucial because they prioritize the mental health and well-being of those affected by active shooter events, which often are the nurses at the bedside with the patients. The nurse leader has an opportunity to ensure these plans reduce the risk of long-term psychological consequences and contribute to healing and resilience of front-line nurses and other health care facility staff. Taking care of our health care teams is an important aspect of active shooter plans. And for the safely of all – staff, visitors and especially our most vulnerable patients – health leaders should prioritize this vital undertaking to ensure a safer health care environment in the future.
The author would like to thank Jodi Eisenberg for her contributions and work on this article.
ABOUT THE AUTHOR AND CONTRIBUTOR
Susan Chishimba, MSN, RN, is senior member networks director at Vizient Inc., Chicago. 
Jodi Eisenberg, MHA, CPHQ, is associate vice president, member networks at Vizient, Inc., Chicago.
