AJN REPORTS
A Cure for Gun Violence Violence intervention programs show promise in treating the public health crisis.
“W
e do need somebody on our side that’s going to be there for us. Because if we don’t, we’re going to feel like, ‘Well, I’m all I’ve got. What do I have to live for?’” This speaker, a young African American man, discussed living in a poor neighborhood of Kansas City, Missouri, in a video played at a “listening session” in that city for the My Brother’s Keeper initiative last August. President Obama started the initiative after the shooting death of Florida teenager Trayvon Martin in 2012. It aims to support young people endangered by gun violence. Indeed, young people and African Americans continue to be disproportionately victimized by shootings and other forms of violence, even though U.S. firearm-related deaths fell nearly 40% between 1993 and 2011, the Bureau of Justice Statistics reported. Every day, 13 young people die violently in this country, and 1,600 of them visit EDs for treatment of injuries sustained in assaults. In 1993 African Americans died by gun violence at three times the rate whites did; by 2010 the rate was lower but still twice that of whites, according to a 2014 study in BMJ Open by Kalesan and colleagues. In the past decade or so, more and more clinicians have adopted a public health model of preventing gun violence. One prominent proponent, a physician named Gary Slutkin, served in Africa and Asia in cholera, HIV, and tuberculosis epidemics. He returned to the United States in the 1990s and began to apply an epidemiologic model to urban street violence. He saw, for instance, that cholera deaths in Bangladesh and homicides in Chicago showed the same patterns of clustering—outbreaks within small groups of people who know one another—which is a key to transmission in any epidemic. And Slutkin knew well the methods used to halt the spread of infectious disease: interrupt transmission, lower the threat of infection in those at highest risk, and alter community norms through education and other interventions. Slutkin launched Cure Violence (http://cureviolence.org), originally called Cease Fire, in one of Chicago’s most violent neighborhoods in [email protected]
Community members attend a candlelight vigil after a shooting at Reynolds High School in Troutdale, Oregon, last June. Photo by Steve Dipaola / Reuters / Newscom.
2000. The initiative trained community members to act as “violence interrupters.” And because as many as 45% of people treated for violent injury sustain another violent injury within five years, the initiative brought together police, clergy, and clinicians to identify those at highest risk for retaliatory, or revenge, violence. Conflict resolution and education would form the basis of reinforcing the area’s “immunity” to violence. The number of shootings fell by 67% in the first year. Since then, several studies have documented the model’s successes, and it has expanded to cities across the United States and around the world. For instance, a 2009 U.S. Department of Justice evalua tion found that three of four sites in a Baltimore, Maryland, program called Safe Streets modeled after Cure Violence showed “large, statistically significant” reductions in fatal and nonfatal shootings, especially at sites providing mediation as a way to resolve conflict. This approach to violence has been adapted in hospitals, where violence intervention programs serving urban communities have operated independently AJN ▼ April 2015
▼
Vol. 115, No. 4
19
AJN REPORTS
or in affiliation with programs like Cure Violence. Such hospital programs may focus their interventions on any number of related issues, such as intimate partner violence, behavioral health, or substance use. Most take a “trauma-informed approach,” one that acknowledges that a violent crime has serious traumatic consequences—for the victim and for her or his entire community. More research is needed, but studies have demonstrated the effectiveness of hospital violence intervention programs in recent years. • The Wraparound Project at San Francisco General Hospital had a six-year reduction in the rate of reinjury in high-risk teens and young adults from 16% to 4.5%, reported Smith and colleagues in the April 2013 issue of the Journal of Trauma and Acute Care Surgery. Interventions involved providing case managers to young victims, referring victims to community resources, and offering legal advocacy. • A randomized controlled trial at the R. Adams Cowley Shock Trauma Center in Baltimore, Maryland, showed that patients treated for violent injuries who received the interventions had half as many convictions of any crime and four times fewer convictions of violent crime at followup more than a year later. The study, by Cooper and colleagues in the September 2006 issue of the Journal of Trauma Injury, Infection, and Critical Care, reported savings of more than $1 million in incarceration costs and $500,000 in health care costs. A team including psychiatric nurses, case managers, and others offered such services as substance abuse treatment, conflict resolution, and employment and educational services.
PROVIDING ALTERNATIVES TO RETALIATION
A Cure Violence partner in Kansas City, Missouri, Aim4Peace (http://kcmo.gov/health/aim4peace) was launched in one historically high-crime Kansas City neighborhood in 2008. It helps the community to “handle its own disputes” through initiatives targeting young people, including life skills and anger management classes, job fairs, conflict resolution, and a hospital-based violence prevention program at Truman Medical Center. The basic premise is that violence is a behavior that can be changed by supporting the creation of healthier community norms. Nurses Mickie Keeling and Teresa Lienhop at Truman Medical Center believe that the ED and trauma center offer unparalleled access to engaging victims, and communities, in ending the cycle of violence. The risk-reduction approach reduced homicide rates by 56% in 2013 in Aim4Peace areas; that’s compared with a 1% increase in homicides citywide. 20
AJN ▼ April 2015
▼
Vol. 115, No. 4
In a recent interview, Keeling said that when a patient with a violent trauma arrives at the ED, she and the hospital chaplain assess the situation and call Aim4Peace. Trained neighborhood residents—the “interrupters”—come quickly to talk with the patient, “even if they have to go to the trauma bay,” she said, which can provide “a moment of clarity” for the wounded person. Nurses in the facility have nearly unanimously supported the initiative, Keeling said. But first they’ve had to understand the contagion infecting their communities. “The issue is that violence is considered the norm in handling problems. What Aim4Peace does is help people in how they live and deal with everyday issues and conflicts,” Keeling said. Lienhop, the director of trauma services at the hospital, agreed that one prime goal is to help victims recognize, even as they’re recovering from their injuries, that there are alternatives to getting even. This requires the cooperation of trauma surgeons, residents, and nurses, as well as clergy and police in the community. Outreach efforts such as the listening session have contributed to the program’s success. But there are barriers, including competition for funding. “When we look at funding in the community, it’s sometimes seen as a scarce resource,” Lienhop said. “But it’s a collaboration. All of us have an important role to play.” Aim4Peace receives funding from a variety of government and private sources, recently receiving a $1.2 million Department of Justice grant. Nurse researcher Mary Muscari, an associate professor and the director of the O’Connor Office for Rural Studies at the Decker School of Nursing, Binghamton University, in New York, has practiced in pediatrics and forensics and now teaches criminology. Mass murders tend to garner a lot of media attention, she said, and debate over gun control legislation in the wake of mass shootings like the one in December 2012 in Newtown, Connecticut, polarize the public into increasingly extreme camps. It’s tempting to want a “quick fix” to gun violence, Muscari said, but the much more complex problem remains the glorification of violence in our culture. The long-term antidote, she said, is empathy. “Shooters objectify. It’s much easier to do damage if a person is an object.” Increasing empathy must begin with children and families, Muscari noted, and one potential benefit in the aftermath of Newtown and other mass shootings is increased attention to the needs of young people, especially those ages 18 to 26, transitioning to adulthood. “We are going in a positive direction,” she said. “We have to ask, ‘What are the risk factors, and how do we minimize risk?’ It’s no different from heart disease.”—Joy Jacobson ▼ ajnonline.com
A Cure for Gun Violence Violence intervention programs show promise in treating the public health crisis.
“W
e do need somebody on our side that’s going to be there for us. Because if we don’t, we’re going to feel like, ‘Well, I’m all I’ve got. What do I have to live for?’” This speaker, a young African American man, discussed living in a poor neighborhood of Kansas City, Missouri, in a video played at a “listening session” in that city for the My Brother’s Keeper initiative last August. President Obama started the initiative after the shooting death of Florida teenager Trayvon Martin in 2012. It aims to support young people endangered by gun violence. Indeed, young people and African Americans continue to be disproportionately victimized by shootings and other forms of violence, even though U.S. firearm-related deaths fell nearly 40% between 1993 and 2011, the Bureau of Justice Statistics reported. Every day, 13 young people die violently in this country, and 1,600 of them visit EDs for treatment of injuries sustained in assaults. In 1993 African Americans died by gun violence at three times the rate whites did; by 2010 the rate was lower but still twice that of whites, according to a 2014 study in BMJ Open by Kalesan and colleagues. In the past decade or so, more and more clinicians have adopted a public health model of preventing gun violence. One prominent proponent, a physician named Gary Slutkin, served in Africa and Asia in cholera, HIV, and tuberculosis epidemics. He returned to the United States in the 1990s and began to apply an epidemiologic model to urban street violence. He saw, for instance, that cholera deaths in Bangladesh and homicides in Chicago showed the same patterns of clustering—outbreaks within small groups of people who know one another—which is a key to transmission in any epidemic. And Slutkin knew well the methods used to halt the spread of infectious disease: interrupt transmission, lower the threat of infection in those at highest risk, and alter community norms through education and other interventions. Slutkin launched Cure Violence (http://cureviolence.org), originally called Cease Fire, in one of Chicago’s most violent neighborhoods in [email protected]
Community members attend a candlelight vigil after a shooting at Reynolds High School in Troutdale, Oregon, last June. Photo by Steve Dipaola / Reuters / Newscom.
2000. The initiative trained community members to act as “violence interrupters.” And because as many as 45% of people treated for violent injury sustain another violent injury within five years, the initiative brought together police, clergy, and clinicians to identify those at highest risk for retaliatory, or revenge, violence. Conflict resolution and education would form the basis of reinforcing the area’s “immunity” to violence. The number of shootings fell by 67% in the first year. Since then, several studies have documented the model’s successes, and it has expanded to cities across the United States and around the world. For instance, a 2009 U.S. Department of Justice evalua tion found that three of four sites in a Baltimore, Maryland, program called Safe Streets modeled after Cure Violence showed “large, statistically significant” reductions in fatal and nonfatal shootings, especially at sites providing mediation as a way to resolve conflict. This approach to violence has been adapted in hospitals, where violence intervention programs serving urban communities have operated independently AJN ▼ April 2015
▼
Vol. 115, No. 4
19
AJN REPORTS
or in affiliation with programs like Cure Violence. Such hospital programs may focus their interventions on any number of related issues, such as intimate partner violence, behavioral health, or substance use. Most take a “trauma-informed approach,” one that acknowledges that a violent crime has serious traumatic consequences—for the victim and for her or his entire community. More research is needed, but studies have demonstrated the effectiveness of hospital violence intervention programs in recent years. • The Wraparound Project at San Francisco General Hospital had a six-year reduction in the rate of reinjury in high-risk teens and young adults from 16% to 4.5%, reported Smith and colleagues in the April 2013 issue of the Journal of Trauma and Acute Care Surgery. Interventions involved providing case managers to young victims, referring victims to community resources, and offering legal advocacy. • A randomized controlled trial at the R. Adams Cowley Shock Trauma Center in Baltimore, Maryland, showed that patients treated for violent injuries who received the interventions had half as many convictions of any crime and four times fewer convictions of violent crime at followup more than a year later. The study, by Cooper and colleagues in the September 2006 issue of the Journal of Trauma Injury, Infection, and Critical Care, reported savings of more than $1 million in incarceration costs and $500,000 in health care costs. A team including psychiatric nurses, case managers, and others offered such services as substance abuse treatment, conflict resolution, and employment and educational services.
PROVIDING ALTERNATIVES TO RETALIATION
A Cure Violence partner in Kansas City, Missouri, Aim4Peace (http://kcmo.gov/health/aim4peace) was launched in one historically high-crime Kansas City neighborhood in 2008. It helps the community to “handle its own disputes” through initiatives targeting young people, including life skills and anger management classes, job fairs, conflict resolution, and a hospital-based violence prevention program at Truman Medical Center. The basic premise is that violence is a behavior that can be changed by supporting the creation of healthier community norms. Nurses Mickie Keeling and Teresa Lienhop at Truman Medical Center believe that the ED and trauma center offer unparalleled access to engaging victims, and communities, in ending the cycle of violence. The risk-reduction approach reduced homicide rates by 56% in 2013 in Aim4Peace areas; that’s compared with a 1% increase in homicides citywide. 20
AJN ▼ April 2015
▼
Vol. 115, No. 4
In a recent interview, Keeling said that when a patient with a violent trauma arrives at the ED, she and the hospital chaplain assess the situation and call Aim4Peace. Trained neighborhood residents—the “interrupters”—come quickly to talk with the patient, “even if they have to go to the trauma bay,” she said, which can provide “a moment of clarity” for the wounded person. Nurses in the facility have nearly unanimously supported the initiative, Keeling said. But first they’ve had to understand the contagion infecting their communities. “The issue is that violence is considered the norm in handling problems. What Aim4Peace does is help people in how they live and deal with everyday issues and conflicts,” Keeling said. Lienhop, the director of trauma services at the hospital, agreed that one prime goal is to help victims recognize, even as they’re recovering from their injuries, that there are alternatives to getting even. This requires the cooperation of trauma surgeons, residents, and nurses, as well as clergy and police in the community. Outreach efforts such as the listening session have contributed to the program’s success. But there are barriers, including competition for funding. “When we look at funding in the community, it’s sometimes seen as a scarce resource,” Lienhop said. “But it’s a collaboration. All of us have an important role to play.” Aim4Peace receives funding from a variety of government and private sources, recently receiving a $1.2 million Department of Justice grant. Nurse researcher Mary Muscari, an associate professor and the director of the O’Connor Office for Rural Studies at the Decker School of Nursing, Binghamton University, in New York, has practiced in pediatrics and forensics and now teaches criminology. Mass murders tend to garner a lot of media attention, she said, and debate over gun control legislation in the wake of mass shootings like the one in December 2012 in Newtown, Connecticut, polarize the public into increasingly extreme camps. It’s tempting to want a “quick fix” to gun violence, Muscari said, but the much more complex problem remains the glorification of violence in our culture. The long-term antidote, she said, is empathy. “Shooters objectify. It’s much easier to do damage if a person is an object.” Increasing empathy must begin with children and families, Muscari noted, and one potential benefit in the aftermath of Newtown and other mass shootings is increased attention to the needs of young people, especially those ages 18 to 26, transitioning to adulthood. “We are going in a positive direction,” she said. “We have to ask, ‘What are the risk factors, and how do we minimize risk?’ It’s no different from heart disease.”—Joy Jacobson ▼ ajnonline.com
