Should I Stay or Should I Go? A Bioethical Analysis of Healthcare Professionals' and Healthcare Institutions' Moral Obligations During Active Shooter Incidents in Hospitals - A Narrative Review of the Literature

Rethinking the Current "Stage-and-Wait" Paradigm

INTRODUCTION

The experience of terrorist incidents involving a secondary explosive device that targeted rescue forces led to changes in the safety protocols of these forces in most countries of the world. These protocols are the foundation of the current "Stage-and-Wait" paradigm that prohibits the entry of Emergency Medical Services (EMS) from entering the scene and treating casualties until it is deemed safe. These guidelines were established absent of an evidence-base detailing the risk to responders and the potential consequences to the injured on-scene. The lack of clarity is compounded by the fact that different situations, as well as operational considerations, such as the length of time until bomb squad arrival at the scene versus time of massive bleeding injuries, for example, impact outcomes must be taken into account.

OBJECTIVE

This study sought to shed light on this matter while employing an evidence-based approach exploring the investigations of the frequency of secondary explosion threats in terrorist attacks over the last 20 years and discussing some of the ethical challenges and ramifications ensuing. While this study does not propose an outright change to current guidelines, in light of the evidence gathered, an open review and discussion based on the findings may be beneficial.

METHODS

The Global Terrorism Database (GTD) was used as the data source of bombing incidents world-wide.

RESULTS

The results revealed that approximately 70 per-1,000 bombing incidents involved secondary explosions across regions and countries within the study period.

CONCLUSION

This study emphasizes the need to rethink the current "Stage-and-Wait" paradigm by recommending brainstorming conferences comprised of multi-sectoral experts aimed at deliberating the matter. World-wide experts in emergency medicine, bioethics, and disaster management should cautiously consider all aspects of bomb-related incidents. These brainstorming deliberations should consider the calculated risk of secondary explosions that account for approximately 70 per-1,000 bombing incidents. This study highlights the need to re-examine the current versus new paradigm to achieve a better balance between the need to ensure EMS safety while also providing the necessary and immediate care to improve casualty survival. This ethical dilemma of postponing urgent care needs to be confronted.

Perceptions of the Moral Obligations of Pediatric Nurses During an Active Shooter Event in a Children's Hospital

PURPOSE

To explore and compare the perceptions of nurses and parent/family advisors regarding pediatric nurses' moral obligations to children and families during an active shooter event in a children's hospital.

DESIGN AND METHODS

This was a descriptive, exploratory study using survey methodology. A convenience sample of all licensed nurses and parent/family advisors from four children's hospitals across the United States were recruited. Surveys consisted of five primary domains including Appropriateness of National Guidelines, Personal Preparedness, Moral Accountability, Professional/Legal Concerns, and Personal Risk Expectations. Frequency counts and percentages were calculated for each survey item.

RESULTS

Data from 874 pediatric nurses and 81 parent/family advisors were analyzed. Most respondents believed the Run-Hide-Fight campaign should be changed to Secure-Preserve-Fight. Only 30% of nurses felt mentally prepared to respond to an active shooter event. Most respondents agreed that nurses have a professional duty to protect their patients, but agreed that it was a personal choice, not a moral obligation, to accept potentially fatal risks. Hospital setting and patient vulnerability often influenced nurses' perceived obligations to patients. Most respondents reported they would not leave their patient/child during an active shooter event.

CONCLUSIONS

Nurses feel morally obligated to patients, but must balance their own personal risk tolerance level against the need to protect patients and families.

PRACTICE IMPLICATIONS

Hospitals need in-depth active shooter training for both nurses and parents as well as safety plans that address both evacuation protocols and measures to secure in place to protect the lives of patients, families, and staff.