Review of the Literature
Our military and other government components such as the Department of
Defense develop technology to keep United States citizens safe by improving on
existing methods that identify and stop combatants. One method used to identify a
suspect is by recovery DNA. When an improvised explosive device (IED) is
detonated bomb fragments are recovered and examined in order to attempt to
determine the identity of the bomb maker. Iris, facial, and vascular recognition are
other biometrics tools used to identify our adversaries. Linking forensic functions
with biometric capabilities is a relatively new form of technology and is discussed in
the literature presented.
According to a study by Chirchi, Waghmare, and Chirchi (2011), choosing the
proper biometric tool to fit the specific situation requires knowledge of
technological developments. One such development is the iris scan. Found to be a
reliable form of authentication the military has evolved this form of biometric
identification into a portable tool on the battlefield. The biometric automated toolset
(BAT) is the primary system used by the U.S Central Command to store biometric
data such as iris scans, (D’Agostino, 2008). The iris scan is a unique form of
identification. In its genetic properties no two eyes are the same and furthermore
the characteristic that is dependent on genetics is the pigmentation of the iris,
(Chirchi, Waghmare, and Chirchi, 2011).
Although not less reliable but a less developed form of biometric
identification is facial recognition. It utilizes automated methods to verify the
identity of a person based on physiological characteristics. Tolba, El-Baz, and ElHarby (2011) describe facial recognition as a way to detect facial patterns even in a
crowded scene using classification algorithms. A computer algorithm “normalizes”
the biometric signature so that it is in the same format as the signatures on the
system’s database (Tolba, 2011). Facial recognition is seen as a convenient
biometric tool due to being both machine-readable and human readable. The
ubiquity of surveillance cameras means that, in a sense, a face can leave a trace and
therefore be useful forensically, as are DNA and fingerprints, (DOD, 2007).
A significant tool in biometric identification is the use of DNA analysis,
particular with recovering fingerprints. Esslinger, Siegel, Spillane, and Stallworth,
(2004) research involved using short tandem repeat (SRT) analysis to detect human
DNA from exploded pipe bomb devices. The effect on the DNA left on the
components correlated with the material the pipe was made of (pvc vs. steel), the
fragmentation pattern, and low vs. high explosives. One issue I noticed and it was
briefly mentioned in the article, was with the reliability of the material the pipes
were made. Steel is known to conduct heat better than PVC. The theory was since
steel generates more heat during an explosion the chance for degradation of the
DNA would increase. However since steel is more durable than PVC the percentage
of larger fragments should increase. The more fragments, the more DNA could be
collected. The data from the experiment showed the steel and PVC pipes had a
similar success rate for DNA recover.
Foran, Gehring, and Stallworth (2009) research included the recovery and
analysis of mitochondrial DNA (mtDNA) from exploded pipe bombs. The importance
and difference from STR analysis is that mtDNA analysis allows DNA that has been
extracted from hair, fingernails, and bone to be examined when nuclear DNA cannot
be recovered. Another significant difference is mtDNA sampling can be obtained
from not only the subject but also related family members. The article discussed the
materials and methods used in the test as well as the resulting bomb fragmentation
and the correlation with the quality and quantity of DNA recovered. The results of
the study showed the value of mtDNA analysis in identifying the manufactures of
various detonated IEDs.
Recovering fingerprints and other forms of DNA from various surface areas is
not always textbook. Elements such as temperature, humidity, moisture, and
material of surface area all affect the quality and ability to recover DNA. Shalhoub et
al, (2008) researched a fast curing silicone-casting material (Isomark) as an
effective method to obtain a reliable DNA profile from the casts of the fingerprints.
Participants were asked to handle six different surfaces of various textures. This
study was significant because various items are often used in IEDs that serve as
projectiles. The Army field manual FM 3-34.119 (2005) describes various casings
used such as pipes, soda cans, metal containers, all which turn into projectiles when
detonated. Once recovered contents inside such as marbles, nails, rocks, and glass
can all be examined for DNA. Through their research Shalhoub et al, (2008)
concluded it was possible to recover DNA from Isomark casts made on all substrates
tested. However, no link was noted between quality of finger marks obtained and
the amount of DNA extracted from them, Shalhoub (2008).
Although the research discovered additional technology questions the
research summaries concluded favorable results for recovering DNA from bomb
components leading to identifying the bomb maker. Biometrics tools such as iris
scanning, facial recognition, and fingerprinting are valuable components to
identifying our adversaries and using that intelligence to mitigate against future
Chirchi, V., Waghmar, L.M., & Chirchi, E.R. (2011). Iris biometric recognition for
person identification in security systems. International Journal of Computer
Applications, 24(9). Retrieved August 25, 2011 from
www.ijcaonline.org/volume24/number9/pxc3874002.pdf - India
D’Agostino, D. 2008. Defense management: DoD can establish more guidance for
biometrics. Retrieved October 2, 2011 from
Department of Defense. 2007. Report of the defense science board task force on
defense biometrics. Retrieved October 2, 2011 from
Department of Defense. (2009). Biometrics task force annual report FY09. Retrieved
September 4, 2011 from
Esslinger, K., Siegel, J., Spillane, H., & Stallworth, S. (2004). Using STR analysis to
detect human DNA from exploded pipe bomb devices. Journal of Forensic Science,
49(3). Retrieved September 7, 2011 from
Federal Bureau of Investigation (FBI). n.d. Terrorist explosive device analytical center
(TEDAC). Retrieved September 15, 2011 from http://www.fbi.gov/aboutus/lab/tedac
Foran, D., Gehring, M., & Stallworth, S. (2009). The recovery and analysis of
mitochondrial DNA from exploded pipe bombs. Journal of Forensic Science (54)1.
Retrieved September 7, 2011 from
Makarski, R., Marrero, J. (2002). A surveillance society and the conflict state:
leveraging ubiquitous surveillance and biometrics technology to improve homeland
security. Retrieved September 4, 2011 from
National Science and Technology Council (NSTC). 2008. Biometrics in government
in post 9-11. Retrieved September 4, 2011 from
Shalhoub, R., Quinones, I., Ames, C., Multaney, B., Curtis, S., Seeboruth, H., . . .Daniel,
B. (2008). The recovery of latent fingermarks and DNA using a silicone-based
casting material. Forensic Science International 178. p 190-203. Retrieved September
23, 2011 from
Tolba, A.S., El-Baz, A.H., & El-Harby, A.A. (2011). Face recognition: A literature
review. International Journal of Signal Processing 2(2). Retrieved September 29,
United States Army. n.d. Chapter 15. Unexploded ordnance and improvised
explosive devices. FM. 3-21.75 Chapter 15. Retrieved September 18, 2011 from
Running Head: RISK PERCEPTION
Literature Review for Risk Perception
Review of Literature
Decision making is arguably the most important element of human cognition. Processes
that aid in decision making occur so rapidly that people often fail to recognize them (Gilbert,
2006). Because the cognitive processes that aid intuitive risk assessment have generally served
humanity well for so long, recognition and identification of said processes can seem purely
academic. Gilbert (2011) argues that these cognitive processes were forged in a much different
world than our current one and although moral heuristics often lead to accurate assessments,
research suggests this may not always be the case. Several decades of research has contributed to
our understanding of the decision process and helped reveal many situations in which heuristics
Although a plethora of research has identified several decision fallacies, very little has
been done to improve the efforts of Disaster Managers and public health experts regarding risk
behavior. Pidgeon (1998) observed that a layperson’s risk assessments are influenced by the
level of dread an event provokes and to a lesser extent, the level of professional disagreement.
Kreuter and Stretcher (1995) found that individuals overestimate their ability to survive disasters
and underestimate their peer’s survivability. Allowing policies to be formed based on visceral
factors such as dread or optimistic biases have led to over-funding of projects for hazards that
elicit fear and under-funding risk mitigation programs for controllable events that people feel
they could safely avoid (Gilbert, 2011; Sjoberg, 1998).
This study aims to implement lessons learned regarding the framing fallacy and other
biases in order to test their efficacy in the field of disaster management. Using lessons drawn
from the heuristics theory, this study attempts to eliminate all possible internal and external
influences in order to gain insight into the public’s risk mitigation needs. Challenges that
Disaster Managers have faced in previous efforts to implement risk perception theories into their
field arise from the complexity of findings.
There appear to be many factors that influence decision making such as individual
characteristics including age, gender, profession, economic status, and religious beliefs
(Anderson & Lundborg, 2007; Archer, Burkle, & Smith, 2010). Characteristics of the event such
as the distribution of risk (how many people affected in a single event), perceived possibility of
avoidance, volunteerism (such as skydiving), and whether the event was caused by an agent (as
in terrorism) or an object (such as an earthquake) all influence risk perception and thus behavior
(Douglas & Widavsky, 1982; Gutscher & Siegrist, 2008; Kazan & Scott, 2008). Furthermore,
experience appears to relegate a layperson’s poor judgment (Keller, Siegrist, & Wang, 2009).
These factors and more influence the success of disaster communication and have thus far
prevented Public Health professionals form implementing lessons learned risk perception
This literature review will provide an overview of risk perception research followed by
evidence supporting (a) gaps between professionals and laypeople in risk perception (b) dualprocess cognition that uses heuristics in order to simplify complex events (c) biases formed by
heuristics and their negative consequences, and (d) how some of the biases can be used to guide
the public and policy-makers during risk mitigation decisions.
The Gap in Risk Perception
There is much research demonstrating the difference in risk perception between
laypeople and professionals (Archer, Burkle, & Smith, 2010; Sjoberg, 1998). Professionals tend
to base risk perception on probability and occurrence and number of fatalities the event
accumulates in a year (Sjoberg, 1998). Conversely, laypeople rely on other factors such as dread
and distribution of harm in order to determine their tolerable level of risk (Pidgeon, 1998). Many
researchers believe that these extra variables should be factored into policy-making and
government spending (Pidgeon, 1998). Decision-makers adopt a Utilitarian approach when
forming policies in that they attempt to do the greatest good for the greatest number of people
while maintaining an acceptable level of fairness. In a hypothetical situation where people are
asked what the maximum number of innocent lives that they would be willing to risk in order to
feel safe the answer I am willing to assume is zero. Therefore, factors such as dread or
distribution of risk should not factor into decision making and the goal should always be to do
the greatest good for the greatest amount of people. Instead of factoring in these external
variables into policy-making, efforts should be made to navigate around the layperson’s
intuitions. Since knowledge regarding a specific event appears to be the factor creating the gap
between professionals and laypeople (being a professional in terrorism doesn’t diminish the risk
perception gap in other disaster fields) efforts to educate the public should be included into
policies (Slovic, 1987).
The dual-processing theory is part of a broader theory of heuristics (Sunstein, 2005).
Heuristics states that humans create frames or schemata in order to simplify events and guide
decision making (Sunstein, 2005). George Miller’s classic research regarding working memory
was the impetus of Heuristics (Reyna, 2004). The thought behind this connection was that
decision making involved many factors and occurs rapidly, yet Miller demonstrated that our
working memory on average stores only seven items (Reyna, 2004). Heuristics was an elegant
theory but lacked practical applications since research demonstrated that reasoning was
independent of remembering (Douglas & Wildavsky, 1982; Reyna, 2004).
The dual-processing theory accounts for the reasoning-remembering independents while
maintaining that heuristics make rapid and efficient decision making possible (Reyna, 2004). The
theory suggests that humans have two types of memory recall methods (Reyna, 2004). Reyna
(2004) calls this the fuzzy-trace system and labels the two types of memory as verbatim and gist.
Verbatim involves conjuring up details of an event and is processed through working memory, as
distracting memory tests have been shown to affect this type of recall (Sunstein, 2005).
Gist memory types are fuzzier (hence fuzzy-trace theory) and involve emotional and
moral based storage and are used to guide decision making (Reyna, 2004). When a person must
solve a problem, they compare the problem facts to several gist representations involving the
same or similar problem facts then chooses which principle is best based on the greatest number
of ‘wins’ that gist produced in the past (Reyna, 2004). This is similar to how a chess master
decides their next move. The last part of the process is important as it can lead to the availability
fallacy discussed in the next section.
It cannot be overstated that this process has evolved for a reason. Using heuristics to
guide decision making allows for rapid and often accurate responses to complex problems.
People learned that betrayal is bad and should elicit greater outrage than harm from a stranger;
that people should never buy their way out of a crime; and that we should always aim to save
lives or do everything we can to avoid loss (Slovic, 1987). The danger lays in how fast and
natural this decision process works, escaping our notice and thus developing an illusion of
accuracy (Gilbert, 2006). The system of comparing events with stored problem sets for example,
runs the risk of being influenced by framing. Saving 2 hundred lives out of 6 hundred involves
the saving lives heuristic but loosing 4 hundred lives out of 6 hundred recalls the loss aversion
heuristic (Sunstein, 2005). Although the two events just mentioned have the same risk, people
are more likely to choose a policy that will save the 2 hundred lives over the policy that risks
losing 4 hundred lives (Sunstein, 2005).
Cognitive Biases Formed by Heuristics
Our brains ability to create schemata in order to aid in rapid assessment and decision
making has been a large factor in the success of humans. The previously mentioned example
regarding the belief that one should not pay their way out of a crime will lead to more successful
rather than unsuccessful decisions (Sunstein, 2005). When policy-makers suggested emission
trading as a way to lower overall pollution, opponents protested due to this ‘paying for crime’
heuristic (Sunstein, 2005). There is no societal benefit in rape, murder, and abuse so no amount
of trade would be worth its acceptance. With pollution however, economies thrive, technology
produced and transportation is available for everyone. Although polluting above the available
allotment maybe a crime, models that allow for trade-offs result in overall lower emission level,
yet due to this heuristic, people in favor of saving the environment deny its enactment (Sunstein,
2005). There are also several known heuristics that are applicable to disaster management.
There is a famous scenario that has been performed in various forms many times over the
past several decades. The scenario involves some type of hazard (say an emerging infectious
disease) that is guaranteed to kill 600 people (Sunstein, 2005). Subjects are given two treatment
options and asked to choose one. Treatment A will save 200 lives while treatment B has a one
third probability that everyone will be saved but a two thirds probability that nobody will be
saved (Sunstein, 2005). For the most part, people tended to play it safe and choose treatment A
(Sunstein, 2005). After the subjects decided between treatments A or B two more treatments
were offered. With treatment C 400 people will die and with treatment D there is a one third
probability that nobody will die and a two thirds probability that 600 people will die (Sunstein,
2005). Despite treatment C and D being reworded versions of treatment A and B, people seemed
to be more willing to risk everyone’s life and chose treatment D (Sunstein, 2005). Knowing that
people will take higher risks avoiding loss than to gain rewards can have powerful implications
while communicating plans in disaster planning.
Another fallacy that leads people to inaccurately assess their level of risk is the optimistic
bias. Kreuter and Strecher (1995) showed that people are more likely to underestimate their level
of risk if they perceived the event to be avoidable. This is because humans on average believe
that they are anything but average (which of course is statistically impossible) (Gilbert, 2006).
The only thing unique about an individual is their personal perspective, which allows for
rationalization through assessing both internal and external factors (Gilbert, 2006). This
egocentrism also prevents people from considering other peoples internal factors and thus they
overestimate their peer’s susceptibility to avoidable risks (Kreuter & Strecher, 1995).
Understanding the optimistic bias, disaster managers and public health experts would be wise to
avoid down playing an events inevitability.
Yet another fallacy in this literature review is the betrayal heuristic. People generally
follow the rule that betrayal is far worse than crimes committed by strangers. We live in a world
where trust in others is necessary, so stigmatizing acts of betrayal has benefited societies a great
deal (Sunstein, 2005). Unfortunately, anthropomorphism occurs effortlessly in humans leading to
a betrayal fallacy. People are willing to take higher risks in order to avoid harm from objects
designed for safety (Sunstein, 2005). When given the choice between two vehicles; one where
the person has a two percent chance of dying in a motor vehicle collision or a vehicle that has a
one percent fatality chance but an extra 0.01 percent chance of dying from a malfunctioned
airbag (total of 1.01 percent fatality risk), people will on average choose the first vehicle
The final fallacy in this review has been well documented and is called the availability
bias. Many people are familiar with the study that asks subjects whether there are more words in
the English language that begin with the letter R or have R as the third letter (Dunlop, Kashima,
& Wakefield, 2010). Subjects instantly begin to search their memory for words and retrieve
many more words that start with R versus having R as the third letter (Dunlop, Kashima, &
Wakefield, 2010). Although this is due to the storage method of words (much like a dictionary,
we look for beginnings to help us retrieve the rest), humans assume they have thought of more R
beginnings because there are more words with R beginnings (Dunlop, Kashima, & Wakefield,
2010). The availability bias relates to disaster medicine in many ways but perhaps the most
notable being news reports. The news reports on rare and exciting events that are memorable to
us the viewer and thus are readily available for recall (Gilbert, 2006). The availability bias leads
people to overestimate the probability in rare and exciting events and underestimate the
probability in common but not newsworthy dangers (Dunlop, Kashima, & Wakefield, 2010).
Using Biases in Disaster Medicine
Keeping in mind that as Disaster Managers or Public Health Professionals the goal is to
maximize lives saved (or to put it in a more motivational frame, to minimize the number of lives
lost), questions may be formed to reveal the public’s unbiased opinion regarding spending for
disaster mitigation. To receive an unbiased opinion, questions should be divided into four broad
categories; (a) lives saved in a single event versus lives saved over one year, (b) total years of
life saved versus number of lives saved, (c) acceptable number of lives lost during voluntary
events, and (d) acceptable number of lives lost for a given benefit. In time this list is likely to
grow, but for now this appears to be a good starting point. These questions will eliminate factors
such as optimistic biases and betrayal heuristics since the qualitative aspect of the disaster has
been taken away. By eliminating the characteristics from decision making, the laypeople are
forced to make decisions that will maximize human survival and allow policy-makers to focus
efforts where they will have the greatest impact.
Anderson, H. & Lundborg. (2007). Perception of own death risk: An analysis of road-traffic and
overall mortality risks. Journal of Risk Uncertainty, 34, 67-87. doi: 10.1007/s11166-0069004-3
Archer, F.L., Burkle, F.M., & Smith, E.C. (2010). Fear, familiarity, and the perception of risk: A
quantitative analysis of disaster-specific concerns of paramedics. Disaster Medicine and
Public Health Preparedness, 5(1), 46-53. Retrieved from www.ncbi.nlm.nih.gov/pubmed
Douglas, M. & Wildavsky, A. (1982). Risk and culture: An essay on the selection of
technological and environmental dangers. Los Angeles, CA: The Regents of the
University of California.
Dunlop, S., Kashima, Y., & Wakefield, M. (2010). Pathways to persuasion: Cognitive and
experiential responses to health-promoting mass media messages. Communication
Research, 37(1), 133-164. doi: 10.1177/0093650209351912
Gilbert, D. (2006). Stumbling on happiness: Think you know what makes you happy? New York,
NY: Random House Inc.
Gilbert, D. (2011). Buried by bad decisions. Nature, 474(7351), 275-277. doi: 10.1038/474275a
Gutscher, H. & Siegrist, M. (2008). Natural hazards and motivation for mitigation behavior:
People cannot predict the affect evoked by a severe flood. Risk Analysis, 28(3), 771-8.
Kazan, E. & Scott, W. (2008). Taking risks. In Everitt (Ed.), Chance rules: An informal guide to
probability, risk and statistics. doi: 10.1007/978-0-387-77415-2_11
Keller, C., Siegrist, M. & Wang, M. (2009). The less you know, the more you are afraid of: A
survey on risk perception of investment products. The Journal of Behavioral Finance,
Working Paper Number 520. Retrieved from http://www.nccrfinrisk.uzh.ch/media/pdf/wp/WP520_A1.pdf
Kreuter, M.W. & Strecher, V.J. (1995). Changing inaccurate perceptions of health risk: Results
from a randomized trial. Health Psychology, 14(1), 56-63. doi: 10.1037/0278618.104.22.168
Pidgeon, N. (1998). Risk assessment, risk values and the social science programme: Why we do
need risk perception research. Reliability Engineering and System Safety, 59(1), 5-15.
Reyna, V.F. (2004). How people make decisions that involve risk: A dual-processes approach.
Current Directions in Psychological Science, 13(2), 60-66. doi: 10.1111/j.09637214.2004.00275.x
Sjoberg, L. (1998). Risk perception: Experts and the public. European Psychologist, 3(1), 1-12.
Slovic, P. (1987). Perception of risk. Science, 236(4799), 280-285. doi: 10.1126/science.3563507
Sunstein, C.R. (2005). Moral heuristics. Behavioral and Brain Sciences, 28(4), 531-573.
Running head: NURSES PERCEPTION
Nurses Perception to Gun Violence in a Community Hospital: Literature Review
Lillian Yadgood Kelly
Applied Research and Statistics
Nurses Perception to Gun Violence in a Community Hospital: Literature Review
No longer considered safe havens for care, hospitals today are confronted with steadily
increasing rates of crime and violence including assault, rape and homicide (The Joint
Commission, 2010). As acts of violence move from the home and street into healthcare facilities,
providing a safe and secure environment for patients, visitors and staff becomes an ongoing
While incidents of violence can occur anywhere within a healthcare facility, emergency
departments are particularly susceptible to violent activity due to their ease of access and high
stress environment (ECRI, 2011; Gillespie, 2010; Kansagra et al., 2008; The Joint Commission,
2010). Many studies show that psychiatric and emergency nurses are the most vulnerable to
workplace violence however, few consistent reporting structures exist to completely account for
the true number of incidents (Child and Mentes, 2010; Gacki-Smith, 2009; Gillespie, 2010).
Despite healthcare efforts to improve safety conditions and modify response strategies,
violence in hospitals remains highly prevalent (ECRI, 2011; Gillespie, 2010; Kansagra et al.,
2008; The Joint Commission, 2010). The Joint Commission’s Sentinel Event Database lists 256
incidents of assault, rape and homicide since 1995 and notes that this reporting category is
consistently among its top ten types of sentinel events reported (The Joint Commission, 2010).
The latest release of an ongoing survey of 7,000 emergency room nurses nationwide supports
these findings and reports that the rates of physical and non physical violence has not decreased
over the last three years (Emergency Nurses Association, Institute for Emergency Nursing
Research (ENA), 2011). Some of the most commonly reported factors that precipitate incidents
of Emergency Department (ED) workplace violence are caring for psychiatric patients in the ED,
drug seeking behaviors by patients and visitors, patients and visitors under the influence of
alcohol, ED crowding, domestic violence, and patients and visitors under the influence of illicit
drugs (ENA 2011; Gacki-Smith, Juarez and Boyett, 2009; Ventura-Madangeng and Wilson,
Although there is a high incidence of workplace violence against ED staff, it is grossly
under-reported (Barlow & Rizzo, 1997). May and Grubbs (2002) noted that nurses only reported
50% of the violent incidents they experienced while Barlow and Rizzo (1997) found that as little
as 20% of assaults against hospital staff were reported. Explaination for the low rates of
reporting have been attributed to fear of repurcussion by management, concern that reporting of
violent incidents may be viewed as poor job performance, and belief that workplace violence is
just a part of the job (Ventura-Madangeng and Wilson, 2009). Additionally the inability to find a
common, coherent definition for the term violence masks its extent. This creates confusion
among nurses who hold varying opinions of terms such as abuse, assault and aggression and who
may only report incidents based on their own perception of risk (Child and Mentes, 2010;
Hegney, Tuckett, Parker, and Eley, 2010; May and Grubbs, 2002). Typically, nurses are better at
self reporting when they have sustained acutal harm (Findorff and McGovern, 2005). Underreporting is a cause for concern because it challenges administrative efforts to assess the
frequency, attributes and consquences of risk to violence and to develop strategies to address and
mitigate the impact of a violent occurance (Child and Mentes, 2010; Henson, 2010).
While healthcare facilities in high-crime urban areas may be more prone to violent
events, the risk of workplace violence in smaller community hospitals is not exempt (ECRI
Institute, 2011). Hospital overcrowding, extended wait times, patients and families under duress
are universal issues. Of greater concern is the more recent references to the prevalence of
handguns and other weapons being carried into hospitals by patients, their families or friends
(ECRI, 2011; Phelps, Russell and Doering, 2007; OSHA 2004). Over a six month period, from
June through December 2006, there were eight reported hospital shootings in the United States
and Canada (Phelps, Russell and Doering, 2007). Between March 2010 and July 2011, eleven
incidents of active shootings were reported with hand guns in both urban and suburban hospitals
in the United States alone (Timeline of violent incidents in hospitals, 2011). Currently, an
estimated 45% of American households currently contain some type of firearm (Center to
Prevent Handgun Violence, 2012). The National Rifle Association reports that privately owned
firearms in the U.S are approaching the 300 million mark, including nearly 100 million
handguns, and the number of firearms is rising over 4 million annually. This number does not
account for the unregistered firearms or those obtained illegally. Of the estimated 70-80 million
gun owners in the US, approximately 40-45 million own handguns. (National Rifle Association
(NRA), 2012). The risk for gun violence within healthcare systems coupled with persistent acts
of aggression and assaultive behavior, challenge the limitations of preparedness for violence in
hospitals and present a public health issue (Marsh, 2007; Pinto, 2008).
Hospital Administration has a responsibility to maintain a safe environment and to keep
patients and the healthcare providers who care for them safe (ECRI Institute, 2011; Occupational
Safety and Health Administration, 2004; The Joint Commission, 2010). Although many nurses
report that their facility has a policy in place for reporting workplace violence only half indicated
that the policy was a zero tolerance policy (ENA 2011). This outcome is disappointing
considering that a similar survey published in 2010 revealed that nearly 70% of the respondents
rated their perception of nurse safety in the ED at 5 or lower on a 10-point scale (Emergency
Nurses Association, 2010).
State mandates require healthcare facilities to perform annual risk assessments for
workplace violence and implement prevention and response plans (sSB 970, 2011). However,
there are few specific standards and each facility is free to determine their own response policies
and procedures (Child and Mentes, 2010; Wiley, 2008). Additionally, ambiguity in the language
of state law results in uneven implementation. Healthcare is required to report any assault or
related offense incidents to the local law enforcement. But if a person committing an act of
violence is considered to have a mental or physical disability they are exempt from being
reported. Even though assault of a healthcare worker is now considered a felony, if the
perpetrators are deemed to be influenced by physical or mental incapacity, it can be used as a
defense (sSB 970, 2011).
Violence against staff has numerous consequences from a personal, fiscal and patient
care perspective. Physical injury, mental and emotional trauma, are some of the most easily
recognizable impacts (May and Grubbs, 2002). Violence can negatively affect subsequent job
performance, productivity and the quality of patient care (Hampton, 2007; Keely, 2002) as well
as job satisfaction, morale, retention and recruitment (Henson, 2010; Gates, Gillespie and
Succop, 2011; May and Grubbs, 2002). The ENA 2011 survey reports that more than a third
(36.7 percent) of emergency nurses has considered leaving their jobs because of workplace
violence. Nearly one in ten (9.5 percent) has considered leaving nursing entirely and the same
proportion have considered looking for a job in another hospital. Almost one in five (17.7)
percent has considered looking for a job in non-emergency nursing. ED nurses report being
unable to work after a violent episode resulting in higher rates of absenteeism and compensation
leave (Child and Mentes, 2010). Psychosocial consequences include feelings of anger,
worthlessness, depression, and anxiety with higher rates of substance abuse and Post Traumatic
Stress Disorder (Hegney et al., 2010; Henson, 2010; Quanbeck, 2006). In 2001, Duhart estimated
that workplace violence cost $4.2 billion annually and was rising. The cost per incident in terms
of legal fees and lost time was estimated to be $250,000 (Morrison and Love, 2003). Workplace
violence against nurses alone accounts for 3.5% of workplace violence in the United States
The importance of training programs to build staff confidence and teach them how to
handle escalating situations has been cited in numerous references (Child and Mentes, 2010;
ECRI, 2011; Gillespie et al, 2010; Kansagra et al. 2008). Yet Kansagra et al. (2008) found that
less than half of EDs surveyed had initiated a focused program. Of the 7,112 nurses surveyed in
the ENA study (2011), approximately 80 percent indicated that they have attended training for
the prevention and diffusion of violence however, only 53.1 percent of nurses stated that their
training was mandated. Hospitals are encouraged to develop robust violence prevention
programs but to date training is erratic and often limited to recognizing warning signs of
escalating behaviors and initiating de-escalation techniques (Gates et al. 2011; Gillespie, 2010;
Howell, 2011). Few studies have addressed protective measures when these techniques fail.
Given the continued escalation of violent events in the ED, the rising prevalence of
firearm ownership, and the randomness of active shooter events in hospitals, proactive safety
measures must be put into place to support staff and patient safety and minimize the potential for
adverse outcomes. Understanding staffs perception of risk is a key step to improving safety
measures for staff in the ED. The challenge is that perception of risk is not a constant but varies
with the event and the individual. Since Risk perception has been identified as a critical
precursor of at risk behavior, failure to understand risk may lead to errors in judgment, unsafe
behavior and place staff, patients and visitors unintentionally in harm’s way. The purpose of this
study is to explore nurse’s perception of risk to gun violence in a community setting to add to
existing knowledge and make decisions for next steps to address safety and training needs.
Barlow, C. B., & Rizzo, A. G. (1997). Violence against surgical residents. Western Journal of
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violence against nurses. Issues in Mental Health Nursing, 31(2), 89-95.
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Emergency Nurses Association, Institute for Emergency Nursing Research. (2010, August).
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Findorff, M. J., & McGovern, P. M. (2005). Reporting violence to a health care employer.
AAOHN Journal, 53(9), 399-406.
Gacki-Smith, J., Juarez, A., Boyett, L. (2009). Violence against nurses working in US emergency
departments. Journal of Nursing Administration, 39(7/8). Retrieved from
Gates, D., Gillespie, G., & Succop, P. (2011). Violence against nurses and its impact on stress
and productivity. Nursing Economics, 29(2), 59-67.
Gillespie, G. G. (2010). Workplace violence in healthcare settings: Risk factors and protective
strategies. Rehabilitation Nursing, 35(5), 177-184.
Hampton, R. (2007). Protecting yourself from abusive patients. Practice Nursing, 18(11), 539542.
Hegney, D., Tuckett, A., Parker, D., & Eley, R. (2010). Workplace violence: Differences in
perceptions of nursing work between those exposed and those not exposed: A crosssector analysis. International Journal of Nursing Practice, 16, 188-202.
Henson, B. (2010). Preventing inerpersonal violence in emergency departments: Practical
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Kansagra, S. R., Rao, S., Sullivan, A. F., Gordon, J. A., Magid, D. J., Kaushal, R., Camargo, C.
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emergency departments. Academic Emergency Medicine, 15, 1268-1274.
Keely, B. R. (2002). Recognition and prevention of hospital violence. Dimensions of Critical
Care Nursing, 21(6), 236-241.
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May, D. D., & Grubbs, L. M. (2002). The extent, nature and precipitating factors of nurse assault
among three groups of registered nurses in a regional medical center. Journal of
Emergency Nursing (28), 11-17.
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Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing
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Pinto, A. (2008, October-December). Engaging health professionals in advocacy against gun
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North America, 29, 743-760.
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Ventura-Madangeng, J., & Wilson, D. (2009). Workplace violence experienced by registered
nurses: A concept analysis. Nursing Praxis in New Zealand, 25(3), 37-50.
Wiley, K. (2008). 2007 Nebraska nurse survey results, making a world of difference: Workplace
violence and nursing. Nebraska Nurse, 14-19.
Review of the Literature
Following the attacks of September 11, 2001 a new era of emergency
preparedness was born. In this newly developed schema, the emphasis was placed
on reinforcing local first responders once their local resources had become
overwhelmed and depleted (Birkland, 2009). This approach places emphasis on the
first responders and communities to be prepared by evaluating their hazard
vulnerability, to develop mitigation tactics, and to develop a response plan. All
emergencies begin at the local level and it is the responsibility of the local
government to develop and maintain adequate emergency response plans. A
preplan is then in place to trigger a quickly mounted first response until additional
resources have time to deploy if needed.
In Pennsylvania the administration of emergency management is directed by
Title 35 of Pennsylvania State law (35 Pa.C.S, 1978). This law mandates that all
levels of local government designate an emergency manager that is professionally
competent to plan, coordinate and control an emergency response. Each
municipality is also responsible to develop, either individually or in cooperation
with other political subdivisions, an emergency response plan. Additionally each
municipality is responsible to equip and man an emergency operations center,
provide disaster training, organize and coordinate all locally available manpower
and supplies, and participate in all drills scheduled by the municipality or Federal
government. Pennsylvania is a diverse state with several large metropolitan regions,
but consists mostly of less populated counties with less populated political
subdivisions. This study evaluates the emergency managers and emergency
operation plans of a single Rural County in Pennsylvania.
Emergency managers are the most local political designees in Pennsylvania
that are tasked with developing an emergency response plan. This task can be
difficult given the wide array of potential manmade and natural threats to an area
and the limited funding and resources available to mitigate and mount an
emergency response. Therefore it is imperative that local emergency managers
assess risk through the now standard use of hazard vulnerability analysis (Somers &
Svara, 2009). While Pennsylvania Title 35 directs the development of emergency
management, there is no mention of standards for the emergency manager or the
emergency response plan that he develops. This could result in an emergency
manager within a Pennsylvania community that may have little to no experience,
expertise and little to no educational background. Nor is there a mention of a
standard or benchmark to be met for the emergency operation plan.
An emergency or disaster can have a significant impact on a community and
not only should local government leaders assure that emergency managers are
qualified; standards must be developed to evaluate their key roles. Standards should
be placed on preparedness, mitigation, response and recovery (Henstra, 2010).
Alexander (2005) also discusses key elements of a disaster plan that could be used
to develop, test and revise emergency response plans. In Illinois a survey tool was
developed to measure homeland security innovation in police departments that
varied from rural to metropolitan (Schafer, Burruss, & Giblin, 2009). Characteristic
of the departments that were deemed innovated were then extrapolated so that
they could be applied across all departments of similar size. A similar approach
could be applied to emergency management.
Regionalization is another approach to emergency management, while not
legally applicable to Pennsylvania, is worth mentioning. It could be considered that
a regional approach to emergency management may be as “local” as emergency
management needs to be. A regional approach could offer several advantages over a
local municipal model. A regional manager would have a larger resource pool, not be
as limited by political boundaries, and face less interoperability difficulties (Waugh,
Emergency Response Plans
While regionalization may never be possible in Pennsylvania, the same
concept often occurs out of need for mutual aid agreements among municipalities.
These agreements are formed out of response capability deficits and geographical
constraints. Another way to measure the strength of an emergency response plan
may breadth of the response work and agreements to pool resources should the
need arrive. This in turn would bolster each local community’s ability to respond to
a wider variety of identified hazards. In a study conducted in South Carolina less
populated and therefor less funded counties were more likely to develop public and
private sector relationships to bolster their emergency response capabilities
(Bowman & Parsons, 2009). The most successful relationships were created when
common goals and needs were identified that motivate public and private entities.
Emergency Preparedness Training
Local emergency preparedness training is another focus of Pennsylvania
Title 35. However, the absence of standards within the law again comes to the
forefront with this topic. When federal emergency preparedness training was
compared to local emergency preparedness training there were several key
differences. Federal training was demonstrated to be comprehensive, skill and
competency framed and consistently reproducible. Whereas local training tended to
focus on local organizational issues, was not comprehensive and weakly controlled
for quality (Maor, 2010). This may indicate that while all emergencies may be local,
not all training should be or at least it should be supervised and provided from the
State or Federal level.
Pennsylvania Title 35 mandates that emergency management exists in every
Pennsylvania municipality. However it does not mandate that standards are applied
to the selected emergency managers or the emergency operations plan that they
develop. This study will evaluate the qualifications of emergency managers within a
single rural county in Pennsylvania and review the emergency operations plans that
they have developed. Suggestions could then be made how to apply the standards
that have been discussed in this review.
35 Pa.C.S, §7501-7504. (1978).
Alexander, D. (2005). Towards the development of a standard in emergency
planning. Disaster Prevention and Nagament , 158-174.
Birkland, A. T. (2009). Disasters, Catastrophes, and Policy Failure in the Homeland
Security Era. Review of Policy Research , 26, 423-438.
Bowman, A., & Parsons, B. M. (2009). State and Local Government Review.
Vulnerability and Resilience in Local Government: Assessing the Stregth of
Performance Regimes , 41 (1), 13-24.
Choi, S., & Brower, R. S. (2006, January). When Proactie Matter More Than
Goverment Plans : A Network Analysis of Local Emergency Management.
Administration & Society , 651-678.
Henstra, D. (2010, March/April). Evaluating Local Government Emergency
Management Programs: What Framework Should Public Managers Adapt. Public
Administration Review , 236-246.
Maor, M. (2010). The Relationship Between Intervention by Central/Federal or
Local Levels of Government and Local Emergency Preparedness Training.
Administration & Society , 315-342.
National Cancer Institute. (2004, Sugust 08). What is randomization. Retrieved
September 21, 2011, from National Cancer Institue at the National Institue of
Schafer, J. A., Burruss, G. W., & Giblin, M. J. (2009). Measuring Homeland Security
Innovation in Small Municipal Agencies : Police in a Post 9/11 World. Police
Quarterly , 263-288.
Somers, S., & Svara, H. J. (2009, March/April). Assessing and Managing
Environmental Risk: Connecting Local Governent Management with Emergency
Management. Public Administration Review , 181-193.
Waugh, W. L. (1994, May/June). Regionalizing Emergency Management: Counties as
State and Local Government. Public Administration Review , 253-258.
Literature Review: PTSD
Literature Review: PTSD in man-made and natural disasters
Literature Review: PTSD
This literature review will examine three areas: (a) the prevalence of PTSD in the average
population, (b) factors that increase the likelihood of developing PTSD, and (c) the prevalence of
PTSD in populations who have experienced a natural or man-made disaster. The present review
is limited to studies targeting adults (18 years or older) and does not include studies done solely
on war veterans or populations affected by long-term conflict or displacement.
Prevalence of PTSD in the Average Population
The National Comorbidity Study (NCS) and the National Comorbidity Study-Replication
(NCS-R) were conducted by Harvard Medical School as the first nationally representative adult
surveys in the United States to assess the prevalence and correlates of the mental health
disorders. The original survey was conducted from 1990 to 1992 using the DMS-III-R. NCS-R
interviews occurred from 2001 to 2002 and used the DSM-IV. The NCS-R indicated that that
lifetime prevalence of post-traumatic stress disorder is 6.8%, with a gender breakdown of 9.7%
female and 3.6% male. Prevalence among adults 18-29 is 6.3%, adults 30-44 is 8.1%, and adults
45-59 is 9.2%. The prevalence of PTSD in adults 60 years and over is only 2.8% (Harvard
Medical School, 2005). NCS-R data found that race-ethnic groupings show slight differences in
lifetime prevalence of PTSD. Non-Hispanic blacks have a rate slightly higher than the national
average with a lifetime prevalence of 7.1%. Hispanics have a lower-than-average lifetime
prevalence of 5.9%, and non-Hispanic whites have a prevalence of 6.8% (Breslau et al., 2007).
Similar results were reported in the Wave 2 National Epidemiologic Survey on Alcohol and
Related Conditions: lifetime prevalences for all adults were reported to be 6.4%, with rates
Literature Review: PTSD
higher among women (8.6%) than men (4.1%) (Pietzrak, et al., 2011). Bromet et al. (1996),
however, cite rates as high as 12.3% in women, and 9.2% in young adults.
An estimated 92.2% of males and 87.1% of females have experienced at least one
traumatic event as defined by the DSM-IV (Breslau et al., 1998). On average 25% of adults who
experience a traumatic event will develop symptoms associated with PTSD. Certain types of
traumatic events as well as pre-existing conditions can predict the likelihood of PTSD
development in certain populations (Bromet et al., 1996).
Risk Factors that Affect PTSD Development
Risk factors that affect PTSD development can be divided into two categories: preexisting conditions and the type of traumatic event itself. The most commonly reported preexisting factors associated with PTSD development are female gender, history of childhood
abuse or neglect, and prior mental health disorder history (Bromet et al., 2005, Briere & Elliott,
2000, Shalev et al. 1998, Kessler et al, 1995, Koopman et al., 1994, Shalev et al., 1996).
Koopman et al. (1994) found that additional life stress, including divorce and loss of a loved one,
was also a predictor for PTSD development. Marital status at the time of trauma and level of
formal education also plays a part in predicting whether individuals will develop PTSD (Bromet
et al., 1995, Shalev et al., 1996).
The type of trauma is an important predictor in the development of PTSD. Friedman et al.
(2007) found that sexual violence accounted for almost half of all PTSD cases in women, and
65% of men and women who experience rape in particular develop PTSD. Combat experience
contributed to 29% of PTSD in men, and 26% of women who experienced violent crime develop
Literature Review: PTSD
PTSD. The incidence of PTSD among those who experience natural or man-made disaster is less
than those who experience violent crime.
PTSD in Natural and Man-made Disasters
In 1998, Breslau et al. (in Lee & Young, 2001) studied the lifetime rates of exposure to
different traumatic events. The exposure rate per 100 Americans for natural disaster was 16.6%.
PTSD rises in populations that have experienced a major natural disaster, such as a hurricane,
flood, or tornado. For example, 36% of sampled Hurricane Andrew survivors met the criteria for
PTSD, and 76% of the sampled survivors of a North Carolina tornado had PTSD symptoms four
months after the event (Breslau et al., 1998 in Lee & Young, 2001, Steinglass and Gerrity, 1990).
However, the conditional risk of PTSD for those who experience a natural disaster is only 3.8%.
This number does not include individuals who experience more than one trauma type, e.g. an
unexpected death of a loved one or serious loss of property during a natural disaster. Experience
variables including damage, loss, life threat and injury were significant predictors for the
development of PTSD after Hurricane Andrew (Shultz et al., 2005). This was echoed in a study
sampling adult Armenians after a major earthquake that showed those who lost a loved one in the
earthquake presented significantly higher rates of PTSD than those further away from the
epicenter that did not lose a loved one (Goenjian et al., 1994).
In the United States and other developed countries, severe levels of mental health
impairment is more likely to occur in those who experience mass violence than those who
experience natural or technological disasters (Norris et al., 2002a). In a study done comparing
type of disaster and level of mental health impairment, all those sampled who experienced mass
violence showed at least moderate impairment and reported the highest rate of very severe
Literature Review: PTSD
impairment. The samples of natural and technological disaster victims showed higher rates of
minimal and moderate impairment, and lower rates of severe and very severe impairment (Norris
et al., 2002a). Norris et al. (2002b) contend that intentional man-made disasters (bombings, mass
murder, etc.) cause significant mental health distress and are linked to higher rates of PTSD.
“Because shooting sprees and terrorist attacks tend to be indiscriminate and random (Stern
1999), they create acute helplessness and anxiety and may be even more likely than other
disasters to shatter beliefs of the self as invulnerable and of the world as a meaningful and just
place (Janoff-Bulman 1985)” (Norris et al., 2002b).
Literature Review: PTSD
Breslau, J., Aguilar-Gaxiola, S., Kendler, K., Su, M., Williams, D., Kessler, R. (2006) Specifying
race-ethinic differences in risk for psychiatric disorder in a U.S. national sample.
Psychological Medicine, 36(1), 57-68.
Brewin, C. R., Andrews, B., Valentine, J. (2000). Meta-analysis of risk factors for posttraumatic
stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology,
Bromet, E., Sonnega, A., Kessler, R. C., (1996). Risk factors for DSM-III-R posttraumatic stress
disorder: Findings from the National Comorbidity Survey. American Journal of
Epidemiology, 147(4), 353-361.
Friedman, M. J., Keane, T. M., Resick, P. A. (2007). Handbook of PTSD: Science and Practice.
New York, NY: Guildford Press.
Goenjian, A. K., Najarian, L. M., Pynoos, R. S., Steinberg, A. M. (1994). The American Journal
of Psychiatry, 151(6), 895-901.
Kessler, R.C., Berglund, P.A., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. (2005).
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National
Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 593602.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B. (1995). Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12),
Koopman, C., Classen, C., Spiegel, D. (1994). Predictors of posttraumatic stress symptoms
among survivors of the Oakland/Berkeley, Calif., firestorm. American Journal of
Psychiatry, 151(6), 888-894.
Lee, D., Young, K. (2001). Post-traumatic stress disorder: Diagnostic issues and epidemiology in
adult survivors of traumatic events. International Review of Psychiatry, 13, 150-158.
Mol, S. L., Arntz, A., Metsemakers, J., Dinant, G., Vilters-Van Montfort, P., Knottnerus, J. A.
(2005). Sypmtoms of post-traumatic stress disorder after non-traumatic events: Evidence
from an open population study. The British Journal of Psychiatry, 186, 494-499. Doi:
Literature Review: PTSD
Norris, F. H., Friedman, M. J., Watson, P. J., Byrne, C. M., Diaz, E., Kaniasty, K. (2002a)
60,000 disaster victims speak: Part I. An empirical review of the empirical literature,
1981-2001. Psychiatry, 65(3), 207-239.
Norris, F. H., Friedman, M. J., Watson, P. J., (2002b) 60,000 disaster victims speak: Part II.
Summary and implications of the disaster mental health research. Psychiatry, 65(3), 240261.
Pietrzak, R.H., Goldstein, R.B., Southwick, S.M., Grant, B.F. (2011, April) Prevalence and Axis
I comorbidity of full and partial posttraumatic stress disorder in the United States: Results
from Wave 2 of the National Epidemiological Suvey on Alcohol and Related Conditions.
Journal of Anxiety Disorders, 25(3), 456-465.
Shalev, A., Freedman, S., Peri, T., Brandes, D. (1998). Prospective study of posttraumatic stress
disorder and depression following trauma. The American Journal of Psychiatry, 155(5),
Shalev, A., Peri, T., Canetti, L., Schreiber, S. (1996). Predictors of PTSD in injured trauma
surivors: A prospective study. The American Journal of Psychiatry, 153(2), 219-225.
Shultz, J. M., Russell, J., Espinel, Z. (2005). Epidemiology of tropical cyclones: The dynamics of
disaster, disease, and development. Epidemiological Reviews, 27(1), 21-35. Doi:
Steinglass, P., Gerrity, E. (1990). Natural disasters and posttraumatic stress disorder: short-term
versus long-term recovery in two disaster-affected communities. Journal of Applied
Social Psychology, 20, 1746–1765.
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