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Crime Prevention and Community Safety (2019) 21:81–93 https://doi.org/10.1057/s41300-019-00062-w

O R I G I N A L A R T I C L E

Employee variables influencing ‘Run Hide Fight’ policy knowledge retention and perceptions of preparedness in the hospital setting

Mallory Darais1,3 · McKenzie Wood2

Published online: 26 March 2019 © Springer Nature Limited 2019

Abstract Nationally, there has been a large increase in the number of active shooter events within healthcare facilities such as hospitals. Due to this upturn, government organ- izations have recently released documents to guide healthcare facilities on imple- menting active shooter policies and updating emergency operation plans. Currently, recommendations from government entities, such as the Federal Bureau of Inves- tigation and the Department of Homeland Security, suggest the ‘Run, Hide, Fight’ approach during an active shooter incident. The current study uses data collected from hospital employees via a survey to determine and assesses variables that influ- ence whether hospital employees retain knowledge related to the ‘Run Hide Fight’ policy, as well as employee perception of whether the training was adequate. Results reveal that level of education, clinical versus non-clinical work role, and work sched- ule are significant variables in determining successful program implementation.

Keywords Active shooter · Armed intruder · Violence prevention · Hospital policy

Introduction

On August 9, 2018, Richard DeLucia entered the Westchester Medical Center in Valhalla, New York and shot his wife before turning the gun on himself (Hajela and Pletz 2018). Almost a year prior, in June 2017, a former physician entered a Bronx, New York hospital and shot seven people before killing himself (Nir 2017). These are just two examples in a long history of active shooters and armed

* Mallory Darais [email protected]

1 Mills County Public Health, Glenwood, USA 2 College of Western Idaho, Nampa, USA 3 Department of Emergency Preparedness, Southwest Iowa Preparedness Partners, 2518 S., 3rd

Street Plaza, Omaha, NE 68108, USA

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intruders in hospitals and related medical and health care institutions. While once described as an ‘emerging hazard’ (Lipscomb and Love 1992), violence in healthcare arenas is now widespread and frequent. Although the exact preva- lence of these violent encounters is unknown, one study determined that there were 154 hospital-related shootings between 2000 and 2011 (Kelen et  al. 2012). Granted, other institutions also face high levels of potential workplace violence, but health care settings are consistently ranked among the highest (Warren et al. 2017; NIOSH, 2002; Duhart 2001).

Although there are many theories as to why violence is so common in the hos- pital setting, a lone reason cannot be identified. Some researchers hypothesize the hospital setting itself might contribute to hostile or aggressive conditions. As one scholar put it:

Violence always has been part of the emotionally charged environment of a hospital. Stress levels are high in health care facilities as families grapple with life-and-death issues. A significant proportion of inpatients and outpatients suffer from mental illness. There’s a long history of violence from the streets spilling over into hospital emergency departments…The country has experi- enced a definite uptick in violent episodes in hospitals” (Frangou 2014; p. 1).

Understanding that in the USA, a shooting occurs in a hospital on average over once a month, the Department of Health and Human Services (DHHS), as well as the Joint Commission, have advised running routine drills and preparatory exercises (Adashi et al. 2015). In attempts to combat casualties of these violent incidents sev- eral institutions have employed training and prevention strategies. One of the most popular and widely used training resources is the ‘Run Hide Fight’ curriculum. A healthcare professional is more likely to respond appropriately during an intense situation if they are well trained and educated on what procedures should take place during these types of events (EDM 2014), and ‘Run Hide Fight’ policies seek to educate employees on the course of action they need to take to protect themselves and others during a violent or deadly encounter. Conversely, if an individual is untrained they are more likely to respond inappropriately and may hinder the efforts to get the situation under control (Healthcare and Public Health Sector Coordinating Council 2015). Ultimately, there is a common goal in every active shooter situation setting: to preserve life and minimize harm to every individual (EDM 2014).

Literature review

The healthcare setting, similar to the educational setting, is a unique environ- ment. The healthcare atmosphere has a highly vulnerable population, with people there for the specific purposes of healing, resting, and recovering from illness and injury. It is also unique because those who are not healing, resting, and recover- ing are often there to support family and friends, and may themselves be emotion- ally vulnerable, in mourning, anxious, or depressed.

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In the few studies that have been conducted on active shooters within the health- care setting, a standard pattern of approach has been identified. Scholar David Mil- len found shooters often go to areas of the hospital they are familiar with, and where there are numerous potential victims. Most often with active shooter cases, the per- son is familiar with at least one of their victims, whether it be an employee or former employee, a significant other, or a student (Millen 2013). When focusing on sole hospital shootings, more trends are identified. The shooters tend to be overwhelm- ingly male, with fewer than 10% of hospital shooters being female from 2000 to 2011 (Kelen et  al. 2012). The emergency department tends to be the most violent and frequent site for shootings, with the parking lot and individual patient rooms both following close behind. Reasons vary for each violent encounter, with research revealing that a grudge is consistently a main motive. ‘Euthanizing’ an ill person is also a strong objective, with prisoner escape, ambient society violence, and mentally unstable patients being other common reasons for hospital shootings (Kelen et  al. 2012).

‘Run Hide Fight’ policy

There are several types of protection measures that can take place during an active shooter situation, however, unless mapped out and practiced, it is likely that most individuals will not be aware of, will not remember, and will not be prepared to enact protective actions. Some of these protective techniques include evacuat- ing the building, sheltering in place, and retaliating against the perpetrator (Millen 2013). According to the ‘Run Hide Fight’ policy, in an active shooting scenario each avenue should be carefully and quickly considered and weighed against the oth- ers in order to decide which one will result in the best outcome. Unfortunately, the common hospital patient and/or visitor will likely not be in a situation to do this. Because of the inability to make these vital decisions, it is necessary that hospitals already have a plan in place, with competent employees prepared to direct and enact the plan should the need arise.

While prior policies used to only stress the importance of ‘hide,’ new research is indicating that other methods, such as running and fighting should also be con- sidered (Stewart 2017). Originating in 2012 with Houston, Texas city officials in conjunction with the Department of Homeland Security, ‘Run Hide Fight’ has now been adopted as the standard of defense in active shooting situations (Binkley 2016; Jacobs et  al. 2013). In an effort to combat what some scholars have deemed ‘the recognized but not regulated’ workplace violence in healthcare (McPhaul and Lipscomb 2004), the Healthcare and Public Health Sector Coordinating Council (HSCC) released ‘Run Hide Fight’ recommendations and guidelines specific to the healthcare setting. This was the first comprehensive guidance that healthcare facili- ties were provided with in preparing for and preventing an active shooter, and was released as a draft in January 2014, with an updated document being provided in April 2015 (HSCC 2015).

The ‘Run Hide Fight’ policy consists of the definition of an active shooter or armed intruder, as well as background information on typical incidents involving

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them. Many institutions continue to recommend the ‘Run, Hide, Fight’ method, as endorsed by Homeland Security (Morris 2014). Additionally, the ‘Run Hide Fight’ policy discusses appropriate responses employees should adhere to when involved in an active shooter situation. The recovery process is outlined clearly, as well as considerations for incident command operations, with responsibilities outlined for all incident command personnel.

Currently, a ‘Run Hide Fight’ policy is the suggested avenue of resistance if caught in an armed and potentially violent intruder situation. Researchers acknowl- edge several defensive actions that should take place during an active shooter encounter and provide recommendations on what to do if one of them occurs in a public setting (U.S. Department of Homeland Security 2018). The first recom- mendation involves fleeing the scene, when possible. If deemed safe, patients and employees should run away to a known safe location, far from the active shooter, and where a phone is available to call emergency services. The second recommen- dation, if running is not a safe or viable option, is to hide. Hiding should be done in the most barricaded area possible, away from the common areas such as hallways and corridors and into secured rooms. Lights should be off, and telephones should be quieted. Finally, if running and hiding are not possible, then the third and final recommendation is to fight. Using anything available as an improvised weapon, the employee should act aggressively to disarm and take down the active shooter (Mor- ris 2014).

A review of the literature has determined active shooter and armed intruder poli- cies to be an understudied arena with few significant findings. The current research examines baseline knowledge about the ‘Run Hide Fight’ policy by hospital employ- ees. The following research questions will be addressed:

1. Do hospital employees know where to correctly locate the ‘Run Hide Fight’ policy?

2. What employee variables influence knowledge retention of the ‘Run Hide Fight’ policy?

3. What employee variables influence perceptions of adequate training of the ‘Run Hide Fight’ policy?

Methodology

The current study analyzes data from employees at a medium-sized Level III trauma center hospital in the Midwest. The hospital is licensed for 230 beds and has a typi- cal patient count of 70 inpatients per day, staffed by 132 physicians and other clini- cal and non-clinical employees. On average, the emergency department adminis- ters to nearly 21,000 patients annually. This hospital has an active shooter strategy in place, taken from the health system with which they are affiliated. If an armed intruder or active shooter enters hospital premises, employees are advised to follow the course of action as outlined in the ‘Run Hide Fight’ policy, which provides guid- ance on responding to this type of situation. This policy was available to all employ- ees through their online employee portal. Upon hire, the ‘Run Hide Fight’ method

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also is reviewed via an orientation video. While this policy was never drilled as a full-scale or functional exercise, tabletop exercises were conducted at the hospital related to an active shooter situation, and all employees have access to the written policy.

Sample population

The hospital of interest was chosen because it encompasses a broad area within a greater Midwest metropolitan area. The placement of the hospital individually caters to multiple different ethnicities, races, and cultures. Contact was made with the Emergency Manager at the medical facility, and arrangements were made to dis- tribute a hospital-wide survey. The sample population was a convenience sample of all hospital employees (approximately 725). These employees include clinical staff (physicians, nurses, mental health associates, etc.), as well as administrators and non-clinical staff (cafeteria employees, custodial workers, etc.).

An email was sent to each hospital employee by the hospital emergency manager. The email contained a brief description of the survey, as well as the survey hyper- link, and a request to complete the survey by a specific date (one week from the day the email was launched). A follow-up email (also containing the survey link) was distributed four days later to remind employees who had not yet completed the survey to please do so. The survey was created using Google Forms in Octo- ber 2015. By enlisting the help of the Emergency Manager, an individual whose sole position is to ensure the safety, productivity, and effectiveness of hospital poli- cies, the researchers hoped hospital employees would view the survey as important and worthwhile. The connection to the Emergency Manager was established by one author who had a previous working relationship at that facility. IRB approval was obtained prior to beginning the research.

The survey itself consisted of 15 close-ended questions, adapted from literature reviews and previous active shooter studies. It was estimated the survey would take approximately eight minutes to complete. Respondents were informed their partici- pation in the survey was voluntary, and if they decided to participate, they were free to stop participating at any time. Respondents were also informed that while they would get no direct benefit from participating in the survey, the benefit would go to the hospital as a whole, as this information could be used to create better, broader, more effective policies.

Variables

Two dependent variables were analyzed in this study. The first dependent variable being examined included whether hospital employees could identify the correct ini- tial response to what they should do when they hear an overhead warning that there is an active shooter or armed intruder at the hospital. The overhead warning is a simple warning, using plain language. The correct response is to ‘Run, Hide, Fight.’ Incorrect responses included singular or fragmented elements of the ‘Run Hide Fight’ triumvirate, such as ‘shelter in place,’ ‘lockdown,’ or ‘confront the armed

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intruder.’ Responses were coded as (0) ‘Run Hide Fight’ correct response, and (1) incorrect responses. The second dependent variable was whether or not hospital employees believed they had been adequately trained for an active shooter/armed intruder incident. Responses were coded as (0) no, (1) yes. Because the dependent variables are dichotomous, binary logistic regression was employed.

Independent variables in this study include demographic characteristics, such as gender (female, male), level of education (college degree or less than college degree), employee role (clinical or non-clinical), length of employment at the hos- pital (less than 5 years, 5 or more years), and work schedule (part time or less, full time). Age was initially included as a variable, however, because of multicollinear- ity issues with education, employee role, and length of employment it was removed from the regression analysis. Additionally, employees were asked whether they were aware of the ‘Run Hide Fight’ policy, and if they knew where the policy was located, by asking the question: ‘Where would you expect to find an active shooter/ armed intruder policy?’

Findings

E-mails were sent out to 725 hospital employees, with 341 surveys returned, yield- ing a robust 47% response rate. Approximately 84.5% of survey respondents identi- fied as female, and 15.5% identified as male (See Table  1). The majority of sur- vey respondents were full-time employees (84.1%), meaning that they worked 32 h or more a week. Approximately 13% considered themselves part-time employ- ees, meaning they worked under 32  h per week, and 3% were less than part time. Those who work less than part time are traditionally on-call employees or options employees, meaning they are not assigned a minimum number of hours that they are required to work each week.

Most respondents were over 50  years old, with the vast minority being younger than 24. Approximately 50% of those who participated in the survey asserted they were over 50  years of age, with 32.6% being between 35 and 50  years old, 16.4% being between 25 and 34 years old, and 4.1% being between the ages of 19 and 24. The vast majority of respondents have been employed at this hospital for greater than 10  years (48.8%). 15.4% have been employed for 5 to 10  years, 23.4% have been employed for 1 to 4 years, and 12.4% have worked at the hospital for less than 1  year. Of those who responded to the survey 58.9% identified themselves as clin- ical staff, 26.5% as non-clinical staff, 8% as administration, and 6.5% as ‘Other.’ Most employees had an undergraduate degree or higher, with 24% having a graduate degree of some sort.

The demographic characteristics of the respondents varied somewhat in rela- tion to the demographic characteristics of the hospital employees. Overall hospital employee information was available regarding gender and full-/part-time status. While the disparity between male and female respondents is significant, the response rate regarding gender was representative of the hospital, which currently employs 85 females to every 15 males. The full-/part-time employment status of respondents deviated slightly from the hospital, who has 65% of employees working full time

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and 35% working part time. While hospital information was not available in rela- tion to age, education level, or clinical verus non-clinical status of employees, it is known that 18% of the hospital staff is comprised of physicians.

The majority of employees (84%) knew where to find the active shooter/armed intruder policy, which is held within the Health Systems intranet under the ‘Poli- cies’ tab (See Table 2). Employees are aware that an active shooter/armed intruder policy exists, and they know where the policy is located among hospital documents, but they are less acquainted with the contents contained in the policy. Fewer than half of employees who responded to the survey were able to identify the appropriate response when the active shooter/armed intruder alert is paged over the hospital’s PA system. When asked what should be done in an active shooter/armed intruder situation, 49.3% correctly identified the Run, Hide, or Fight scheme as the cor- rect course of action. Other respondents identified only one part of the policy, with

Table 1 Descriptive statistics of survey respondents

Variable N %

Gender Male 53 15.5 Female 288 84.5 Age Over 50 160 46.9 35–50 111 32.6 25–34 56 16.4 19–24 14 4.1 Employment experience 0–1 years 42 12.4 1–5 years 79 23.4 5–10 years 52 15.4 Greater than 10 years 165 48.8 Employee classification Administrative 27 8 Clinical 198 58.9 Non-clinical 89 26.5 Employment schedule Full-time 286 84.1 Part time 44 12.9 Less than part time 10 2.9 Education Doctorate 15 4.4 Graduate degree 67 19.6 Undergraduate degree 131 38.4 Some college 89 26.1 High school grad 37 10.9 Less than high school 2 0.6

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38.4% identifying lockdown as the best course of action, 11.7% voting to shelter in place, and 0.6% acknowledging they would initially confront the intruder.

To identify what employee characteristics were substantial in correctly deter- mining the course of action in active shooter/armed intruder situations, a regres- sion found that level of education, employee role, and employee work schedule all emerged as significant variables (See Table  3). Interestingly, those with less than a college degree were more likely to identify the correct course of action in active shooter/armed intruder situations as outlined in the ‘Run Hide Fight’ policy. Clini- cal staff were more likely to respond correctly than non-clinical staff, and those who reported working part time or less were more likely to correctly identify course of action than full-time employees.

When asked if they felt they had been adequately trained for an active shooter/ armed intruder incident, slightly more than half revealed they did not believe they have been adequately trained for this type of circumstance (52.1%), while 47.9% felt

Table 2 Employee knowledge of ‘Run Hide Fight’ policy

Variable N %

Where would you expect to find an active shooter/armed intruder policy? System Intranet 282 83.9 Hospital Homepage 37 11 With administration 6 1.8 Other 11 3.3 What should be your initial response when hearing active shooter/armed intruder overhead? Run, hide, or fight 168 49.3 Lockdown 131 38.4 Shelter in place 40 11.7 Confront intruder 2 0.6 Do you feel you have been adequately trained for an active shooter/armed intruder incident? Yes 163 47.9 No 177 52.1

Table 3 Logistic regression model of variables influencing correct identification of ‘Run Hide Fight’ policy by hospital employees

*p .05 **p .01

Variable B (B)exp S.E.

Gender − .21 .81 .32 Education − .61** .54 .25 Employee role .62** 1.86 .25 Length of employ .26 1.30 .24 Work schedule − .63* .53 .32 Constant .43 Naglekerke R2 .07 Cox and Snell R2 .05

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the training received was adequate. In regard to what employees felt the training was inadequate, a binary logistic regression was utilized. Results of the regression found that the only variable of significance was hospital role, with non-clinical staff more likely to believe that they did not receive adequate training than clinical staff (See Table 4).

Discussion

The finding that less than half of employees could correctly identify ‘Run, Hide, Fight’ as the correct course of action in an active shooter/armed intruder situation is troubling. Additionally puzzling is that there does not seem to be a common link between employees who correctly identify ‘Run Hide Fight’ and those who do not. It is possible that those with less than a college degree were better able to identify the correct response pattern because those without a degree may also be younger than those with a degree. ‘Run Hide Fight’ is a new-age mantra that many schools and other institutions have recently adopted (Babel 2016), potentially offering younger employees the advantage of having learned about ‘Run Hide Fight’ while in high school (Schweit 2017). Clinical staff may understand that they are at a greater risk of being a victim of an active shooter than non-clinical staff, which may explain why they are more inclined to know the policy. No explanation is provided as to why part-time employees might better understand the policy than full-time employees, but it is possible that perhaps physicians and nurses who are full-time employees choose not to read or engage in training for new, non-medical related policies. It is also possible that employees who work only part time at the hospital also work part time at another establishment which might also promote ‘Run Hide Fight’ strategies, allowing these employees additional training and knowledge on the policy.

Essentially, employees are given instruction on how to find all hospital policies dur- ing employee orientation, but no further action is taken by the hospital to ensure that policies are read, understood, practiced, or enacted, unless individual unit managers take it upon themselves to do so. The idea that the policy explicitly states that it is the

Table 4 Logistic regression model of variables influencing perceptions of adequate training by hospital employees

*p .05

Variable B (B)exp S.E.

Gender .18 1.20 .32 Education − .04 .96 .24 Employee role − .53* .59 .24 Length of employ − .06 .94 .24 Work schedule − .19 .83 .31 Constant .38 Naglekerke R2 .03 Cox and Snell R2 .02

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duty of the employees to know the policy in order to be knowledgeable in the event of an active shooter/armed intruder seems ambitious without further training.

When it came to feelings of whether they had been adequately trained, non-clinical staff were more likely than clinical staff to believe they were poorly or inadequately trained for an active shooter/armed intruder situation. Some studies have determined that violence is most likely to occur in the psychiatric wards of hospitals, emergency rooms, waiting rooms, and geriatric units (OSHA 2016). This indicates that perhaps clinical staff, those who are specifically tending to patients and families in those areas are more likely to be victims than non-clinical staff, such as administration, who may be found in offices located throughout the hospital. However, this education may need to extend beyond hospital employees as other studies have revealed that patients and visitors are more likely to be victims than nursing staff, physicians or pharmacists (Kelen et  al. 2012). Furthermore, it is possible that no matter the quality or quantity of training, some individuals may never believe they are adequately trained for such a traumatic event.

While many institutions rely heavily on ‘Run Hide Fight’ related policies, recently contemporary viewpoints related to workplace violence have been introduced, such as ‘Zero Incidents’ philosophies (Sawyer, p. 16, 2015). Separate from ‘Run Hide Fight’ which responds to a violent or deadly episode that is currently happening, ‘Zero Inci- dents’ aims to teach employees how to identify and deflate potentially violent situations before they ever occur, largely by identifying warning signs and teaching employees not only to document and report all minor offenses, but also encouraging them to fol- low their intuition if they suspect an individual or situation might be amiss (Sawyer 2015). While these departures from ‘Run Hide Fight’ may be impactful at preventing violent situations, assessment of the efficacy of constructs such as ‘Zero Incidents’ is difficult to obtain.

Limitations

As with any survey study, there are limitations. Due to time constraints, the survey was open to hospital employees for only one week. While more responses may have been obtained if the survey was kept open for a longer period of time, particularly for part time or less than part-time employees, survey results showed a large decline in the number of response rates as each day passed, indicating that it is unlikely a large increase in survey responses would have been obtained. Finally, it would be inappro- priate to generalize or compare the results of this study to other institutions such as educational facilities, government establishments, or business organizations as this research is purely hospital-based. It should also be noted that this particular hospital system has over 1,000 policies, and any particular policy seems to be hidden among the others. Employees are not specifically directed to this policy, so it is expected that some employees were unaware of its existence.

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Suggestions for future study

A lack of preparedness for an active shooter situation can have disastrous conse- quences for everyone involved, which could include patients, family members, hos- pital employees, or bystanders. Knowing that responding effectively could be the difference between life and death, these guidelines were put into place to assist employees in appropriate responses in cases of active shooters. Although histori- cally, hospital violence prevention methods have been largely understudied and unevaluated (Rothaus 2016), new research has indicated that with appropriate pre- paredness methods in place, dire consequences can be avoided and loss of life has the ability to be minimized (HSCC 2015). Additional research needs to be con- ducted to determine the best way to implement the ‘Run Hide Fight’ program so it meets the needs of all hospital employees.

While having an active shooter situation in a healthcare setting is not novel, hav- ing a written policy and procedure for healthcare facilities is a fairly new construct, only drawing attention to the need for them in the past few years. Although health- care facilities tend to have Emergency Operation Plans (EOPs) in place, it seems prudent for a separate document to be operational, specifically regarding an active shooter situation that includes preventing, preparing for, and responding to an active shooter. This is important as the number of active shooter incidents has been sig- nificantly increasing in the hospital workplace over the past several years, starting at nine on a yearly basis in 2000 and raising to nearly 17 annually by 2011 (Hartley 2015). Furthermore, as research has suggested, strong policies and procedures need to be accompanied with strong training programs (Peek-Asa et al. 2007). A written policy without proper training may not provide the intended outcome.

The following suggestions are designed to assist in nurturing a safe and pro-active hospital environment: First, ‘Run Hide Fight’ and other policies should be clearly labeled, easy to access, and visible to all hospital employees. Ideally, this includes both electronic policies as well as hardcopies. Hardcopies may be more accessible in the midst of a chaotic situation than searching for instructions or direction on a com- puter. Second, ‘Run Hide Fight’ should be discussed and practiced frequently, not just during new-employee orientation. Intervention and training have been shown to increase policy knowledge and feelings of preparedness (Landry et  al. 2018; Sanchez et al. 2018). Refreshers should be provided to all hospital personnel. Third, employees should be trained on how to fully implement all aspects of ‘Run Hide Fight.’ For example, if running is the best option in the given scenario, employees should be aware of the nearest exits, stairways, elevators, and other routes conducive to fleeing the event. Similarly, potential hiding arenas should be addressed, such as doors that lock or do not lock, which entrances/exits may require key cards, and ethi- cal implications of hiding in or near patient rooms. Beyond simply locking down, employees can be trained about differences between ‘hard’ and ‘soft’ lockdowns (Morris, p. 240, 2014), and given examples of which lockdown might be appropri- ate given various circumstances. Breaking down trainings according to employee role may offer some employees the opportunity to consider their responsibility to patients, as well as how their role might influence whether their best option is to run, hide, or fight. Recently, institutions have investigated the efficacy of active shooter

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trainings specifically for nurses and built active shooter preparedness into a program for medical students (Rega and Fink 2017; Sikes et  al. 2018). Finally, ‘Run Hide Fight’ exercises should include a short de-brief period, where employees are given the opportunity to consider their strengths and weaknesses during the training, and what actions could be taken to improve their own safety (Morris 2014).

A lack of preparedness for an active shooter situation can have disastrous con- sequences for everyone involved, including patients, family members and friends of patients, hospital employees, and bystanders. Responding effectively to these traumatic situations could be the difference between life and death. Because these guidelines were put into place to assist employees in appropriate responses in cases of active shooters, with appropriate preparedness methods in position, dire conse- quences can be avoided, and loss of life has the ability to be minimized.

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  • Employee variables influencing ‘Run Hide Fight’ policy knowledge retention and perceptions of preparedness in the hospital setting
    • Abstract
    • Introduction
    • Literature review
    • ‘Run Hide Fight’ policy
    • Methodology
      • Sample population
      • Variables
    • Findings
    • Discussion
      • Limitations
      • Suggestions for future study
    • References