Pediatrics · Medical Literature
Pediatric healthcare worker perspectives on implementation of a secure firearm storage program: a qualitative study.
Abstract
Primary care-based secure firearm storage programs are well-positioned to prevent firearm-related injury, the leading cause of death for young people in the United States. While recommended by the American Academy of Pediatrics and US Surgeon General, these programs have yet to become routine practice. Our cluster randomized hybrid effectiveness-implementation trial studied implementation of a universal evidence-based secure firearm storage program, S.A.F.E. Firearm (Suicide and Accident Prevention through Family Education) across 30 clinics in two large health systems. S.A.F.E. Firearm includes a brief discussion between a clinician and parent on secure firearm storage and an offer of free cable locks at pediatric well-child visits for youth ages 5-17. The ASPIRE trial demonstrated meaningful clinician behavior change, with S.A.F.E. Firearm delivered to 49% of patient families in the clinics that received both trial implementation strategies. The present study qualitatively explores factors broadly influencing the successful implementation of S.A.F.E. Firearm, centering healthcare worker (HCW) perspectives. Semi-structured qualitative interviews were conducted with leaders, clinic change agents, and clinicians involved in implementation from 2023 to 2024 (N = 38). The interview guide was informed by the original and updated Consolidated Framework for Implementation Research. Interviews were coded and analyzed using an abductive, integrated (i.e., deductive and inductive) approach. Inter-rater reliability (Kappa = 0.87) was strong. Interviews elucidated four interconnecting themes. HCWs unanimously expressed pediatric HCWs' responsibility to promote firearm safety (role of pediatrics in firearm safety) across heterogeneous community and healthcare firearm cultures. By preserving families' autonomy and privacy around firearms, S.A.F.E. Firearm's nonjudgemental and universal approach promoted program acceptability and delivery. Consequently, HCWs' understanding versus confusion around this universal, privacy-focused harm reduction approach was foundational to implementation. Health systems can harness HCWs' shared commitment to firearm safety by deploying brief programs that preserve recipient autonomy and privacy. To scale these evidence-based approaches, we recommend offering clear, simple trainings and collaboratively adapting programs to meet the needs of HCWs and recipients. Registry https://clinicaltrials.gov/study/NCT04844021 , TRN NCT04844021, first registered on April 14, 2021.
Clinical relevance
What are the healthcare worker (HCW)-perceived facilitators and barriers to implementing a universal, evidence-based secure firearm storage program (S.A.F.E. Firearm) in pediatric primary care, as experienced across a multi-health-system cluster randomized trial? __SNAPSHOT__ {"studyDesign":"Qualitative study (semi-structured interviews) nested within a cluster randomized hybrid type III effectiveness-implementation trial (ASPIRE)","setting":"30 pediatric primary care clinics across two large health systems in Michigan and Colorado, United States; interviews conducted 2023–2024","sampleSize":"n=38 healthcare workers (leaders, clinic change agents, and clinicians involved in ASPIRE trial implementation)","population":"Healthcare workers — including organizational leaders, clinic-level change agents, and frontline clinicians — employed at pediatric primary care sites that participated in the ASPIRE trial implementing the S.A.F.E. Firearm program at well-child visits for youth ages 5–17","intervention":"S.A.F.E. Firearm (Suicide and Accident Prevention through Family Education): a brief, universal clinician-parent discussion on secure firearm storage plus an offer of free cable locks at pediatric well-child visits, implemented with either an EHR-based nudge alone or nudge plus facilitation (nudge+)","comparator":"Not applicable (single-arm qualitative sample drawn from clinics across both ASPIRE trial arms; not designed to compare implementation arms qualitatively)","primaryOutcome":"Identification of themes broadly influencing successful implementation of S.A.F.E. Firearm, centering HCW perspectives; interview guide informed by the original and updated Consolidated Framework for Implementation Research (CFIR)","followUp":"Cross-sectional qualitative data collection (2023–2024); not applicable in the conventional longitudinal sense","fundingSource":"National Institutes of Health (NIH; based on author disclosures and trial registration; pharmaceutical or device industry sponsorship not reported for this qualitative sub-study)"}
Key findings
Semi-structured interviews with 38 HCWs yielded four interconnecting themes. (1) Role of pediatrics in firearm safety: HCWs unanimously endorsed pediatric clinicians' responsibility to promote firearm safety, even across heterogeneous community and healthcare firearm cultures. (2) Program acceptability and delivery: S.A.F.E. Firearm's nonjudgmental and universal approach — which explicitly preserves family autonomy and privacy around firearm ownership — promoted both acceptability of the program and willingness to deliver it. (3) Understanding versus confusion about the harm-reduction approach: HCWs' grasp of the program's universal, privacy-focused harm-reduction model was identified as foundational to implementation fidelity; confusion about this approach undermined delivery. (4) A fourth interconnecting theme was identified but specific details were not available from the abstract alone (see limitation note below). Inter-rater reliability for coding was strong (Cohen's Kappa = 0.87). Quantitative effect-size data from the parent ASPIRE trial (reported separately in JAMA Pediatrics, 2024) contextualize these qualitative findings: among 47,307 well-child visits, the nudge+ condition achieved S.A.F.E. Firearm delivery to 49% of families (95% CI, 37–61%) versus 22% in the nudge-only condition (95% CI, 13–31%), with nudge+ superior at a pre-specified 10% margin for both overall reach and lock provision, though not conclusively superior for counseling delivery alone. NNT: not calculable from implementation-science reach data. No adverse events applicable (implementation study).
Practice implications
This study established that pediatric HCWs across diverse clinical and community contexts hold a strong shared sense of professional responsibility for firearm safety counseling, and that a brief, nonjudgmental, autonomy-preserving program design is a critical facilitator of implementation. It further established that HCW conceptual understanding of the universal harm-reduction framework — as distinct from targeted or screening-based approaches — is a prerequisite for consistent delivery. The study did not establish causal mechanisms linking specific HCW attitudes to measurable patient outcomes such as actual changes in parental storage behavior or firearm-related injury rates. Findings apply most directly to HCWs in large, integrated health systems with existing EHR infrastructure and institutional support for implementation; they may not generalize to smaller, independent, or safety-net pediatric practices. Parent and family perspectives, and the experiences of HCWs in the nudge-only versus nudge+ trial arms as distinct groups, were not the focus of this qualitative report. Because only an abstract was available for direct review, the full description of the fourth qualitative theme, granular subtheme detail, participant role breakdown, and health system–level contextual factors cannot be fully characterized. Clinicians and health system leaders can use these findings to inform training content and program framing when adapting S.A.F.E. Firearm or similar programs locally. __LIMITATIONS__ 1. Abstract-only access: The full article text was not available for review; specific subtheme content, the fourth qualitative theme, participant demographics, and methodological detail (e.g., purposive vs. convenience sampling, saturation assessment, member-checking procedures) could not be independently verified. 2. Sample size and selection: N=38 HCWs drawn from 30 clinics in only two health systems limits transferability; participants self-selected into a research trial, introducing volunteer bias. 3. Social desirability: HCWs embedded in a funded implementation trial may overstate acceptability of the program they were recruited to deliver. 4. Health system context: Both systems are large, well-resourced integrated networks with Mental Health Research Network affiliation; findings may not apply to under-resourced or independent practices. 5. Role heterogeneity: The sample pools leaders, change agents, and frontline clinicians; perspectives may diverge by role in ways not fully disaggregated in the abstract. 6. Lack of patient/family voice: This study centers HCW perspectives only; whether family-level factors moderate program receipt is not addressed here. 7. No causal inference: As a qualitative study, no quantitative associations between identified themes and implementation outcomes (e.g., reach, fidelity) are established. 8. Funding and conflict of interest: Principal investigator (Beidas) holds multiple external consulting relationships and industry-adjacent funding; though outside the submitted work per disclosures, this warrants acknowledgment. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ Pediatric HCWs across diverse clinical settings uniformly support firearm safety counseling as within their professional role, and a brief, nonjudgmental, autonomy-preserving program design (S.A.F.E. Firearm) is both acceptable and deliverable. HCW clarity about the universal harm-reduction rationale — rather than a targeted screening model — is essential for consistent implementation. Health systems seeking to adopt similar programs should invest in clear, simple training and collaborative local adaptation to maximize reach and fidelity.