Training in Secure Firearm Storage to Save Children
Post Date: February 3, 2025 | Publish Date:

Research led by experts at Cincinnati Children’s employs novel approaches to address the leading cause of childhood death
Firearm-related injuries are the leading cause of death in children under the age of 19 in the United States. That’s more than cancer, infectious diseases, car crashes or any other single cause of death. In fact, firearms account for 20% of all childhood deaths in the country. In 2020 alone, more than 4,300 children died from firearm-related injuries. That’s the equivalent of five school buses full of children every month.
Roughly one in three U.S. households has at least one firearm and nearly half of those do not store them securely (locked, unloaded and separate from ammunition). Moreover, 75% of children in those homes know where those firearms are located.

Cincinnati Children’s, along with the American Academy of Pediatrics, recommends that providers have discussions around the secure storage of firearms with families during regular pediatric visits. To accomplish this, the health system has taken a proactive approach to this issue in a way no other institution in the country is doing – by creating an interactive, virtual-reality-based training tool that teaches providers how to have these life-saving conversations with families in their care.
Watch a video about the importance of safe gun storage
Three recent studies by Cincinnati Children’s experts outline both the need and efficacy of the virtual reality training program and point to important data on the feasibility of widespread adoption for the next generation of providers.
The creation of, and investment in, this training is predicated on the idea that pediatric providers endorse having the responsibility to counsel families in clinical practice but often do not due to minimal firearm-related education, limited knowledge of secure storage devices, a lack of training on firearm safety counseling techniques, and insufficient time during visits.
“A lot of us (pediatricians) don’t know much about firearms or secure storage devices, and we might not know how best to communicate with families on this very important topic,” said Joe Real, MD, general pediatrician and co-lead of Digital Simulation in Cincinnati Children’s Center for Simulation and Research. “Virtual reality offers a safe and realistic environment to practice that conversation before counseling families in real life.”

The virtual reality training program was developed by Cincinnati Children’s Digital Technologies Team supporting digital training efforts under the leadership of Bradley Cruse. The platform allows providers to practice having these conversations and receive real-time coaching on how to frame these discussions in a way that is non-judgmental and that provides families with actionable information to help keep their children safe. Moreover, by leveraging virtual reality that can be delivered effectively via a screen and a video conferencing platform such as Zoom, the cost of these trainings is notably less than using patient actors, allows for purposeful design of graphical characters to monitor for biased behaviors, and allows for access to the training from anywhere.
“As we formally assess how useful the platform is – how well tolerated it is, whether the learning outcomes are what we expect, etc. – then the goal is to apply it in practice and see if it makes an impact for our patients,” said Matt Zackoff, MD, pediatric intensivist and co-lead of Digital Simulation in Cincinnati Children’s Center for Simulation and Research and Co-Director of the PICU Innovation Accelerator. “Does it change what providers document that they’re talking with families about? Do patients and families cared for by those who have received the training feel like their concerns have been heard or walk away with actionable information? And, ultimately, does this lead to a reduction in injuries and poor outcomes for patients related to firearms?”
Families want pediatricians to talk frankly with them
One Cincinnati Children’s study led by a former Cincinnati Children’s fellow and now community physician Michelle March, published in June 2024 in the Journal of Pediatrics: Clinical Practice, recounts the results of several focus group sessions the researchers held in 2023 – including people from a neighborhood that experienced 160 shootings in four years.
“Across all focus groups, participants expressed a desire for their child’s pediatrician to discuss firearm safety,” the research team reports.
Yet most pediatric providers do not provide firearm-related counseling in clinical practice. This study makes three key recommendations:
- Embed firearm safety within routine injury prevention counseling.
- Screen for storage practices rather than firearm ownership.
- Providers should be ready to describe what secure storage means and partner with families to identify what secure storage approach may work best for them.
Feasibility and acceptability of virtual reality as a training strategy
Researchers at Cincinnati Children’s partnered with firearm safety experts at the Massachusetts General Hospital’s (MGH) Gun Violence Prevention Center to develop the virtual reality training program incorporating the previously described caregiver feedback. Given the impact of residency training on future care provision, the research term sought to understand pediatric residents’ perspectives on virtual reality as a modality for training on conversations around firearm safety.
In a new report published in December 2024 in the Journal of Graduate Medical Education, residents identified the training as immersive and realistic. They noted the rehearsal of specific verbiage as critical to supporting behavior change. Notably, residents reported that the training helped overcome prior barriers to counseling by providing a framework for efficient and actionable counseling.
As one resident stated: “I liked the opportunity to practice with patients multiple times, especially to do it once and then receive some feedback and education and then go back and do it again.”
Virtual reality training appears effective
So, does participation in the virtual reality training actually improve a providers’ skills related to firearm safety counseling? In this study, published Aug. 10, 2024, in Academic Pediatrics, the Cincinnati Children’s and MGH research teams described a randomized controlled trial that sought to answer that question. The researchers found that, “Compared with didactic training alone, a virtual reality intervention using deliberate practice improved residents’ skills and confidence related to firearm safety counseling.”

Scaling up VR training is feasible
Zackoff and Real continue to see demand for this impactful training.
“With the support of our Center for Simulation and Research, we have continued to offer the virtual reality training throughout Cincinnati Children’s with notable uptake by providers within our primary care clinics and trauma team,” Zackoff says. “We have also spread the training to pediatric residents at the University of Kentucky and have partnered with the Ohio AAP to bring training to pediatricians across Ohio. We are frequently contacted by hospitals and programs who want to train their teams on this critical topic.”
How effective will VR training be? Time will tell
What’s next for the virtual reality training program? Zackoff and Real have been collaborating with several institutions to scale up the program.
In October 2024, Cincinnati Children’s began a collaboration with The New England Journal of Medicine (NEJM) and MGH’s Gun Violence Prevention Center to allow providers access to the virtual reality curriculum through a landing page on the NEJM’s website. The team also is working with non-profit organizations to fund a national implementation effort and to adapt the curriculum specifically for military veterans.
Meanwhile, funding from the National Institute of Child Health and Human Development will allow Real and Zackoff to assess ways to use artificial intelligence to expand delivery of this impactful training experience.
One part of a wider effort
The virtual reality training program is one of several efforts underway through the Cincinnati Children’s Firearm-Related Injury Task Force, which is working with the City of Cincinnati and UC Health to build the first joint pediatric and adult hospital-based violence intervention program.
The work includes rolling out Stop the Bleed and Active Assailant education for all 19,000+ Cincinnati Children’s employees, and working with the community via focus groups and listening sessions to identify root causes and test interventions to reduce gun violence.
The task force’s work was recently published in the NEJM Catalyst and can be read about here.
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