Table 1. Barriers to integration of ERPOs into the clinical workflow.

(n = 1,126).

Barrier	Representative Quote
Outside of professional scope	“Healthcare providers have a different set of tasks and priorities and have no business in counseling on purely legal matters. Majority of healthcare providers have no legal education, let alone background, to counsel on anything so far outside their profession and specialty.” ~Physician
	“There has been a lot of talking about replacing police with social workers. Our jobs are not the same. As a person of color who has been mistreated by police, I do not trust the police and do not wish to work with them. I also think it is dangerous for the profession to align itself and/or be seen as an alternative to police, especially since social work is also a white-dominant field.” ~Social Worker
Knowledge gaps	“As a psychiatrist in a high acuity setting I am often in the position of deciding whether or not to refer for [involuntary] detention, which will remove firearms legally. ERPO is a lower threshold and a welcome addition that I have not used for lack of knowledge.” ~Physician
	“It can be hard to find information [about] many things on government websites” ~Social Worker
Perceived ERPO effectiveness and lawfulness	“This is a ‘slippery slope’ to go down! Where does it end? Firearms are most certainly not the only weapon a patient could use to harm themselves or others. Do we start restricting access to knives? Restrain the patient based on a ‘fear’ that they ‘might’ harm someone else or themselves?” ~ ARNP
	“Often I have clients, especially young people, say ’I don’t have a gun but I can easily get one from somebody’ which these tools would not capture this population. Not an easy fix, but just wanted to point this out as I hear it quite often and it always worries me as it is hard to make a safe plan around potential to obtain from other people.” ~Social Worker
Relationship with patients	“I think ERPOs will be detrimental to the provider-patient relationship. No one will disclose how they are feeling if they cannot trust their providers. This is more harmful than involuntary psychiatric holds.” ~ARNP
	“It would almost certainly damage any therapeutic alliance that I had developed with the patient, which could make the patient less willing or receptive to care planning with the [social worker]. Patients could also interpret this action as a violation of their trust.” ~Social Worker
Concern for patient and family safety	“I worry about the safety of undocumented patients in the setting of having the authorities involved.” ~Physician
	“From an [Equity, Inclusion, and Diversity] perspective, if my patient is a person of color my trust in the court system diminishes the darker their skin color is.” ~ARNP
	“Transfers risk to family. I think it is my responsibility to contact police if I have concerns. If patient is willing, I would have them have family take guns away from the home, but I would measure that very closely. If patient feels threatened it could escalate very quickly.” ~Social Worker
Concern for personal (clinician) safety	“I would be concerned about my own safety with initiating as there is likely lag time from when it is filed to when the patient stops having access to firearms.” ~Physician
	“Some families get very angry and/or threaten to sue when we escalate care appropriately.” ~ARNP
Institutional barriers	“Very limited resources in rural areas, no social workers and deputy sheriffs are busy. Who do I send them to?” ~Physician
	“I am paid to shuffle patients through and do a lot of tests and procedures to them, not to protect them. This must change.” ~Physician
	“Time is a huge factor. As it is with the responsibilities that Medical Social Workers currently have, there is not enough time in the day to get everything done. I would be very reluctant to advocate for any additional responsibilities that could necessitate court time, consultation with law enforcement or additional paperwork responsibilities to a schedule that is already overfilled.” ~Social Worker