Empower nurses with screening tools and effective communication techniques.

RECENT FEDERAL UPDATES to the national vaccine schedule and state immunization requirements have intensified public debate about vaccine administration, timing, and combination vaccines such as measles, mumps, rubella, varicella (MMRV). On January 5, 2026, the U.S. Department of Health and Human Services (HHS), in collaboration with the Centers for Disease Control and Prevention (CDC), acted on a Presidential Memorandum revising the childhood immunization schedule. The number of recommended vaccines decreased from 18 to 11, to align with peer developed nations, and reassigned non-consensus vaccines to high-risk groups or shared clinical decision-making.

Since the 1930s, the vaccine schedule, developed through collaboration among organizations such as the American Academy of Pediatrics (AAP), the CDC, and later the Advisory Committee on Immunization Practices (ACIP), has guided pediatric care. (See Vaccines and immunity.)

The recent change to vaccination recommendations has resulted in conflicting guidance for families. Diverging from the federal schedule, the AAP continues to recommend routine immunization against 18 diseases. This inconsistency risks undermining public trust in immunization science and may place parents and guardians in a more complex decision-making environment, where uncertainty may contribute to vaccine hesitancy.

Nurses play a critical role in providing evidence-based guidance by translating evolving vaccine science to mitigate hesitancy. Nursing strategies—such as effective communication techniques, screening tools, and advocacy efforts to inform family-centered vaccination decisions—can impact immunization outcomes.

Public health and herd immunity

Public health efforts related to vaccination success aim to establish herd immunity. When a sufficient number of individuals within a population are vaccinated or immunized against a specific pathogen, diseases have fewer opportunities to spread, establishing herd immunity.

Herd immunity protects vulnerable individuals such as newborns and immunocompromised children unable to be vaccinated or for whom naturally acquired exposure and infection to a disease could prove fatal. Although acquired natural infection or natural immunity may serve as a potential mechanism to establish herd immunity for some, the method risks unnecessary hospitalizations and deaths before achieving population-level immunity, making vaccination a critical component of public health.

Each infectious disease has a specific level of required immunization coverage to demonstrate adequate herd immunity. To maintain herd immunity against measles, for example, the CDC recommends 95% or higher immunization coverage. However, vaccination rates for MMR are declining, with the CDC reporting 91.6% MMR coverage among children born during 2018 and 2019. Declining rates caused by missed or incomplete coverage among children dismantles herd immunity and threatens progress toward sustained disease control and elimination.

This concern is amplified in states such as Florida, where potential elimination of school vaccine mandates coincides with measles herd immunity levels already below protective thresholds, as identified by Vermund, thereby increasing outbreak risk. Measles remains one of the most contagious human viruses, and even small declines in vaccination coverage can have significant consequences.

Hesitancy, policy, and nursing practice

The World Health Organization (WHO) defines vaccine hesitancy as a refusal or delay in accepting vaccines despite the availability of vaccination services. A complex array of factors can influence a parent’s decision to have their child vaccinated.

Vaccine hesitancy, along with rising school exemptions as outlined by Hill and colleagues, contributes to declining vaccination rates, heightening the risk of outbreaks like pertussis and measles and increasing disease burden on individuals and communities.

The first year of life represents a critical window for establishing herd immunity and ensuring individual protection. Nurses can educate families, address concerns, and advocate for timely vaccination at every point of entry into the healthcare system during this vulnerable period.

Recent federal updates to U.S. vaccine schedules—including those for human papilloma virus (HPV), hepatitis B, hepatitis A, respiratory syncytial virus (RSV), influenza, rotavirus, and meningococcal disease, as well as combination vaccines such as MMR and MMRV—have lacked convincing evidence, causing confusion among families. A systematic review by Ellingson and colleagues demonstrated that the HPV vaccine is most effective when administered to younger adolescents (ages 9 to 14), with effectiveness ranging from 74% to 93%, compared to a broader and lower range (12% to 90%) in those ages 15 to 18. Additionally, Prymula and colleagues’ 10-year follow-up study found that the safety and incidence of serious adverse events were comparable between children receiving the MMRV vaccine and those receiving separate MMR and varicella vaccines.

Any federal policy regarding vaccines should maintain uncompromising access to immunizations, without restrictions, barriers, or reductions in availability. Implementation of widespread federal and state policy without a discussion from all stakeholders could result in dangerous and unstable infectious disease outcomes for children across the country.

Mical and colleagues have highlighted the importance of healthcare providers building trusting relationships that guide families’ immunization decisions. Positioned across healthcare settings, nurses can address vaccine hesitancy by leveraging their clinical expertise, patient-centered care, and long-term relationships with families. To promote vaccine confidence, nurses should be well-equipped and educated to screen, communicate, and advocate for vaccine administration.

Vaccine hesitancy screening tools

Validated, evidence-based screening tools efficiently identify and address parental vaccine hesitancy in pediatric care. These tools enhance the nurse’s ability to understand specific vaccination concerns and can be integrated into electronic health records (EHR) for use during newborn and well-child visits.

Mical and colleagues’ 2021 study identified the need for provider proactive, not reactive, efforts to avert the spread of vaccine-preventable diseases. The researchers found that participants classified as vaccine-hesitant during pre-intervention screening benefited from interventions.

The use of a validated instrument allows for a standard assessment. The Parent Attitudes about Childhood Vaccines (PACV) survey, a standardized tool developed in Seattle, identifies, measures, and classifies the unique problems and needs of vaccine-hesitant parents and guardians. Mical and colleagues found the survey to be an effective tool to identify vaccine-hesitant parents, leading providers to address parental concerns.

The WHO’s Strategic Advisory Group of Experts on Immunization developed the Vaccine Hesitancy Scale (VHS). Kempe and colleagues described the VHS as a validated 10-item tool for assessing vaccine confidence and risk. They found both the VHS and PACV adaptable for clinical use to pinpoint hesitancy drivers and tailor conversations to build parental trust.

Communication techniques

Nurses can communicate in a way that makes vaccination the default behavior. For example, Mical and colleagues describe presumptive communication as phrasing statements so as to assume acceptance. This technique can instill confidence and reassure parents and caregivers of safe medical management.

Mical and colleagues report that using participatory language allows for shared decision-making; however, in some cases, certain communication approaches also may be associated with higher vaccine hesitancy and reduced vaccination uptake.

Along with presumptive communication, motivational interviewing serves as an effective tool for addressing vaccine hesitancy. Gagneur and colleagues describe motivational interviewing as supportive of decision-making by eliciting and strengthening a person’s motivation to change behavior. This well-established approach to behavioral change seeks to strengthen the relationship between the provider and parent or guardian to improve vaccine rates. Focusing on intrinsic motivators, like a parent’s desire for a healthy child and community, while also listening actively, seeking permission to educate, and respecting autonomy, reinforces the nurse’s and family’s shared goal.

Studies also have addressed communication strategies that don’t work and should be avoided. For example, nurses shouldn’t assume vaccine misconceptions result from a lack of knowledge. According to Mical and colleagues, making this assumption and then providing more information has the potential to increase rates of vaccine hesitancy. Instead, nurses should address concerns and questions arising from screening tools but should provide facts, answer questions, and offer patient education that focuses on reducing disease risk rather than refuting myths.

Refuting myths can unintentionally reinforce false assumptions and may even trigger defensiveness, as noted by Limaye and colleagues. By maintaining a nonjudgmental, nonargumentative, and emotionally neutral approach, nurses can emphasize education and present scientific, evidence-based information to support families in making informed decisions for their child. (See Communication strategies.)

Advocacy

Addressing policy concerns serves as a key component to the systemic and global uptake of vaccines. Sustained nursing advocacy at the local, state, and federal levels is imperative to counter misinformation and ensure that policies affecting children and families remain guided by evidence and best practices.

As consistently trusted healthcare professionals, at the bedside and in policy discussions with key stakeholders, nurses can engage in advocacy that promotes equitable vaccine access, sustained funding for the Vaccines for Children program (a nationwide initiative providing vaccines at no cost to eligible children), and dissemination of credible vaccine information. In addition, nurses can model best practices by maintaining full immunization themselves.

Of particular importance, local vaccination requirements for daycare and school entry remain critical tools for sustaining high vaccination coverage rates. All states have similar mandates; however, heterogeneity across states permits religious and philosophical exemptions unrelated to medical concerns. Vaccine exemptions tend to cluster geographically, placing some communities at greater risk for outbreaks. To achieve high vaccine coverage, a strong school-entry mandate with allowances only for medical exemptions may serve as an effective strategy to support public health efforts to reduce morbidity and mortality due to infectious disease.

Many nursing organizations, including the American Nurses Association, endorse immunizations as essential for protecting public health and support vaccine mandates for school entry with allowances only for medical exceptions. The AAP supports regulations and laws requiring certification of immunization to attend childcare and school. In addition, the AAP views nonmedical exemptions to school-required immunizations as inappropriate and advocates for their elimination.

Practice implications

Hesitancy toward vaccines has existed in the United States since their first implementation. According to Kempe and colleagues, approximately 1 in 15 U.S. parents feel hesitant about routine childhood vaccines, and 1 in 4 report hesitancy regarding the influenza vaccine. Nurses can mitigate vaccine hesitancy, which ranges from a reluctant acceptance to partial or delayed acceptance to outright refusal. A family hesitant to have their children vaccinated may delay the frequency and number of immunizations during a single visit, request selective vaccinations, or ask for an alternative vaccine schedule. Nurses play a key role in supporting these families. Through experience, education, and training, nurses can confidently research, understand, and address vaccine hesitancy using screening, effective communication, and advocacy to promote vaccination uptake, prevent disease resurgence, and optimize child health.

Children typically see their primary care provider annually, but infants in their first year of life see their provider at least seven times. These visits offer critical opportunities for nurses to build a trusting relationship with the family and provide essential information and guidance in collaboration with the interprofessional team.

Vaccinations start at birth and should follow AAP-recommended guidelines for immunizations at 2, 4, 6, and 12 months. Anticipatory guidance, supported by technology- and EHR–based reminder and recall systems, serve as essential tools for ensuring adherence to recommended immunization schedules, especially for children exposed to early childhood learning environments and preschools, which make them vulnerable to a plethora of infectious risks that vaccines can prevent.

Guided by evidence-based vaccination tools and patient history, nurses can potentially address concerns and structural barriers to immunization. Assessment of under-vaccination can help distinguish between true hesitancy, undereducation, or inequitable social determinants of health, such as limited resources, transportation challenges, financial constraints, or competing responsibilities. Nurses also can anticipate and be attentive to culturally influenced hesitancy. By actively exploring families’ religious and cultural preferences to understand how these beliefs shape vaccination decisions, nurses can foster trust and provide culturally sensitive guidance.

All families deserve access to immunizations and education about their benefits. To support this, state and federal policies must ensure vaccine availability, accessibility, and affordability for all children, regardless of socioeconomic status. Nurses, in collaboration with case management and social work, are integral to informing families about programs such as Vaccines for Children, assisting with enrollment when eligible, and advocating for services that reduce barriers to vaccination, including transportation support, extended clinic hours, and walk-in appointments.

Nurses can be confident in supporting immunization efforts because the U.S. Department of Health and Human Services and the Food and Drug Administration ensure vaccines are proven safe and effective. Vaccine design, a complex, rigorous process involving strict clinical trials, includes large population sampling.

A fundamental role

Vaccine hesitancy remains a growing concern, compounded by an evolving political climate that may confuse families. Nurses build long-term, trusting relationships with patients and their families and play a pivotal role in patient education, direct communication, and empathetic engagement. By cultivating trust, nurses help strengthen vaccine confidence.

Implementing evidence-based communication and screening tools, such as VHS and PACV, allows nurses to identify specific sources of hesitancy. Nurses can then address misunderstandings and misinformation related to vaccine safety and efficacy.

The nursing workforce, a cornerstone of the U.S. health infrastructure, can lead efforts to advocate for and implement policy reforms. To do so effectively, nurses require ongoing opportunities to build knowledge, skills, and competencies that support effective practice and leadership. Their role is fundamental to countering rising anti-vaccine sentiment and promoting safe vaccination practices that prevent the resurgence of preventable diseases.

Emily Baughman is a clinical nurse at Children’s Hospital of Philadelphia in Pennsylvania. Sunny G. Hallowell is an associate professor at Villanova University M. Louise Fitzpatrick College of Nursing and a nurse scientist at Children’s Hospital of Philadelphia.

American Nurse Journal. 2026; 21(7). Doi: 10.51256/ANJ072643

References

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Key words: vaccine hesitancy, pediatric vaccination, patient communication