Find out how to improve influenza vaccination rates among healthcare workers.
- Barriers to influenza vaccination include inconvenience and cost, previous negative experiences, personal and religious beliefs, and health concerns.
- Education is the best way to address barriers and increase vaccination rates among healthcare workers.
- Incentives may help encourage healthcare workers to get their annual flu vaccine.
By Lyndy Beckley, RN, MSN
It’s that time of year again. Children are back in school, leaves are changing, the air is chilly, and signs of flu season are all around—sniffling, coughing, and brightly colored flyers posted throughout the workplace reminding you it’s time to get vaccinated.
What’s your first reaction when you see those flyers? More than a few nurses cringe. And many nurses continue to decline the influenza vaccine, even though the Centers for Disease Control and Prevention (CDC) recommends it for all healthcare workers. The CDC estimates that the influenza vaccine prevented about 966,000 medical visits and 67,000 hospitalizations during the 2014-2015 flu season. However, healthcare workers, who are most frequently exposed to the influenza virus, had only a 77.3% vaccination rate for the 2014-2015 influenza season, short of the 90% goal.
To improve vaccination rates among nurses and other healthcare staff, we need to understand why they aren’t getting vaccinated and develop strategies to overcome barriers.
The influenza vaccine can decrease the number of missed days of school or work and reduce influenza-related illnesses, visits to healthcare providers, and hospitalizations. But if flu shots are so helpful, why do nurses hesitate to get them? We may be able to answer that question by exploring vaccination barriers, including inconvenience and cost, previous negative experiences, personal and religious beliefs, and health concerns.
Inconvenience and cost
Healthcare employers aren’t required to supply vaccines to their staff, and some may not even take steps to remind and encourage personnel to get a flu shot. According to a 2014 study conducted by AHC Media, just over half of surveyed healthcare workers who work in extended-care facilities reported that their employer required or recommended a seasonal influenza vaccination.
Hours and location of administration also affect vaccination rates. In the same study, only 27% of nurses surveyed reported that their employers offered vaccinations on-site. Many of the employers that did offer vaccinations did so only during “business hours,” leaving few options for off-shift employees.
The cost of getting a vaccine may deter some healthcare workers. Depending on insurance coverage, a vaccine may cost $60 or more if a provider visit is required.
Previous negative experiences
Healthcare workers who’ve had a negative personal or professional experience with vaccines may be reluctant to get vaccinated. More than half of unvaccinated healthcare workers surveyed by Heinrich-Morrison and colleagues expressed a negative opinion about the influenza vaccine, believing it to be ineffective or that it makes them unwell. Other sources report that some healthcare workers insisted they “got the flu” as a result of the vaccine and others feared potential side effects.
Personal and religious beliefs
Individual principle may stop some healthcare workers from getting vaccinated. Some may feel that injecting certain foreign substances into the body is wrong based on their religious beliefs. Many healthcare workers whose personal or religious beliefs prevent vaccination rely on antidiscrimination laws to protect them when they refuse an annual flu shot.
Nurses with egg allergies or those who’ve had a previous reaction to a flu shot component may decline the vaccine. For others, pregnancy or immune deficiencies may give rise to concerns.
Strategies for improvement
Understanding what prevents healthcare workers from getting an annual influenza vaccination provides opportunities to develop strategies to break through those barriers. Increasing access to vaccines, decreasing employee cost, and providing education may help improve vaccination rates.
Increase access and decrease cost
In an attempt to vaccinate the highest percentage of healthcare workers, employers should consider offering no-cost vaccinations at all locations, during all shifts, and over the course of several days. According to AHC Media, employee vaccination rates increase significantly when a facility offers free on-site vaccinations for more than one day.
Providing education about influenza vaccine effectiveness, side effects, and options may increase vaccination rates. (See Influenza virus and vaccine: Fast facts.) For example, when an employee believes that the vaccine will cause an active influenza infection, explain that although someone might feel ill from vaccine side effects, the vaccine can’t transmit the illness. If an employee declines a vaccine because of an egg allergy or previous reaction, make sure he or she knows about alternative vaccines, such as the recombinant egg-free vaccine that can be safely administered to adults. For those who dislike needles and traditional injections, let them know about jet injectors. These needleless, high-pressure devices are used to introduce a trivalent influenza vaccine into the skin. And let staff know that an influenza vaccine is generally recommended even for those who are pregnant or immunocompromised.
Open dialogue and incentives
Because unvaccinated healthcare personnel pose an increased risk of spreading influenza to patients and other staff members, which contributes to patient morbidity and mortality as well as increased costs to the facility, many organizations no longer permit personal or religious belief exemptions. In fact, these exemptions may soon become obsolete. In 2016, California enacted legislation to repeal laws that allow these exceptions, and a North Carolina court upheld the termination of an employee who cited religious grounds for refusing an influenza vaccine.
These ongoing changes require an open dialogue between employers and employees. Many employees simply want to be heard and have their beliefs considered. Employers should ask healthcare personnel about their concerns so they can address specific issues and develop strategies for improving vaccination rates. To facilitate this process, employers can offer counseling during vaccine administration times.
And rather than making influenza vaccines mandatory, some organizations have successfully implemented incentive programs. One large community-based healthcare system that offered incentives increased vaccination rates among all employees to 93%.
Protect staff and patients
The influenza vaccine is the best way to protect against seasonal influenza viruses and accompanying complications. Breaking down the barriers to vaccination through education, open dialogue, and incentives can increase vaccination rates and protect staff and patients throughout the flu season.
Lyndy Beckley is an intensive care staff nurse at Union Hospital in Dover, Ohio, and a critical care nursing instructor at Kent State University, Stark Campus, in North Canton, Ohio.
|These resources from the American Nurses Association (ANA) offer more information
you can put to use in implementing strategies to increase nurse and other
healthcare worker influenza vaccination rates.ANA Immunize website:
nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/ANA-ImmunizeImmunizations: ANA position statement:
AHC Media. CMS flu shot reporting raises thorny issue of vaccination status of hospital workers. December 1, 2014.
Centers for Disease Control and Prevention. Influenza (flu). May 27, 2017.
Drees M, Wroten K, Smedley M, Mase T, Schwartz JS. Carrots and sticks: Achieving high healthcare personnel influenza vaccination rates without a mandate. Infect Control Hosp Epidemiol. 2015;36(6):717-24.
Heinrich-Morrison K, McLellan S, McGinnes U, et al. An effective strategy for influenza vaccination of healthcare workers in Australia: Experience at a large health service without a mandatory policy. BMC Infect Dis. 2015;15:42.
Kung YM. A quality improvement project to increase influenza vaccination in healthcare personnel at a university health center. J Am Assoc Nurse Pract. 2014;26(3):148-54.
Lei Y, Pereira J, Quach SA, et al. Examining perceptions about mandatory influenza vaccination of healthcare workers through online comments on news stories. PLoS One. 2015;10(6):e0129993.
National Conference of State Legislatures. States with religious and philosophical exemptions from school immunization requirements. August 23, 2016.
Rainey RL. North Carolina court upholds employee’s termination for refusing flu shot. HR.BLR.com®. November 4, 2015.
Stewart AM, Cox MA. State law and influenza vaccination of health care personnel. Vaccine. 2013;31(5):827-32.influenza vaccine nurse flu shot