Nurses’ experiences of the seasonal influenza vaccine in residential care Gemma Quinn
Abstract
The experience of nurses who work in the residential elderly care setting regarding the seasonal influenza vaccine is often overlooked, with a paucity of published qualitative studies. The aim of this study is to present an insight into the issues concerning nurses with regard to the seasonal influenza vaccine. The study purposively sampled registered nurses (n=11) working in a large long-term care facility for older people (n=142) in Ireland. Using a broad qualitative research approach, data were collected through interviews, transcribed, analysed and grouped into the following themes: knowing: the seasonal influenza vaccine; mandatory vaccination: balancing autonomy and control; and meaningful education. This study reveals the complexity of issues and concerns for nurses when it comes to the seasonal influenza vaccine. These issues and concerns include influences such as family, friends, peers, the media and how nurses inform themselves. The position of nurses within the organisation and recommendations for meaningful nurse education are also discussed. The findings of this study provide an insight that could inform future influenza policy and education, which should be explored before the introduction of any mandatory influenza campaigns. Key words: Public health ■ Vaccination ■ Older people ■ Residential care ■ Qualitative research
A
review of the literature shows a persistent low level of uptake of the influenza vaccine by healthcare workers (Thomas et al, 2010). Compared with other healthcare workers, nurses have the lowest level of uptake of seasonal influenza vaccination (BaronEpel et al, 2012). Nurses are also the largest group of health professionals providing 24-hour direct care to older people (Centers for Disease Control and Prevention, 2011; Health Service Executive (HSE), 2011; Poland et al, 2012). For this reason, the vaccination of healthcare workers, including nurses working in the residential long-term older person care setting in Ireland, is recommended (HSE, 2012). The literature to date has been mainly quantitative, with very little emphasis on the views of registered nurses around seasonal influenza vaccination (Rhudy, 2010). Systematic
reviews of the literature by Thomas et al (2010) and Zhang et al (2010) acknowledge this deficiency and make reference to the need to explore the specific views of nurses. There are very few studies in Ireland regarding the uptake of the influenza vaccine by healthcare workers. A quantitative study carried out by survey questionnaire was conducted in public healthcare facilities in Ireland in 2012 (Health Protection and Surveillance Study, 2012).The aim of the study was to determine seasonal influenza vaccine uptake among healthcare workers employed in acute hospitals (n=46 287) and long-term care settings for older people (n=6806). The overall vaccination rate for healthcare workers in the longterm care setting was 13.5% (n=920). Nursing staff working in the long-term care setting in Ireland (n=2540) had the second-lowest uptake of the seasonal influenza at 11.6% (n=294). This report was consistent with other studies that showed low rates of uptake of the seasonal influenza vaccine (Smedley et al, 2007; Fernandez et al, 2009; Toronto and Mullaney, 2010; Hollmeyer et al, 2012; Baron-Epel et al, 2012; Health Protection and Surveillance Centre, 2012). The study by the Health Protection and Surveillance Centre (2012) was limited by the fact that it used a self-report questionnaire and collected statistics. The report summarised trends of influenza rates and vaccine uptake—it did not examine the issues and concerns of healthcare workers. The report recommended that the reasons for non-vaccination of healthcare workers be urgently identified.
Methods There are at least two different types of phenomenological approach. For the purpose of the research presented here, the methodology used is the interpretative or ‘hermeneutic’ approach. The important aspect of all forms of interpretative phenomenology is the ‘phenomenological attitude’—that is, the desire to understand the world as it appears for the participant. This is achieved by focusing on experience, by an emphasis on description, and by the use of epoche (bracketing) where the researcher suspends assumptions, beliefs and judgements from the process. A qualitative study with semi-structured interviews was deemed the most appropriate design.
Accepted for publication: September 2014
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This study was conducted in a large public residential longterm care setting for older people. Registered nurses working at the research site were selected based on the fact that they had direct experience of the seasonal staff influenza vaccination campaign in the long-term care of the older person setting. Full
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Study setting Gemma Quinn, Infection Prevention & Control Manager, Mid West Primary, Community and Continuing Care, Ireland
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VACCINATIONS ethical approval for the study was granted by the local regional hospital research ethics committee. Participant confidentiality was guaranteed and all data were anonymised.
Sample The participants of this study represented registered nurses working in the specialist field of older person care. The level of experience of participants ranged from 7 to 22 years of exclusive experience in the setting of long-term care for older people. All participants were female and the level of experience reflected in the grade of nurse ranged from staff nurse to manager. All the participants who worked full-time chose to work with older people; hence, participants showed clear career pathways that lead to working in this specialist area of nursing. It could be assumed that participants felt strongly about older person nursing and were committed to advocating on behalf of these patients.
Interviews and analysis The interviews were semi-structured, transcribed verbatim (word for word) and thematically analysed with the Braun and Clarke Framework (2006).
Findings The data from the interviews are presented in the following themes: ■■ Knowing: the seasonal influenza vaccine ■■ Mandatory vaccination: balancing autonomy and control ■■ Meaningful education. Sub-themes in this study were considered to be the foundation for the main themes, constructing the rich stories inherent in the data. Data extracts are used to demonstrate the underlying essence of the issues concerning nurses.
Knowing: the seasonal influenza vaccine This theme exemplifies the complex nature of nurses’ knowing and understanding of the seasonal influenza vaccine. ‘Knowing’ as embodied in this theme related to empirical, personal, ethical and aesthetic ways of knowing that influenced nurses’ decision-making regarding the vaccine. These ways of knowing are reminiscent of seminal work by Carper (1978) who espoused the view that nurses’ decision-making regarding patient care is informed by four fundamental ways of knowing. In addition, ‘knowing’ describes myriad influences (e.g. media, family, peers) that shaped each nurse’s unique ways of knowing and in turn their ultimate decision to take the influenza vaccine. Finally, ‘knowing’ highlights ‘different understandings’ held by some participants around the vaccine and its side-effects, and how these could influence their decision to take it.
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Empirical knowing regarding the seasonal influenza vaccine Throughout the interviews, participant responses demonstrated a broad level of understanding regarding the seasonal influenza vaccine from a professional, fact-based, empirical perspective. This is in contrast to the literature reviewed suggesting that nurses’ level of knowledge regarding the seasonal influenza vaccine is poor. Participant responses
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reflected a professional work-related context. It was clear that the participants had evidence-based knowledge regarding influenza vaccination, as exemplified in the following extract. ‘The CDC says … those at risk are people with diabetes and chronic illness. There are many different strains’ (Registered nurse (RN) 6)
Different understandings on the seasonal influenza vaccine Although findings showed good knowledge of the seasonal influenza vaccine, different understanding of the side-effects of the vaccine was reflected throughout the interviews. All the participants believed that one side-effect of receiving the vaccine was actually catching influenza. This belief is of major concern and suggests that nurses’ understanding of the vaccine and its side-effects may diverge from the empirical evidence. This belief is common and consistent with the other studies (Martinello et al, 2003; Piccirillo et al, 2006; Christini et al, 2007; Willis and Wortley, 2007; Abramson and Levi, 2008; Tucker et al, 2008; Fernandez et al, 2009; Toronto and Mullaney, 2010; Wicker and Rabenau, 2010). The notion that the seasonal influenza vaccine causes influenza is exemplified in the following extract. ‘… I have known too many people personally that have become so ill after getting the flu vaccine and I said, “No, I’m not going to get it, I’ve seen too many people.” Even here, you just know for a fact that once they get the vaccination, give them 7 to 10 days, and you will see the increase. The next thing is you see an increase in the use of antibiotics because of that’ (RN 5) It is possible that participants were fully informed by the empirical information available to them, but were more influenced by other ways of knowing. Individuals may have put a different emphasis on each aspect of knowing, depending on their unique experience of the seasonal influenza vaccine. Due to the prevalence of this finding in the study, it is a concern that participants seemed to have a broad awareness of the seasonal influenza vaccine, yet appeared to assume, wrongly, that it is a live vaccine.
Concerns about the H1N1 influenza Participants may also have been uncertain about the seasonal influenza vaccine because of concerns with other influenza vaccines, such as the H1N1 influenza (‘swine flu’) vaccine. Recent advances in empirical knowledge of side-effects of previous vaccines may have resulted in concerns about the future unknown side-effects of the seasonal influenza vaccine. The following extract epitomises the uncertainty around staff influenza vaccination generally: ‘Swine flu, the panic about swine flu. People are not sure of what they are getting now. Are we getting the swine flu now, or are we getting vaccinated against the normal flu? Nobody understands’ (RN 1)
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Influence of media and the internet Participants’ responses suggested that nurses have a desire to learn more about the seasonal influenza vaccine by seeking out further empirical knowledge. It is possible that clear, unambiguous empirical information regarding the seasonal influenza vaccine was not available to participants in the workplace. It is also possible that the empirical information was available, but the influence of other sources of knowing was stronger or was delivered in a more appealing way. The influence of media and internet as other sources of information were exemplified by RN 8: ‘I mean, that’s what it says on the … national media at the moment … they are talking about the flu and that an antibiotic really is of no benefit to the flu and I totally agree with it, that you have to rest and give it a chance. It’s viral so you actually have no benefit going on antibiotics’ (RN 8)
Own immunity Nurses’ personal experiences, along with empirical ways of knowing, provided them with a whole view of a situation, showing that their views are informed by many different sources of knowing. Some participants discussed the use of health-food supplements to enhance immunity. One participant discussed alternative medicine. Faith in one’s own immunity and alternative medicine was congruent with some of the studies reviewed in the literature (O’Reilly et al, 2005; Trivalle et al, 2006).The following extracts showed a high level of confidence on the part of participants in their own immunity to the seasonal influenza, which seemed to be informed by selfunderstanding around improving natural immunity: ‘Most nurses wouldn’t take the flu vaccine because they feel they have an immunity built up themselves’ (RN 8) Participants informed themselves and shaped their views on the seasonal influenza vaccine in many different ways: ‘… I would be influenced a lot by, some would call it, New Age medicine, and its medicine of the future that is more energy-based. It’s about having an authentic relationship between patients and staff ’ (RN 2)
It is possible that participants intuitively suspected that there were other ways of gaining information about the seasonal influenza vaccine, and they may have been more strongly influenced by other ways of knowing (such as personal knowing) to address this gap.
Interestingly, this participant (RN 2) included the patients in the response, which indicates a concern for older people and a concordant approach to care.
Personal knowing regarding the influenza vaccine
Influence of family and friends
People innately use their experiences to inform their personal knowing. This sub-theme showed the many ways that participant nurses added to their knowing with regard to the seasonal influenza vaccine. Without exception, all the participants talked about the influence of others, such as peers, relatives and family members, who had had negative experiences of the influenza vaccine. Interestingly, participants did not recount any positive experience of influenza vaccination (experiences were predominantly negative). This is understandable, as it is very difficult to experience the vaccine in a positive way once it is given. Intuitively, nurses sought other ways to inform their understanding about the seasonal influenza vaccine. In line with Carper’s ways of knowing (1978), the participants used experience. The essence of personal knowing is illustrated by the following excerpt:
This sub-theme showed the very personal experiences that shaped decisions about work-related issues. This finding is congruent with the study by Rhudy et al (2010), which suggested that nurses’ decision-making regarding the seasonal influenza vaccine was mainly influenced by personal factors. Participants’ personal ways of knowing may have been a greater influence on knowledge regarding the seasonal influenza vaccine if the empirical knowing was incomplete. Equally, even with greater empirical knowing, personal experience of the vaccine may have been a stronger influence. Participants articulated their experiences of the seasonal influenza vaccine and the perceived effect on family members and friends:
‘Well I feel … that the swine flu vaccine may have had something to do with … the illness I got. Especially when you hear there were other people admitted with the same thing after getting the vaccine’ (RN 9) Participants expressed a level of confusion and frustration about the level of information provided in the seasonal influenza vaccination campaign. Earlier, one of these
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participants had expressed the need for influenza campaigns to include a higher level of research evidence.
‘He got the flu vaccine and 3 days later … well, he died as a consequence. And I can’t help thinking in the back of my mind: if we hadn’t given him the vaccine, maybe he would have been all right’ (RN 3) At the same time, participants appeared to take into account the views of work colleagues when discussing the seasonal influenza vaccine.
The influence of peers The significant influence of peers as a personal source of knowledge in the study findings was linked to participants’
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The influence of concerns about H1N1 influenza may have stemmed from sources outside the organisation. It is possible that issues around other vaccines, such as the combined measles, mumps and rubella vaccine, may have influenced the participant responses. Some participants also alluded to the influence of media and the internet as information resources.
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VACCINATIONS overall personal experiences. It is possible that participants were seeking validation of personal views of the seasonal influenza vaccine by consulting their peers and leadership figures. The importance of this discourse is expressed by RN 2: ‘… The way we all talk, we all dialogue at work, that then I would sell it on to someone else. We are definitely influenced by others, there are definite strong personalities that you listen to’ (RN 2) The influence of past experiences, personally and professionally, with clients around the seasonal influenza vaccine may play a part in how nurses approach decision-making. These findings are congruent with qualitative studies such as Rhudy et al (2010) and Baron-Epel et al (2012) who suggested that personal issues play a more significant role in nurses’ thinking and decision-making than empirical knowledge.
Ethical ways of knowing regarding the vaccine Although participants may have had issues around the uptake of the seasonal influenza vaccine, they were morally and ethically aware of the need to safeguard older people from influenza infection. Participants demonstrated understanding of the risks to older persons and therefore a moral way of knowing by acknowledging the importance of the vaccine for older people. This ethical way of knowing is also related to the fact that participants had earlier shown particular care and compassion for older people by choosing to work in the specialist area of older person nursing. This fact contrasts with findings in the literature suggesting that self-protection, as opposed to patient protection, is the primary motive for uptake of the influenza vaccine by nurses (O’Reilly et al, 2005). In addition to empirical and personal knowing, the following extract embodies one nurse’s moral caring: ‘I think it is very important for the older person to receive the flu vaccine. My parents get it every year and studies have shown that you … their instances of serious illness are reduced because obviously they are not going to get this debilitating illness, which could lead to pneumonia or death’ (RN 4) Responses from participants also provided insight into the moral conflict that exists for nurses around the seasonal influenza vaccine. The theme of ethical ways of knowing showed the inherent professionalism of nurses in their desire to protect older people, even when they have their own reservations regarding the vaccine. For example: ‘But now I have to ask myself the question, am I letting down the people I’m working for, the patient’ (RN 2)
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Moral ways of knowing were also evident as an underlying assumption regarding the notion of mandatory vaccination.
Aesthetic ways of knowing regarding the vaccine Aesthetic ways of knowing refer to the way that nurses make decisions based on the wholeness of a situation or set of circumstances (Carper, 1978; Chinn and Kramer, 2008). With regard to issues concerning the uptake of the seasonal
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influenza vaccine by nurses working in the long-term care of the older person setting, it is possible that participants combined empirical, personal and ethical ways of knowing to inform themselves and shape their own views. This aesthetic way of knowing suggests complex critical thinking on the part of participants. It was difficult to capture this merging of information from the transcripts. However, RN 7 expressed the essence of aesthetic ways of knowing used by participants to inform decision-making. ‘Well it’s both professional and personal’ (RN 7) The findings in theme one showed the complexity of issues concerning the uptake of the seasonal influenza vaccine by nurses in the long-term care of the older person setting. The myriad ways of knowing that participants use in decisionmaking regarding the care of older people may be the same ways of knowing used to make other decisions and form other views. Findings in theme one are congruent with the findings in the literature that allude to the unique ways that nurses inform themselves (Thomas et al, 2010; Zhang et al, 2010). Influences on knowing are social, professional, empirical and personal, among others. Findings in theme one also suggest some significant gaps in awareness that need to be addressed regarding the seasonal influenza vaccine.
Mandatory vaccination: balancing autonomy and control Autonomy for nurses is defined as: ‘freedom to make discretionary and binding decisions consistent with one’s scope of practice and freedom to act on those decisions’ (Batey and Lewis, 1982: 15). The inference is that to be autonomous is to have power and control over self-determination and decision-making. Therefore, the absence of autonomy felt by participants suggested a loss of power and control. This theme was the strongest in terms of depth of feeling and the very personal nature of participant responses. Participants also included personal knowing by showing empathy for the patient and ethical knowing of self as a professional nurse and for the safeguarding of older people: ‘I suppose it just makes you feel angry. If we did this to a patient, we injected them with something against their wishes, it would be classed as abuse, a form of assault’ (RN 1) There was a high level of anger articulated by participants regarding mandatory vaccination. It is possible that the seasonal influenza vaccine was viewed as the taking away of nurses’ decision-making and autonomy—as opposed to the provision of a health-promoting intervention given on the part of the organisation. Some participants expressed their frustration in terms of an all-round assessment of their position within the organisation. It is possible that participants felt undervalued and not recognised as professionals. One of the participants expressed how they felt about mandatory vaccination with powerful simplicity: ‘Disempowered’ (RN 6) Equally, it can be argued that participants viewed themselves as highly skilled professionals who should be consulted about
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‘I feel it would take away our own decisionmaking really, and our own expertise, and that, you know, as nurses, part of our work ethic really is to advise other people and that surely we are able to make a decision for ourselves and are qualified personnel’ (RN 8)
Absenteeism Participants also believed that the organisation’s primary motive for the seasonal influenza vaccine was to prevent absenteeism. ‘Ah sick time. I suppose to avoid sick time’ (RN 3) There were other negative views of mandatory vaccination too. Some perceived that it was offered to nurses in the context of productivity and patient protection, as opposed to staff health and wellbeing. Some participants felt a lack of caring from the organisation. The fact that participants felt the vaccine would reduce staff absenteeism may show an implicit knowledge about the efficacy of the vaccine itself. Findings from theme two illuminated the depth of the underlying feelings of anger and discontent regarding the mandatory vaccination. Professional guidance provided by the Nursing and Midwifery Board of Ireland articulate the responsibilities of a nurse as an autonomous practitioner with authority to make decisions within their scope of practice (An Bord Altranais, 1999). Autonomy for nurses empowers nurses as individuals and as a group. There was a perception that this hard-fought-for position for nurses was being eroded and undermined. Hence, findings revealed a sense of power imbalance between nurses and the organisation. Participants felt a sense of disbelief that they seemed to be making autonomous clinical decisions with and on behalf of older people—only for the organisation to take away this power. It is possible that this perceived power imbalance was the result of a poorly communicated seasonal influenza campaign that failed to address the specific requirements of nurses.
Meaningful education The needs of nurses regarding support and resources in the workplace was a particularly prevalent theme (n=10/10) eliciting a large amount of rich data. The participant nurses gave detailed responses and recommendations regarding how the seasonal influenza campaign should be managed. That nurses were not included in the management of the seasonal influenza campaign is implicit in the following extract: ‘I think it’s the management of it. Is it balanced? No, don’t think so. I would like to hear other’ views’ (RN 5) Participant responses indicated that if they had extra knowledge that met their requirements, they would have felt satisfied with the seasonal influenza campaign. It may be assumed that nurses felt a desire for a holistic, balanced
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campaign that encompassed the needs of nurses and the needs of older persons in a meaningful way. The previous theme, exploring nurses’ different ways of knowing and how nurses inform themselves from many sources, is intertwined with their desire to get a whole picture of a situation before forming a decision. It is almost as if participants wanted a second opinion before making a decision. It is possible that participants were not averse to the seasonal influenza vaccine and would be more open to vaccination if their educational needs were met, and if the campaign were delivered in an adjusted way. Participants highlighted the importance of addressing nurses’ questions and concerns, and giving them further information: ‘I am one of those people that would be willing to change if more information came out that could sway me’ (RN 6) The adjustments required to the delivery of the campaign articulated by participants included the involvement and collaboration of trusted role models to satisfy their need for balanced information from multiple sources.
Trusted role models/leaders A key sub-theme was the level of emphasis participants placed on the need for face-to-face education from trusted colleagues. The desire for information and leadership from a trusted colleague is connected to the ways of knowing in theme one. Participants specified particular trusted role models that they felt were best-equipped to deliver the education campaign for the seasonal influenza vaccine. This need for trusted role models was alluded to by Harbath et al (1998). However, the recommendation of a specific role model such as the infection control nurse was absent in the literature reviewed. The preference for education around the vaccine to be made more meaningful was evident from participants’ responses. This type of learning is linked to the personal way of knowing espoused by Carper (1978), and outlined in theme one of this study. Some studies also allude to a different type of education and learning for nurses (Gazmaraian et al, 2007; Hollmeyer et al, 2009). The preference for a trusted role model to deliver face-to-face education on the seasonal influenza vaccine is exemplified in the following extracts: ‘Well I suppose if someone sat me down and said this and this are the reasons, then I would say, OK, you’ve convinced me, I am going to do it … a person of integrity (RN 4) ‘Short brief meetings they should discuss with them, someone to talk to’ (RN 6) Finally, some participants expressed concern at the timing and manner in which information on the seasonal influenza campaign was managed. It is possible that participants felt rushed into making decisions: ‘There’s not enough information throughout the year’ (RN 3) Equally, it may be assumed that participants do not respond to the plethora of written material (Gazmaraian et al, 2007)
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the seasonal influenza vaccine. RN 8, for example, expressed disbelief that nurses are not trusted professionals seen as capable of making decisions:
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VACCINATIONS that accompanies the yearly influenza education campaign and may have become indifferent to written empirical information distributed by the organisation: ‘There’s a splurge of leaflets’ (RN 7) From the responses of the participants, the theme of meaningful education is significant. It may be assumed that participants wanted a concordant approach to the seasonal influenza campaign that consulted nurses in a way they could relate to about their learning needs and educational preferences before the campaign began.
Discussion As this study shows, nurse participants’ unique personal and social experiences are a significant factor in how they view the seasonal influenza vaccine, and possibly explain why there are issues and concerns about it. Clarification and collaborative programme development that include tailormade educational sessions may assist nurses in their decision making. In verbalising their discontent with the organisation’s approach to vaccination, participants expressed feelings of powerlessness and anger. The inference is that participants did not feel valued by the organisation as professionals, and that this feeling may have affected their sense of professional autonomy. This dissatisfaction manifested in a general lack of trust in the organisation’s motives for the seasonal influenza vaccine campaign. Participants also felt disempowered. This finding is congruent with the findings of Yassi et al (2010) suggesting that healthcare workers would be more open to influenza vaccination if they felt supported by the organisation. The findings of Yassi et al are supported by those of Rhudy et al (2010) and Baron-Epel et al (2012), both of which make reference to the ‘emotional intelligence’ and confidence of nurses as factors affecting their decision-making on vaccination. Education programmes with a particular emphasis may be necessary to correct the nurses’ varying understanding of influenza before the introduction of any mandatory vaccination programmes.
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Implications and recommendations for policy The findings of this study showed that multiple factors and should be considered when developing policy. Policy developers should recognise the unique patterns of knowing that nurses use to make clinical decisions. They also need to be aware that nurses may be applying these same patterns of knowing to decision-making regarding their own health and wellbeing. Future policy on the seasonal influenza vaccine for nurses should endeavour to be in the context of inclusive holistic health care for nurses, as opposed to being an organisational directive. One recommendation from this study is that healthcare policy makers should collaborate with nurses to devise health strategies that incorporate the diverse empirical, aesthetic and moral ways of knowing that are unique to nurses (Carper, 1978) to devise a holistic policy that considers the wellbeing and concerns of nurses as well as patients. It is clear from this
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study that efforts need to be made to engage with nurses via methods that nurses respond to.
Implications and recommendations for education From this study and the existing body of literature, it is evident that there are some important misconceptions about the influenza vaccine. This study suggests that a different approach is urgently required for the education of nurses in order to address their specific concerns about the seasonal influenza campaign. Indeed, for the first time, this study gave nurses an opportunity to identify the supports and resources that they felt were necessary to improve the seasonal influenza campaign. This study also supports the need for increased efforts by the health service to be informed of the current issues and views of nurses, and the need to provide targeted education sessions to address their concerns. Another recommendation is the introduction of an educational programme about the seasonal influenza vaccine, delivered to nurses in a more personal way by a trusted colleague, preferably an expert nurse. This recommendation provides an opportunity for the organisation to improve the way that the seasonal influenza campaign is delivered and help nurses make evidence-based decisions, which may ultimately improve outcomes for older persons. Equally, it may be prudent to include education about vaccines and preventable diseases as part of the academic preparation of student nurses.
Implications and recommendations for further research This study represents a departure from the dominant empiricist studies cited in the literature.While it has presented invaluable insights into nurses’ views about the uptake of the seasonal influenza vaccine, further in-depth explorations of nurses’ experiences are needed. One possibility is a future interventional study to address major gaps in knowledge, including the misconception that the influenza vaccine causes influenza, and the reality that nurses can be asymptomatically infected with the influenza virus. The creative use of research methodologies in future studies could also be mixed to build on the findings of this study. Perhaps Carper’s (1978) fundamental patterns of knowing should be used as a theoretical framework to guide future research within this area, with this unique group of healthcare workers.
Limitations The conclusion and recommendations of this study are transferable to educational practice. However, this study was conducted on a small scale and the qualitative findings alone cannot be generalised to all healthcare workers’ experiences of the seasonal influenza vaccine. The study may have been enriched by including other healthcare workers. Another possible limitation was gender imbalance in that all participants were female. However, this imbalance was difficult to correct given that all nursing staff in the research site were female. Nonetheless, for the first time in the
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36(2): 201–6. doi: 10.1016/j.jemermed.2007.07.070 Gazmararian JA, Coleman M, Prill M, et al (2007) Influenza vaccination of healthcare workers: policies and practices of hospitals in a community setting. Am J Infect Control 35(7): 441–7 Harbarth S, Siegrist C, Schira J, Wunderli W, Pittet D (1998) Influenza immunisation: improving compliance of health care workers. Infect Control Hosp Epidemiol 19(5): 337–42 Health Protection and Surveillance Centre (2012) Study determines flu vaccine uptake among staff in HSE funded hospitals and residential units. http://tinyurl. com/pnc53vn (accessed 15 September 2014) Health Service Executive (2011) National Clinical Programmes. HSE, Dublin Health Service Executive (2012) Public Health Guidelines on the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Ireland. HSE, Dublin Hollmeyer FH, Hayden F, Poland G, Buchholz U (2009) Influenza vaccination of health care workers in hospitals – a review of studies on attitudes and predictors. Vaccine 27(30): 3935–44 Hollmeyer HG, Hayden F, Mounts A, Buchholz U (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses 7(4): 604–21 Martinello RA, Jones L, Topal JE (2003) Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol 24(11): 845–7 O’Reilly FW, Cran GW, Stevens AB (2005) Factors affecting influenza vaccine uptake among health care workers. Occup Med (Lond) 55(6): 474–9 Piccirillo B, Gaeta T (2006) Survey on use of and attitudes toward influenza vaccination among emergency department staff in a New York metropolitan hospital. Infect Control Hosp Epidemiol 27(6): 618–22 Poland G, Tucker S (2012) The nursing profession and patient safety and healthcare provider influenza immunization: the puzzling stance of the American Nursing Association. Vaccine 30(10): 1753–5 Rhudy LM, Tucker SJ, Ofstead CL, Poland GA (2010) Personal choice or evidencebased nursing intervention: nurses decision-making about influenza vaccination. Worldviews Evid Based Nurs 7(2):111-20. doi: 10.1111/j.1741-6787.2010.00190.x Smedley J, Poole J, Waclawski E, Stevens A, Harrison J, Watson A, Hayward D (2007) Influenza immunisation: attitudes and beliefs of UK healthcare workers. Occup Environ Med 64(4): 223–7 Toronto CE, Mullaney SM (2010) Registered nurses and influenza vaccination: an integrated review. AAOHN J 58(11): 463–71 Thomas RE, Jefferson T, Lasserson TJ (2010) Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010 Feb 17(2): CD005187 Trivalle C, Okenge E, Hamon B, Taillandier J, Falissard B (2006) Factors that influence influenza vaccination among health care workers in a French Geriatric Hospital. Infect Control Hosp Epidemiol 27(11): 1278–80 Tucker S, Poland G, Jacobson R (2008). Requiring influenza vaccination for health care workers: the case for mandatory vaccination with informed declination. Am J Nurs 108(2): 32-4. doi: 10.1097/01.NAJ.0000310328.47809.d4 Wicker S, Rabenau HF (2010) The reluctance of nurses to get vaccinated against influenza. Vaccine 28(45): 48–9 Willis B, Wortley P (2007) Nurses’ attitudes and beliefs about influenza and the influenza vaccination: a summary of focus groups in Alabama and Michigan. Am J Infect Control 35(1): 20–4 Yassi A, Lockhart K, Buxton JA, McDonald I (2010). Vaccination of health care workers for influenza: promote safety culture, not coercion. Can J Public Health 101(7 suppl 1):S41-5 Zhang J, While AE, Norman IJ (2010) Knowledge and attitudes regarding influenza vaccination among nurses: a research review. Vaccine 28(44): 7207–14
KEY POINTS n The
findings of this study illuminate the complexity of issues concerning the uptake of the seasonal influenza vaccine by nurses working in the long-term older person care setting in Ireland
n Employers
and nurses need to agree on support mechanisms to correct misconceptions regarding the seasonal influenza vaccine
n It
is possible that nurses use the same multi-faceted decision-making process regarding patient care to make decisions regarding the seasonal influenza vaccine
n The
influences of media, family, friend and peers were highlighted as possible stronger influences on nurses’ decision making than empirical knowing
n The
seasonal influenza vaccine campaign needs to be managed in a different way to take account of the different ways that nurses inform themselves
Republic of Ireland, this study may represent a foundation for BJN further research in this complex area of interest. Conflict of interest: none Abramson ZH, Levi O (2008) Influenza vaccination among primary healthcare workers. Vaccine 26(20): 2482–9. doi: 10.1016/j.vaccine.2008.03.011. An Bord Altranais (1999) Review of Scope of Practice for Nursing and Midwifery: Interim Report. An Bord Altranais, Dublin Baron-Epel O, Bord S, Madjar B, Habib S, Rishpon S (2012) What lies beneath nurses low vaccination? Vaccine 30(21): 3151–4 Batey M, Lewis F (1982) Clarifying autonomy and accountability in nursing service: part 1. JONA 12(9): 13–18 Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101 Carper BA (1978) Fundamental patterns of knowing in nursing. Advances Nursing Science 1(1): 13–24 Centers for Disease Control and Prevention (2011) Influenza Vaccination Coverage Among Health-care Personnel United States, 2010–11, Influenza Season. MMWR 60(32): 1073–7 Chinn PL, Kramer KK (2008) Integrated Theory and Knowledge Development in Nursing. 7th edn. Mosby Elsevier, St Louis Christini AB, Shutt KA, Byers KE (2007) Influenza vaccination rates and motivators among healthcare worker groups. Infect Control Hosp Epidemiol 28(2): 171–7 Fernandez W, Oyama L, Mitchell P, et al (2009) Attitudes and practices regarding influenza vaccination among emergency department personnel. J Emerg Med
Understanding Patient Safety About this book
Edited by Lynne Currie
This book begins with an introduction charting the geneaology of patient safety both internationally and in the UK from the late 1980s up until the present time. Other chapters in the book discuss the patient’s role in safety and the role of the National Patient Safety Agency, the role of the professionals in keeping patients safe, safe staffing levels, risk management, infection control, how patients evaluate safety, information for safety, evidence-based practice for safety, and the importance of learning the lessons from safety failures.
n Timely evidence-based text on safety practices
Understanding Patient Safety
This book offers a wide range of views on the emergence of patient safety in the NHS, which is now considered an area of high priority in healthcare.
Understanding Patient Safety
About the editor
n Discusses governmental and the patient’s role in safety Lynne Currie is Project Manager: Evaluating and Improvement, Royal College of Nursing Institute, Oxford
n Includes a review of the history of patient safety ISBN: 978-1-85642-289-5, 192 pages, publication 2007, £25.99
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Edited by Lynne Currie
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Edited by Lynne Currie
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Abstract
The experience of nurses who work in the residential elderly care setting regarding the seasonal influenza vaccine is often overlooked, with a paucity of published qualitative studies. The aim of this study is to present an insight into the issues concerning nurses with regard to the seasonal influenza vaccine. The study purposively sampled registered nurses (n=11) working in a large long-term care facility for older people (n=142) in Ireland. Using a broad qualitative research approach, data were collected through interviews, transcribed, analysed and grouped into the following themes: knowing: the seasonal influenza vaccine; mandatory vaccination: balancing autonomy and control; and meaningful education. This study reveals the complexity of issues and concerns for nurses when it comes to the seasonal influenza vaccine. These issues and concerns include influences such as family, friends, peers, the media and how nurses inform themselves. The position of nurses within the organisation and recommendations for meaningful nurse education are also discussed. The findings of this study provide an insight that could inform future influenza policy and education, which should be explored before the introduction of any mandatory influenza campaigns. Key words: Public health ■ Vaccination ■ Older people ■ Residential care ■ Qualitative research
A
review of the literature shows a persistent low level of uptake of the influenza vaccine by healthcare workers (Thomas et al, 2010). Compared with other healthcare workers, nurses have the lowest level of uptake of seasonal influenza vaccination (BaronEpel et al, 2012). Nurses are also the largest group of health professionals providing 24-hour direct care to older people (Centers for Disease Control and Prevention, 2011; Health Service Executive (HSE), 2011; Poland et al, 2012). For this reason, the vaccination of healthcare workers, including nurses working in the residential long-term older person care setting in Ireland, is recommended (HSE, 2012). The literature to date has been mainly quantitative, with very little emphasis on the views of registered nurses around seasonal influenza vaccination (Rhudy, 2010). Systematic
reviews of the literature by Thomas et al (2010) and Zhang et al (2010) acknowledge this deficiency and make reference to the need to explore the specific views of nurses. There are very few studies in Ireland regarding the uptake of the influenza vaccine by healthcare workers. A quantitative study carried out by survey questionnaire was conducted in public healthcare facilities in Ireland in 2012 (Health Protection and Surveillance Study, 2012).The aim of the study was to determine seasonal influenza vaccine uptake among healthcare workers employed in acute hospitals (n=46 287) and long-term care settings for older people (n=6806). The overall vaccination rate for healthcare workers in the longterm care setting was 13.5% (n=920). Nursing staff working in the long-term care setting in Ireland (n=2540) had the second-lowest uptake of the seasonal influenza at 11.6% (n=294). This report was consistent with other studies that showed low rates of uptake of the seasonal influenza vaccine (Smedley et al, 2007; Fernandez et al, 2009; Toronto and Mullaney, 2010; Hollmeyer et al, 2012; Baron-Epel et al, 2012; Health Protection and Surveillance Centre, 2012). The study by the Health Protection and Surveillance Centre (2012) was limited by the fact that it used a self-report questionnaire and collected statistics. The report summarised trends of influenza rates and vaccine uptake—it did not examine the issues and concerns of healthcare workers. The report recommended that the reasons for non-vaccination of healthcare workers be urgently identified.
Methods There are at least two different types of phenomenological approach. For the purpose of the research presented here, the methodology used is the interpretative or ‘hermeneutic’ approach. The important aspect of all forms of interpretative phenomenology is the ‘phenomenological attitude’—that is, the desire to understand the world as it appears for the participant. This is achieved by focusing on experience, by an emphasis on description, and by the use of epoche (bracketing) where the researcher suspends assumptions, beliefs and judgements from the process. A qualitative study with semi-structured interviews was deemed the most appropriate design.
Accepted for publication: September 2014
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This study was conducted in a large public residential longterm care setting for older people. Registered nurses working at the research site were selected based on the fact that they had direct experience of the seasonal staff influenza vaccination campaign in the long-term care of the older person setting. Full
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Study setting Gemma Quinn, Infection Prevention & Control Manager, Mid West Primary, Community and Continuing Care, Ireland
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VACCINATIONS ethical approval for the study was granted by the local regional hospital research ethics committee. Participant confidentiality was guaranteed and all data were anonymised.
Sample The participants of this study represented registered nurses working in the specialist field of older person care. The level of experience of participants ranged from 7 to 22 years of exclusive experience in the setting of long-term care for older people. All participants were female and the level of experience reflected in the grade of nurse ranged from staff nurse to manager. All the participants who worked full-time chose to work with older people; hence, participants showed clear career pathways that lead to working in this specialist area of nursing. It could be assumed that participants felt strongly about older person nursing and were committed to advocating on behalf of these patients.
Interviews and analysis The interviews were semi-structured, transcribed verbatim (word for word) and thematically analysed with the Braun and Clarke Framework (2006).
Findings The data from the interviews are presented in the following themes: ■■ Knowing: the seasonal influenza vaccine ■■ Mandatory vaccination: balancing autonomy and control ■■ Meaningful education. Sub-themes in this study were considered to be the foundation for the main themes, constructing the rich stories inherent in the data. Data extracts are used to demonstrate the underlying essence of the issues concerning nurses.
Knowing: the seasonal influenza vaccine This theme exemplifies the complex nature of nurses’ knowing and understanding of the seasonal influenza vaccine. ‘Knowing’ as embodied in this theme related to empirical, personal, ethical and aesthetic ways of knowing that influenced nurses’ decision-making regarding the vaccine. These ways of knowing are reminiscent of seminal work by Carper (1978) who espoused the view that nurses’ decision-making regarding patient care is informed by four fundamental ways of knowing. In addition, ‘knowing’ describes myriad influences (e.g. media, family, peers) that shaped each nurse’s unique ways of knowing and in turn their ultimate decision to take the influenza vaccine. Finally, ‘knowing’ highlights ‘different understandings’ held by some participants around the vaccine and its side-effects, and how these could influence their decision to take it.
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Empirical knowing regarding the seasonal influenza vaccine Throughout the interviews, participant responses demonstrated a broad level of understanding regarding the seasonal influenza vaccine from a professional, fact-based, empirical perspective. This is in contrast to the literature reviewed suggesting that nurses’ level of knowledge regarding the seasonal influenza vaccine is poor. Participant responses
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reflected a professional work-related context. It was clear that the participants had evidence-based knowledge regarding influenza vaccination, as exemplified in the following extract. ‘The CDC says … those at risk are people with diabetes and chronic illness. There are many different strains’ (Registered nurse (RN) 6)
Different understandings on the seasonal influenza vaccine Although findings showed good knowledge of the seasonal influenza vaccine, different understanding of the side-effects of the vaccine was reflected throughout the interviews. All the participants believed that one side-effect of receiving the vaccine was actually catching influenza. This belief is of major concern and suggests that nurses’ understanding of the vaccine and its side-effects may diverge from the empirical evidence. This belief is common and consistent with the other studies (Martinello et al, 2003; Piccirillo et al, 2006; Christini et al, 2007; Willis and Wortley, 2007; Abramson and Levi, 2008; Tucker et al, 2008; Fernandez et al, 2009; Toronto and Mullaney, 2010; Wicker and Rabenau, 2010). The notion that the seasonal influenza vaccine causes influenza is exemplified in the following extract. ‘… I have known too many people personally that have become so ill after getting the flu vaccine and I said, “No, I’m not going to get it, I’ve seen too many people.” Even here, you just know for a fact that once they get the vaccination, give them 7 to 10 days, and you will see the increase. The next thing is you see an increase in the use of antibiotics because of that’ (RN 5) It is possible that participants were fully informed by the empirical information available to them, but were more influenced by other ways of knowing. Individuals may have put a different emphasis on each aspect of knowing, depending on their unique experience of the seasonal influenza vaccine. Due to the prevalence of this finding in the study, it is a concern that participants seemed to have a broad awareness of the seasonal influenza vaccine, yet appeared to assume, wrongly, that it is a live vaccine.
Concerns about the H1N1 influenza Participants may also have been uncertain about the seasonal influenza vaccine because of concerns with other influenza vaccines, such as the H1N1 influenza (‘swine flu’) vaccine. Recent advances in empirical knowledge of side-effects of previous vaccines may have resulted in concerns about the future unknown side-effects of the seasonal influenza vaccine. The following extract epitomises the uncertainty around staff influenza vaccination generally: ‘Swine flu, the panic about swine flu. People are not sure of what they are getting now. Are we getting the swine flu now, or are we getting vaccinated against the normal flu? Nobody understands’ (RN 1)
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Influence of media and the internet Participants’ responses suggested that nurses have a desire to learn more about the seasonal influenza vaccine by seeking out further empirical knowledge. It is possible that clear, unambiguous empirical information regarding the seasonal influenza vaccine was not available to participants in the workplace. It is also possible that the empirical information was available, but the influence of other sources of knowing was stronger or was delivered in a more appealing way. The influence of media and internet as other sources of information were exemplified by RN 8: ‘I mean, that’s what it says on the … national media at the moment … they are talking about the flu and that an antibiotic really is of no benefit to the flu and I totally agree with it, that you have to rest and give it a chance. It’s viral so you actually have no benefit going on antibiotics’ (RN 8)
Own immunity Nurses’ personal experiences, along with empirical ways of knowing, provided them with a whole view of a situation, showing that their views are informed by many different sources of knowing. Some participants discussed the use of health-food supplements to enhance immunity. One participant discussed alternative medicine. Faith in one’s own immunity and alternative medicine was congruent with some of the studies reviewed in the literature (O’Reilly et al, 2005; Trivalle et al, 2006).The following extracts showed a high level of confidence on the part of participants in their own immunity to the seasonal influenza, which seemed to be informed by selfunderstanding around improving natural immunity: ‘Most nurses wouldn’t take the flu vaccine because they feel they have an immunity built up themselves’ (RN 8) Participants informed themselves and shaped their views on the seasonal influenza vaccine in many different ways: ‘… I would be influenced a lot by, some would call it, New Age medicine, and its medicine of the future that is more energy-based. It’s about having an authentic relationship between patients and staff ’ (RN 2)
It is possible that participants intuitively suspected that there were other ways of gaining information about the seasonal influenza vaccine, and they may have been more strongly influenced by other ways of knowing (such as personal knowing) to address this gap.
Interestingly, this participant (RN 2) included the patients in the response, which indicates a concern for older people and a concordant approach to care.
Personal knowing regarding the influenza vaccine
Influence of family and friends
People innately use their experiences to inform their personal knowing. This sub-theme showed the many ways that participant nurses added to their knowing with regard to the seasonal influenza vaccine. Without exception, all the participants talked about the influence of others, such as peers, relatives and family members, who had had negative experiences of the influenza vaccine. Interestingly, participants did not recount any positive experience of influenza vaccination (experiences were predominantly negative). This is understandable, as it is very difficult to experience the vaccine in a positive way once it is given. Intuitively, nurses sought other ways to inform their understanding about the seasonal influenza vaccine. In line with Carper’s ways of knowing (1978), the participants used experience. The essence of personal knowing is illustrated by the following excerpt:
This sub-theme showed the very personal experiences that shaped decisions about work-related issues. This finding is congruent with the study by Rhudy et al (2010), which suggested that nurses’ decision-making regarding the seasonal influenza vaccine was mainly influenced by personal factors. Participants’ personal ways of knowing may have been a greater influence on knowledge regarding the seasonal influenza vaccine if the empirical knowing was incomplete. Equally, even with greater empirical knowing, personal experience of the vaccine may have been a stronger influence. Participants articulated their experiences of the seasonal influenza vaccine and the perceived effect on family members and friends:
‘Well I feel … that the swine flu vaccine may have had something to do with … the illness I got. Especially when you hear there were other people admitted with the same thing after getting the vaccine’ (RN 9) Participants expressed a level of confusion and frustration about the level of information provided in the seasonal influenza vaccination campaign. Earlier, one of these
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participants had expressed the need for influenza campaigns to include a higher level of research evidence.
‘He got the flu vaccine and 3 days later … well, he died as a consequence. And I can’t help thinking in the back of my mind: if we hadn’t given him the vaccine, maybe he would have been all right’ (RN 3) At the same time, participants appeared to take into account the views of work colleagues when discussing the seasonal influenza vaccine.
The influence of peers The significant influence of peers as a personal source of knowledge in the study findings was linked to participants’
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The influence of concerns about H1N1 influenza may have stemmed from sources outside the organisation. It is possible that issues around other vaccines, such as the combined measles, mumps and rubella vaccine, may have influenced the participant responses. Some participants also alluded to the influence of media and the internet as information resources.
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VACCINATIONS overall personal experiences. It is possible that participants were seeking validation of personal views of the seasonal influenza vaccine by consulting their peers and leadership figures. The importance of this discourse is expressed by RN 2: ‘… The way we all talk, we all dialogue at work, that then I would sell it on to someone else. We are definitely influenced by others, there are definite strong personalities that you listen to’ (RN 2) The influence of past experiences, personally and professionally, with clients around the seasonal influenza vaccine may play a part in how nurses approach decision-making. These findings are congruent with qualitative studies such as Rhudy et al (2010) and Baron-Epel et al (2012) who suggested that personal issues play a more significant role in nurses’ thinking and decision-making than empirical knowledge.
Ethical ways of knowing regarding the vaccine Although participants may have had issues around the uptake of the seasonal influenza vaccine, they were morally and ethically aware of the need to safeguard older people from influenza infection. Participants demonstrated understanding of the risks to older persons and therefore a moral way of knowing by acknowledging the importance of the vaccine for older people. This ethical way of knowing is also related to the fact that participants had earlier shown particular care and compassion for older people by choosing to work in the specialist area of older person nursing. This fact contrasts with findings in the literature suggesting that self-protection, as opposed to patient protection, is the primary motive for uptake of the influenza vaccine by nurses (O’Reilly et al, 2005). In addition to empirical and personal knowing, the following extract embodies one nurse’s moral caring: ‘I think it is very important for the older person to receive the flu vaccine. My parents get it every year and studies have shown that you … their instances of serious illness are reduced because obviously they are not going to get this debilitating illness, which could lead to pneumonia or death’ (RN 4) Responses from participants also provided insight into the moral conflict that exists for nurses around the seasonal influenza vaccine. The theme of ethical ways of knowing showed the inherent professionalism of nurses in their desire to protect older people, even when they have their own reservations regarding the vaccine. For example: ‘But now I have to ask myself the question, am I letting down the people I’m working for, the patient’ (RN 2)
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Moral ways of knowing were also evident as an underlying assumption regarding the notion of mandatory vaccination.
Aesthetic ways of knowing regarding the vaccine Aesthetic ways of knowing refer to the way that nurses make decisions based on the wholeness of a situation or set of circumstances (Carper, 1978; Chinn and Kramer, 2008). With regard to issues concerning the uptake of the seasonal
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influenza vaccine by nurses working in the long-term care of the older person setting, it is possible that participants combined empirical, personal and ethical ways of knowing to inform themselves and shape their own views. This aesthetic way of knowing suggests complex critical thinking on the part of participants. It was difficult to capture this merging of information from the transcripts. However, RN 7 expressed the essence of aesthetic ways of knowing used by participants to inform decision-making. ‘Well it’s both professional and personal’ (RN 7) The findings in theme one showed the complexity of issues concerning the uptake of the seasonal influenza vaccine by nurses in the long-term care of the older person setting. The myriad ways of knowing that participants use in decisionmaking regarding the care of older people may be the same ways of knowing used to make other decisions and form other views. Findings in theme one are congruent with the findings in the literature that allude to the unique ways that nurses inform themselves (Thomas et al, 2010; Zhang et al, 2010). Influences on knowing are social, professional, empirical and personal, among others. Findings in theme one also suggest some significant gaps in awareness that need to be addressed regarding the seasonal influenza vaccine.
Mandatory vaccination: balancing autonomy and control Autonomy for nurses is defined as: ‘freedom to make discretionary and binding decisions consistent with one’s scope of practice and freedom to act on those decisions’ (Batey and Lewis, 1982: 15). The inference is that to be autonomous is to have power and control over self-determination and decision-making. Therefore, the absence of autonomy felt by participants suggested a loss of power and control. This theme was the strongest in terms of depth of feeling and the very personal nature of participant responses. Participants also included personal knowing by showing empathy for the patient and ethical knowing of self as a professional nurse and for the safeguarding of older people: ‘I suppose it just makes you feel angry. If we did this to a patient, we injected them with something against their wishes, it would be classed as abuse, a form of assault’ (RN 1) There was a high level of anger articulated by participants regarding mandatory vaccination. It is possible that the seasonal influenza vaccine was viewed as the taking away of nurses’ decision-making and autonomy—as opposed to the provision of a health-promoting intervention given on the part of the organisation. Some participants expressed their frustration in terms of an all-round assessment of their position within the organisation. It is possible that participants felt undervalued and not recognised as professionals. One of the participants expressed how they felt about mandatory vaccination with powerful simplicity: ‘Disempowered’ (RN 6) Equally, it can be argued that participants viewed themselves as highly skilled professionals who should be consulted about
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‘I feel it would take away our own decisionmaking really, and our own expertise, and that, you know, as nurses, part of our work ethic really is to advise other people and that surely we are able to make a decision for ourselves and are qualified personnel’ (RN 8)
Absenteeism Participants also believed that the organisation’s primary motive for the seasonal influenza vaccine was to prevent absenteeism. ‘Ah sick time. I suppose to avoid sick time’ (RN 3) There were other negative views of mandatory vaccination too. Some perceived that it was offered to nurses in the context of productivity and patient protection, as opposed to staff health and wellbeing. Some participants felt a lack of caring from the organisation. The fact that participants felt the vaccine would reduce staff absenteeism may show an implicit knowledge about the efficacy of the vaccine itself. Findings from theme two illuminated the depth of the underlying feelings of anger and discontent regarding the mandatory vaccination. Professional guidance provided by the Nursing and Midwifery Board of Ireland articulate the responsibilities of a nurse as an autonomous practitioner with authority to make decisions within their scope of practice (An Bord Altranais, 1999). Autonomy for nurses empowers nurses as individuals and as a group. There was a perception that this hard-fought-for position for nurses was being eroded and undermined. Hence, findings revealed a sense of power imbalance between nurses and the organisation. Participants felt a sense of disbelief that they seemed to be making autonomous clinical decisions with and on behalf of older people—only for the organisation to take away this power. It is possible that this perceived power imbalance was the result of a poorly communicated seasonal influenza campaign that failed to address the specific requirements of nurses.
Meaningful education The needs of nurses regarding support and resources in the workplace was a particularly prevalent theme (n=10/10) eliciting a large amount of rich data. The participant nurses gave detailed responses and recommendations regarding how the seasonal influenza campaign should be managed. That nurses were not included in the management of the seasonal influenza campaign is implicit in the following extract: ‘I think it’s the management of it. Is it balanced? No, don’t think so. I would like to hear other’ views’ (RN 5) Participant responses indicated that if they had extra knowledge that met their requirements, they would have felt satisfied with the seasonal influenza campaign. It may be assumed that nurses felt a desire for a holistic, balanced
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campaign that encompassed the needs of nurses and the needs of older persons in a meaningful way. The previous theme, exploring nurses’ different ways of knowing and how nurses inform themselves from many sources, is intertwined with their desire to get a whole picture of a situation before forming a decision. It is almost as if participants wanted a second opinion before making a decision. It is possible that participants were not averse to the seasonal influenza vaccine and would be more open to vaccination if their educational needs were met, and if the campaign were delivered in an adjusted way. Participants highlighted the importance of addressing nurses’ questions and concerns, and giving them further information: ‘I am one of those people that would be willing to change if more information came out that could sway me’ (RN 6) The adjustments required to the delivery of the campaign articulated by participants included the involvement and collaboration of trusted role models to satisfy their need for balanced information from multiple sources.
Trusted role models/leaders A key sub-theme was the level of emphasis participants placed on the need for face-to-face education from trusted colleagues. The desire for information and leadership from a trusted colleague is connected to the ways of knowing in theme one. Participants specified particular trusted role models that they felt were best-equipped to deliver the education campaign for the seasonal influenza vaccine. This need for trusted role models was alluded to by Harbath et al (1998). However, the recommendation of a specific role model such as the infection control nurse was absent in the literature reviewed. The preference for education around the vaccine to be made more meaningful was evident from participants’ responses. This type of learning is linked to the personal way of knowing espoused by Carper (1978), and outlined in theme one of this study. Some studies also allude to a different type of education and learning for nurses (Gazmaraian et al, 2007; Hollmeyer et al, 2009). The preference for a trusted role model to deliver face-to-face education on the seasonal influenza vaccine is exemplified in the following extracts: ‘Well I suppose if someone sat me down and said this and this are the reasons, then I would say, OK, you’ve convinced me, I am going to do it … a person of integrity (RN 4) ‘Short brief meetings they should discuss with them, someone to talk to’ (RN 6) Finally, some participants expressed concern at the timing and manner in which information on the seasonal influenza campaign was managed. It is possible that participants felt rushed into making decisions: ‘There’s not enough information throughout the year’ (RN 3) Equally, it may be assumed that participants do not respond to the plethora of written material (Gazmaraian et al, 2007)
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the seasonal influenza vaccine. RN 8, for example, expressed disbelief that nurses are not trusted professionals seen as capable of making decisions:
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VACCINATIONS that accompanies the yearly influenza education campaign and may have become indifferent to written empirical information distributed by the organisation: ‘There’s a splurge of leaflets’ (RN 7) From the responses of the participants, the theme of meaningful education is significant. It may be assumed that participants wanted a concordant approach to the seasonal influenza campaign that consulted nurses in a way they could relate to about their learning needs and educational preferences before the campaign began.
Discussion As this study shows, nurse participants’ unique personal and social experiences are a significant factor in how they view the seasonal influenza vaccine, and possibly explain why there are issues and concerns about it. Clarification and collaborative programme development that include tailormade educational sessions may assist nurses in their decision making. In verbalising their discontent with the organisation’s approach to vaccination, participants expressed feelings of powerlessness and anger. The inference is that participants did not feel valued by the organisation as professionals, and that this feeling may have affected their sense of professional autonomy. This dissatisfaction manifested in a general lack of trust in the organisation’s motives for the seasonal influenza vaccine campaign. Participants also felt disempowered. This finding is congruent with the findings of Yassi et al (2010) suggesting that healthcare workers would be more open to influenza vaccination if they felt supported by the organisation. The findings of Yassi et al are supported by those of Rhudy et al (2010) and Baron-Epel et al (2012), both of which make reference to the ‘emotional intelligence’ and confidence of nurses as factors affecting their decision-making on vaccination. Education programmes with a particular emphasis may be necessary to correct the nurses’ varying understanding of influenza before the introduction of any mandatory vaccination programmes.
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Implications and recommendations for policy The findings of this study showed that multiple factors and should be considered when developing policy. Policy developers should recognise the unique patterns of knowing that nurses use to make clinical decisions. They also need to be aware that nurses may be applying these same patterns of knowing to decision-making regarding their own health and wellbeing. Future policy on the seasonal influenza vaccine for nurses should endeavour to be in the context of inclusive holistic health care for nurses, as opposed to being an organisational directive. One recommendation from this study is that healthcare policy makers should collaborate with nurses to devise health strategies that incorporate the diverse empirical, aesthetic and moral ways of knowing that are unique to nurses (Carper, 1978) to devise a holistic policy that considers the wellbeing and concerns of nurses as well as patients. It is clear from this
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study that efforts need to be made to engage with nurses via methods that nurses respond to.
Implications and recommendations for education From this study and the existing body of literature, it is evident that there are some important misconceptions about the influenza vaccine. This study suggests that a different approach is urgently required for the education of nurses in order to address their specific concerns about the seasonal influenza campaign. Indeed, for the first time, this study gave nurses an opportunity to identify the supports and resources that they felt were necessary to improve the seasonal influenza campaign. This study also supports the need for increased efforts by the health service to be informed of the current issues and views of nurses, and the need to provide targeted education sessions to address their concerns. Another recommendation is the introduction of an educational programme about the seasonal influenza vaccine, delivered to nurses in a more personal way by a trusted colleague, preferably an expert nurse. This recommendation provides an opportunity for the organisation to improve the way that the seasonal influenza campaign is delivered and help nurses make evidence-based decisions, which may ultimately improve outcomes for older persons. Equally, it may be prudent to include education about vaccines and preventable diseases as part of the academic preparation of student nurses.
Implications and recommendations for further research This study represents a departure from the dominant empiricist studies cited in the literature.While it has presented invaluable insights into nurses’ views about the uptake of the seasonal influenza vaccine, further in-depth explorations of nurses’ experiences are needed. One possibility is a future interventional study to address major gaps in knowledge, including the misconception that the influenza vaccine causes influenza, and the reality that nurses can be asymptomatically infected with the influenza virus. The creative use of research methodologies in future studies could also be mixed to build on the findings of this study. Perhaps Carper’s (1978) fundamental patterns of knowing should be used as a theoretical framework to guide future research within this area, with this unique group of healthcare workers.
Limitations The conclusion and recommendations of this study are transferable to educational practice. However, this study was conducted on a small scale and the qualitative findings alone cannot be generalised to all healthcare workers’ experiences of the seasonal influenza vaccine. The study may have been enriched by including other healthcare workers. Another possible limitation was gender imbalance in that all participants were female. However, this imbalance was difficult to correct given that all nursing staff in the research site were female. Nonetheless, for the first time in the
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36(2): 201–6. doi: 10.1016/j.jemermed.2007.07.070 Gazmararian JA, Coleman M, Prill M, et al (2007) Influenza vaccination of healthcare workers: policies and practices of hospitals in a community setting. Am J Infect Control 35(7): 441–7 Harbarth S, Siegrist C, Schira J, Wunderli W, Pittet D (1998) Influenza immunisation: improving compliance of health care workers. Infect Control Hosp Epidemiol 19(5): 337–42 Health Protection and Surveillance Centre (2012) Study determines flu vaccine uptake among staff in HSE funded hospitals and residential units. http://tinyurl. com/pnc53vn (accessed 15 September 2014) Health Service Executive (2011) National Clinical Programmes. HSE, Dublin Health Service Executive (2012) Public Health Guidelines on the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Ireland. HSE, Dublin Hollmeyer FH, Hayden F, Poland G, Buchholz U (2009) Influenza vaccination of health care workers in hospitals – a review of studies on attitudes and predictors. Vaccine 27(30): 3935–44 Hollmeyer HG, Hayden F, Mounts A, Buchholz U (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses 7(4): 604–21 Martinello RA, Jones L, Topal JE (2003) Correlation between healthcare workers’ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol 24(11): 845–7 O’Reilly FW, Cran GW, Stevens AB (2005) Factors affecting influenza vaccine uptake among health care workers. Occup Med (Lond) 55(6): 474–9 Piccirillo B, Gaeta T (2006) Survey on use of and attitudes toward influenza vaccination among emergency department staff in a New York metropolitan hospital. Infect Control Hosp Epidemiol 27(6): 618–22 Poland G, Tucker S (2012) The nursing profession and patient safety and healthcare provider influenza immunization: the puzzling stance of the American Nursing Association. Vaccine 30(10): 1753–5 Rhudy LM, Tucker SJ, Ofstead CL, Poland GA (2010) Personal choice or evidencebased nursing intervention: nurses decision-making about influenza vaccination. Worldviews Evid Based Nurs 7(2):111-20. doi: 10.1111/j.1741-6787.2010.00190.x Smedley J, Poole J, Waclawski E, Stevens A, Harrison J, Watson A, Hayward D (2007) Influenza immunisation: attitudes and beliefs of UK healthcare workers. Occup Environ Med 64(4): 223–7 Toronto CE, Mullaney SM (2010) Registered nurses and influenza vaccination: an integrated review. AAOHN J 58(11): 463–71 Thomas RE, Jefferson T, Lasserson TJ (2010) Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010 Feb 17(2): CD005187 Trivalle C, Okenge E, Hamon B, Taillandier J, Falissard B (2006) Factors that influence influenza vaccination among health care workers in a French Geriatric Hospital. Infect Control Hosp Epidemiol 27(11): 1278–80 Tucker S, Poland G, Jacobson R (2008). Requiring influenza vaccination for health care workers: the case for mandatory vaccination with informed declination. Am J Nurs 108(2): 32-4. doi: 10.1097/01.NAJ.0000310328.47809.d4 Wicker S, Rabenau HF (2010) The reluctance of nurses to get vaccinated against influenza. Vaccine 28(45): 48–9 Willis B, Wortley P (2007) Nurses’ attitudes and beliefs about influenza and the influenza vaccination: a summary of focus groups in Alabama and Michigan. Am J Infect Control 35(1): 20–4 Yassi A, Lockhart K, Buxton JA, McDonald I (2010). Vaccination of health care workers for influenza: promote safety culture, not coercion. Can J Public Health 101(7 suppl 1):S41-5 Zhang J, While AE, Norman IJ (2010) Knowledge and attitudes regarding influenza vaccination among nurses: a research review. Vaccine 28(44): 7207–14
KEY POINTS n The
findings of this study illuminate the complexity of issues concerning the uptake of the seasonal influenza vaccine by nurses working in the long-term older person care setting in Ireland
n Employers
and nurses need to agree on support mechanisms to correct misconceptions regarding the seasonal influenza vaccine
n It
is possible that nurses use the same multi-faceted decision-making process regarding patient care to make decisions regarding the seasonal influenza vaccine
n The
influences of media, family, friend and peers were highlighted as possible stronger influences on nurses’ decision making than empirical knowing
n The
seasonal influenza vaccine campaign needs to be managed in a different way to take account of the different ways that nurses inform themselves
Republic of Ireland, this study may represent a foundation for BJN further research in this complex area of interest. Conflict of interest: none Abramson ZH, Levi O (2008) Influenza vaccination among primary healthcare workers. Vaccine 26(20): 2482–9. doi: 10.1016/j.vaccine.2008.03.011. An Bord Altranais (1999) Review of Scope of Practice for Nursing and Midwifery: Interim Report. An Bord Altranais, Dublin Baron-Epel O, Bord S, Madjar B, Habib S, Rishpon S (2012) What lies beneath nurses low vaccination? Vaccine 30(21): 3151–4 Batey M, Lewis F (1982) Clarifying autonomy and accountability in nursing service: part 1. JONA 12(9): 13–18 Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101 Carper BA (1978) Fundamental patterns of knowing in nursing. Advances Nursing Science 1(1): 13–24 Centers for Disease Control and Prevention (2011) Influenza Vaccination Coverage Among Health-care Personnel United States, 2010–11, Influenza Season. MMWR 60(32): 1073–7 Chinn PL, Kramer KK (2008) Integrated Theory and Knowledge Development in Nursing. 7th edn. Mosby Elsevier, St Louis Christini AB, Shutt KA, Byers KE (2007) Influenza vaccination rates and motivators among healthcare worker groups. Infect Control Hosp Epidemiol 28(2): 171–7 Fernandez W, Oyama L, Mitchell P, et al (2009) Attitudes and practices regarding influenza vaccination among emergency department personnel. J Emerg Med
Understanding Patient Safety About this book
Edited by Lynne Currie
This book begins with an introduction charting the geneaology of patient safety both internationally and in the UK from the late 1980s up until the present time. Other chapters in the book discuss the patient’s role in safety and the role of the National Patient Safety Agency, the role of the professionals in keeping patients safe, safe staffing levels, risk management, infection control, how patients evaluate safety, information for safety, evidence-based practice for safety, and the importance of learning the lessons from safety failures.
n Timely evidence-based text on safety practices
Understanding Patient Safety
This book offers a wide range of views on the emergence of patient safety in the NHS, which is now considered an area of high priority in healthcare.
Understanding Patient Safety
About the editor
n Discusses governmental and the patient’s role in safety Lynne Currie is Project Manager: Evaluating and Improvement, Royal College of Nursing Institute, Oxford
n Includes a review of the history of patient safety ISBN: 978-1-85642-289-5, 192 pages, publication 2007, £25.99
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Edited by Lynne Currie
ISBN 1-85642-289-5
Edited by Lynne Currie
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