Strategies for Flu Vaccination Compliance Among Staff
By Paul Webber
Approximately 19 percent of any North American population has experienced the flu or know someone who has and will forever get vaccinated to avoid that experience. Telling them about the necessity for the vaccine is preaching to the choir. Its the other 81 percent that have to be bribed, threatened or otherwise persuaded to roll up their sleeves every October. Many of those people work in your hospital.
This article will explore the psychological foundations of why some of the 81 percent of your staff resist the flu vaccine so vehemently, and will provide some suggestions from the trenches on specific workable strategies that others have used to increase their staff vaccination success rate.
The original request for this project came from Christine Cameron in Cornwall, Ontario, and many people in Canada and the United States (and in several other countries) have contributed and continue to contribute to the information that follows.
The Psychology of Refusal
It seems like a no-brainer. Front-line healthcare professionals, particularly physicians and nurses, should take whatever precaution is reasonable to protect the health of their patients. Sounds reasonable, doesnt it? So every year, every staff member dutifully lines up for his or her flu vaccine, right? No?
Why do hospital staff members refuse to get vaccinated against influenza? These are not irresponsible people. There is a logical argument in their minds that is sufficiently compelling to force them to this action (or nonaction). From my vantage point, I see three categorical reasons: health concerns, political statements, and fear with some overlap between them.
This list does not apply to those staff members who will get their flu immunization if it is made supremely convenient for them to do so, but who wont go out of their way to get vaccinated.
The excuses are many: The flu vaccine will make me sick. I dont put foreign substances into my body. I dont ever get sick, so why should I get vaccinated? My naturopath told me that it is not necessary. I have an allergy to eggs. These specific statements and other similar arguments against the vaccine are health concerns. The last one, an allergy to eggs, is acceptable and verifiable. For all the others, the solution is information based and might call on your powers of persuasion. No amount of bribery, pleading or pretty posters will sway these workers, particularly if their ego and self-worth are drawn from the strength of their resistance.
Strategies to approach these workers should include a large component of personal interaction. Flu-season inservices to dispel myths are effective for those with only mild anti-vaccine convictions. One-on-one meetings with experts (thats you), and peer interventions by coworkers who are firmly in favor of the flu vaccine are also good strategies for those who are more solidified in their position. Third-party evidence will be required. The evidence needs to be authoritative, unequivocal and absolutely unavoidable. Copies of good information can be sent in payroll packets, by e-mail, by mail to the workers homes, posted on bulletin boards, left in staff lounges and on the back of toilets or toilet stall doors in staff washrooms. Most importantly, this cannot be directed at specific employees but must be sent to all. Third-party evidence should be readily available from your local public health agency, from your province/state, or from the Centers for Disease Control and Prevention (CDC). If all else fails, contact me and Ill share what Ive got with you if you share what resources youve found with me.
For one-on-one approaches, try a match-and-lead strategy. Match their argument by finding some sort of common ground, a point of agreement, and then lead into your position. It might sound something like this:
Them: The flu vaccine will make me sick. You (match): I understand your concern. Ive heard a few people say that they knew someone who never got the flu until they got the flu vaccine, and its reasonable to be hesitant under those circumstances.
You (lead): Can we agree that not everyone gets sick after getting vaccinated? Maybe those people who got sick gave themselves food poisoning or caught a cold. In fact, studies show that almost all of us get at least one bout of mild food poisoning every year and we sometimes call it the 24-hour flu. We both know that the influenza vaccine is a dead virus and cant give you the flu. It can, however, save you from the indignity of a horrible and debilitating illness, and it can help keep our patients alive, and it can reduce the possibility that you will experience coronary problems or stroke. Really, doesnt it make sense to be vaccinated?
All right, thats a little stiff, and I might say it slightly differently when I was face to face with someone, but you get the idea. Almost any health based argument for not getting the vaccine can be matched and led if you think through your responses to the usual statements. Remember though that your intent counts more than your technique. If you are genuinely concerned for their welfare and for the welfare of their patients, that intent will show through. So too will your intent show through if your primary objective is to get more people vaccinated than you did last year, to improve your statistics. Intent counts more than technique.
If your message is to be delivered to a broader audience than just one other person, then it should be framed appropriately. In their paper Shaping Perceptions to Motivate Healthy Behavior: The Role of Message Framing,1 Alexander Rothman and Peter Salovey note that the most effective message intended to motivate a healthy behavior will be framed as a gain. For example, it is more effective to say, The influenza vaccine will protect your income, or will improve your patients health outcomes, or will make it much less likely that you will lose time to sickness. A gain-framed message will note that the vaccinated person will gain something desirable or will avoid something that is undesirable. A less effective message would inform the unvaccinated person that if they dont get vaccinated they will lose out on desirable things and will have to suffer undesirable things.
Killing the messenger ... some acts of refusal surface because the people who are asking (demanding/pleading/nagging) them to get vaccinated are disliked or not respected for whatever reason and this is an opportunity to make those in authority squirm. After all, hospital administrators report their vaccination levels, and poor vaccination compliance can reflect poorly on that administration. In hospitals that have been through upheaval, a refusal to get vaccinated for influenza can be a statement of power, a line in the sand, preserving of self-respect. There is no simple solution to what is usually representative of a very complex organizational problem.
If there is the will to do so, opening a dialogue with the employee leaders (not leaders by position, but leaders by influence often the people who are both the loudest, and who whisper with other people the most) is a good step. Your position that the flu vaccination is something that they do for the benefit of themselves, their families, and their patients, not for the benefit of the administration might just sway their influence. If you can sell that position you will still have to work with those employee leaders to convince the other staff members, all the while weaving your influenza vaccine campaign into every corner of your facility, but you will have a tremendous ally.
If there is to be no negotiation, no seeing of the logic or the duty of healthcare workers to protect their patients, then all that you are left with is threats. What have you got in your arsenal? I make no suggestions. I hate to think that this might be necessary because it will further poison the relationships in the hospital. It must be an absolute last resort.
People also will opt out of taking a flu vaccine for religious reasons. Although I dont pretend to have an intimate knowledge of world religions, there is at least one that forbids interventions like immunizations. Dont argue against this reason. This is a huge issue involving religious freedom and discrimination and its not up to us to disagree. If your facility is struck with the flu, it is up to the administrators and hospital lawyers and even legislators to decide the best course of action. Our role is to maintain the relationship and open communication with those staff members who refuse for religious reasons.
Surely this is an important root cause of hesitation and refusal to get vaccinated. A study that I heard about, although have not yet seen, stated that the single largest obstacle to a successful vaccination program is the fear of needles. Im not too proud to admit that I am a bit of a needle-phobe. Even nurses and doctors are in this category (perhaps especially nurses and doctors since they get to see so often how others react to the needles administer). Find some vaccination specialists, brag about them endlessly, make them famous for their gentle, painless technique, and give them the thinnest possible needle. People who have received their injection from these stars need to be coached to spread the word of their skill. All of us fraidy cats will be lining up.
Fear is also a key influence factor in the power of peer pressure. Target the leader of the pack and do everything possible to get him or her immunized. Alternatively, when you are sending out information directly to your staff members, let them know where the community clinics are located and when they are open so that they can get their needle away from the hood.
Lastly, and most importantly, and I beg you to consider this carefully: stop calling it a flu shot. This is not just trivial nomenclature, this can make a big difference. With what do we associate the word shot? In our society, shot means violence gun shot, shot to the head. Shot means put-down humor He really nailed you with that shot! Shot means failure, disappointment, embarrassment - Oh man, did she ever get shot down! Shot means a loss I took a real financial shot! Other than a shot of some alcoholic substance, the word carries very little but bad karma. And we encourage people to get shot. Does it sound inviting to you? Youll notice that at no time in the writing of this article have I used the words flu shot (this paragraph excepted). The sooner everyone stops calling it that, the better our uptake will be.
Have you wondered what other hospitals do to increase their flu vaccination uptake among their staff? At my request, hospital infection control professionals and occupational health managers sent in descriptions of the strategies that they employ to promote the influenza vaccine.
I have separated the strategies into three core categories:
- Awareness and Visibility Strategies
- Carrot (incentive) Strategies
- Stick (punishment)
Strategies Awareness and Visibility Strategies find as many ways as possible to let people know what flu is, what vaccination means, and when and where they can get their flu needle. Carrot Strategies are toward gain strategies that reward staff members for getting immunized. Stick Strategies encourage staff to get their flu vaccine in order to avoid some sort of pain moral, financial, health, peer pressure, etc.
Many of the submissions from hospitals were dissected and divided between the three categories. Thanks to everyone who participated.
Awareness & Visibility Strategies
We have numerous flu clinics to cover all shifts at all of the St-Joseph sites (Parkwood, Marion Villa Mt Hope, Grosvenor site RMHC-L RMHC-ST ), plus educational sessions concerning benefits of taking vaccine; information on our intranet web sites concerning location of clinics, as well as information concerning flu vaccine. This information is also included in our Imprint newsletter for staff. We also have regular updates to leaders and staff concerning number of staff vaccinated as the flu campaign progresses.
Heather Newman, RN, COHN
Staff influenza vaccination programs are promoted by:
- Facility-wide posters
- Inter-hospital e-mail to all department heads to be posted for staff
- Overhead public service announcements during an immunization clinic
- Notices included with pay stubs for the pay period preceding a clinic
- Visiting high-risk areas with vaccine
- Holding inservices on the vaccine
- Bringing in experts to talk about vaccine
- Having administration receive theirs at a kick-off session
- Advertising in the facility newsletter
New staff are targeted when they return their health history questionnaire. Staff having titers done who are found susceptible are offered the vaccine. Periodic clinics to update staff vaccination are offered with similar, aforementioned notices. The mobile cart can be very successful, however it is often the personality, assertiveness, knowledge base and determination for success, of the individual administering the vaccine that determines the uptake. It can be costly if the uptake isnt there. Clinics are held to cover all shifts and in readily accessible locations, outside locker rooms or the cafeteria.
This is what we did last year and I thought we had a very good response:
- Publish the flu vaccination information in the bimonthly newsletter
- Scheduled days to vaccinate the staff while on duty on busy units (this was done on several shifts)
- Continuous announcement in the newsletter as to how much vaccine is left at staff health services
- Review compliance during annual visits if staff was ever sick with the flu.
As far as we know, no one reported getting the flu last season.
Sarah Alvarez, RN, BSN
The week we start giving the flu shots to the patients, a film made by public health regarding the vaccine is put on the patients televisions and staff sees bits and pieces while taking care of the patients. Inservices conducted by the infection control nurse are provided to the wards that request information about the flu shot. Handouts, which are made available through public health, are made available on each ward. Posters advertising the flu shot, which are given to us from public health, are posted throughout the hospital. It is announced hourly on the PA system that the vaccine is available in the staff health department. Nurses are hired to go to the wards on off hours so the vaccine is available on evening and nights for those who want it. Information is put on each table in the cafeteria reminding staff that the vaccine is available. Staff health, infection control nurse and nurse managers promote the vaccine. We also had a day that is open to staff and the public on the weekend in the auditorium to receive the flu shot.
We offer free flu vaccine to our employees, volunteers and 500 doses to individuals in the community. We always publicize the dates and times (given over a threeweek period, at different times to accommodate all shifts). Even though these are health care workers they still have some misconceptions about flu vaccine.
Barbara Jones and Peggy Morrison
Each year we start talking about the benefits of influenza vaccine early; we propose it at various committees such as infection control and safety, and at departmental and division meetings. Our employee health staff make up a cart and travel to individual units to immunize the healthcare providers on their own units; they take it to medical staff meetings and even wait for some committee meetings to end to catch people as they leave. Notices are sent out frequently to the system reminding employees about the flu vaccine. Overall, we break our record each year for participation. I cant say that with immunizations we get much resistance. People will generally do what they can to promote/protect their own health. I think the key is continuous education, both formal and informal and then continue to monitor. The approach has to be seen to be of their benefit and the benefit of patient safety. People today have lots of questions they want to be convinced. Back up your teaching with scientific fact, regulatory guidelines theyre hard to argue with. Most importantly, keep in mind that you will never win every battle so pick your issues to fight for, accept frustration as a part of life and part of what we do but dont let it overtake you and keep plugging along. Lastly, brainstorm with your colleagues were all in this together!
Mary M. McNally RN CIC
We have a poster campaign with photos of different staff in some funny and serious photos that include detailed schedule on a calendar. Most important of all, go when and where the staff are. Be in their face! Meet them early in the morning going and coming from work, in the evening and on weekends. Work in conjunction with infection control. It shares the load.
There are no hidden secrets but perseverance! I have provided vaccinations to staff for many years and each year the numbers increase. The biggest success that I have is through the Flu Mobile which is just a cart that I wheel around the facility most afternoons for a couple of weeks (takes about an hour a day), as well as an open-door policy that allows people to pop in when they can (provided Im available). I make announcements over the PA as a reminder. Other things help, like posters/notices/tent cards/paystub attachments, but accessibility has got to be the key. Often I hear from staff, I just cant get away so I bring it to them. In 2001 my goal was to immunize greater than 50 percent of staff and I ended up with 62 percent (165 of 267 staff). Another important point is to dispel the myths about I was sicker from the vaccine then I have ever been from the flu. Get those naysayers in a group and debate the issue. And recruit those who have received for many years to tell their story.
Carrot (incentive) Strategies
I think the most novel approach I heard was one hospital calling their flu shot immunization program Beer and shots. They provided free root beer to all flu shot recipients. The most effective but most time-consuming strategy for those giving the shots is to tour your hospital and give the shots in the employees work area.
We offer drawings for a day off with pay, tickets to sporting events, T-Shirts and sports bags, as well the local health unit offering prizes.
The best year was a poster that said, Who Wants to be a Millionaire? Anyone who signed up to come for a flu shot had a $1 lotto ticket waiting for them after their shot. The staff were pretty excited and we had a great turnout. It only cost a dollar per staff member for the ticket. Once they got going with their shot and saw that it wasnt so bad after all; then the following years they just came without the bribery.
I have dressed up as a Germbuster and used a traveling cart to go from department to department. This works if you have a strong advocate for immunization in that department but can just as easily backfire if you have someone who is very vocal against it. Have all participants enter their name for a daily and weekly and overall draw for prices. Have used immunization or infection control promotional materials (mugs, pens, etc.) for prizes. We also bought things like fancy boxes of chocolates/candy and Christmas ornaments. A gift certificate for a popular restaurant also works. We have had free coffee, donuts, cookies, or candy available for those who attend. Give staff a sticker or button to wear after receiving the vaccine as positive reinforcement of the program and a friendly reminder for their coworkers. One needs the full support of management and some extra funds to make this program a success.
For the most part, people do not want the flu shot because they do not like needles. I use a 25 gauge needle and always change after withdrawing from the vial so it is very sharp. Their arms might hurt after but if they dont feel the needle going in they are very relieved. Also the needle is 1.5 inches long (I vary the depth of insertion based on the size of the person and the depth of the muscle); some think that a superficial needle would cause less pain but actually if the vaccine is distributed properly in the deep muscle tissue it causes much less pain. Be accessible, be honest and know the correct answers, give a good needle (it helps to chatter aimlessly when inserting). Set goals and celebrate when you reach them; we have cake or donuts, sometimes door prizes. I almost forgot the suckers Lifesaver suckers I think there would be mutiny if they didnt get a sucker with their needle!
I try very hard to target a few influential staff at all levels of the hierarchy. I work on these people to convince by reason, education or cajoling, harassment or flattery whatever it takes to gain a positive outlook on immunization. The influential person should be someone other than an ICP or occupational health nurse, someone who is positive about it all, and has a tremendous influence for good on their peers. It would seem a lot of people who refuse the vaccine seem to do so just to assert their independence. It is human nature, I guess. Very few of these people have a good grasp of the real facts around immunization. I have a handful of people who have experienced influenza first hand and these people are now first in line for their flu shot each year. I gently cultivate these people. A soft hand and personal testimonial carries a lot of weight.
Stick (punishment) Strategies
We distribute literature covering ethical reasons for getting vaccines, i.e., a duty of care, and we show videos about previous pandemics when many people died worldwide.
Mary Lou Martsinkiw
The worst that can happen is for a well-respected nurse/HCW to claim that she got the flu from the vaccine. There is much research to prove that it just cant happen and I work hard to dispel those notions. The best that can happen is for a well-respected nurse/HCW to get the flu (when they havent received the vaccination) they then become loyal supporters as they Do not ever want to be that sick again. I also play up the fact that we do not want to prevent the HCW from getting sick but rather we want to prevent them from getting sick and then bringing it to the hospital where it will jeopardize the health of their patients. Its not about sick time, which is what many think its about those who cant fight off influenza. Militancy and heavy resistance has been worn down to the point where they are the minority and thus much quieter.
We leaned on managers heavily to get their staff immunized. Managers are accountable during a declared outbreak to have only immunized staff working. They received weekly lists from occupational health of immunized, and non-immunized staff and their percentage of immunized staff.
Paul Webber is director of Webber Training, a provider of teleclass education on infection control and public health.