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By Paul Webber
Approximately 19 percent of any NorthAmerican population has experienced the flu or know someone who has and willforever get vaccinated to avoid that experience. Telling them about thenecessity for the vaccine is preaching to the choir. Its the other 81 percentthat have to be bribed, threatened or otherwise persuaded to roll up theirsleeves every October. Many of those people work in your hospital.
This article will explore the psychological foundations of why some of the 81percent of your staff resist the flu vaccine so vehemently, and will providesome suggestions from the trenches on specific workable strategies thatothers have used to increase their staff vaccination success rate.
The original request for this project came from Christine Cameron inCornwall, Ontario, and many people in Canada and the United States (and inseveral other countries) have contributed and continue to contribute to theinformation that follows.
The Psychology of Refusal
It seems like a no-brainer. Front-line healthcare professionals, particularlyphysicians and nurses, should take whatever precaution is reasonable to protectthe 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 theirminds that is sufficiently compelling to force them to this action (ornonaction). 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 fluimmunization if it is made supremely convenient for them to do so, but who wontgo out of their way to get vaccinated.
The excuses are many: The flu vaccine will make me sick. I dontput foreign substances into my body. I dont ever get sick, so whyshould I get vaccinated? My naturopath told me that it is not necessary.I have an allergy to eggs. These specific statements and other similararguments against the vaccine are health concerns. The last one, an allergy toeggs, is acceptable and verifiable. For all the others, the solution isinformation based and might call on your powers of persuasion. No amount ofbribery, pleading or pretty posters will sway these workers, particularly iftheir ego and self-worth are drawn from the strength of their resistance.
Strategies to approach these workers should include a large component ofpersonal interaction. Flu-season inservices to dispel myths are effective forthose with only mild anti-vaccine convictions. One-on-one meetings with experts(thats you), and peer interventions by coworkers who are firmly in favor ofthe flu vaccine are also good strategies for those who are more solidified intheir position. Third-party evidence will be required. The evidence needs to beauthoritative, unequivocal and absolutely unavoidable. Copies of good information can be sent in payroll packets, by e-mail, by mailto the workers homes, posted on bulletin boards, left in staff lounges and onthe 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 healthagency, from your province/state, or from the Centers for Disease Control andPrevention (CDC). If all else fails, contact me and Ill share what Ive gotwith 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 thatthey knew someone who never got the flu until they got the flu vaccine, and itsreasonable to be hesitant under those circumstances.
You (lead): Can we agree that not everyone gets sick after gettingvaccinated? Maybe those people who got sick gave themselves food poisoning or caught acold. In fact, studies show that almost all of us get at least one bout of mildfood poisoning every year and we sometimes call it the 24-hour flu. We both knowthat 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, andit can help keep our patients alive, and it can reduce the possibility that youwill experience coronary problems or stroke. Really, doesnt it make sense tobe vaccinated?
All right, thats a little stiff, and I might say it slightly differentlywhen I was face to face with someone, but you get the idea. Almost anyhealth based argument for not getting the vaccine can be matched and led if youthink through your responses to the usual statements. Remember though that yourintent counts more than your technique. If you are genuinely concerned for theirwelfare and for the welfare of their patients, that intent will show through. Sotoo will your intent show through if your primary objective is to get morepeople vaccinated than you did last year, to improve your statistics. Intentcounts more than technique.
If your message is to be delivered to a broader audience than just one otherperson, then it should be framed appropriately. In their paper Shaping Perceptions to Motivate Healthy Behavior: The Role of Message Framing,1Alexander Rothman and Peter Salovey note that the most effective messageintended 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 muchless likely that you will lose time to sickness. A gain-framed message willnote that the vaccinated person will gain something desirable or will avoidsomething that is undesirable. A less effective message would inform theunvaccinated person that if they dont get vaccinated they will lose out ondesirable things and will have to suffer undesirable things.
Killing the messenger ... some acts of refusal surface because the people whoare asking (demanding/pleading/nagging) them to get vaccinated are disliked ornot respected for whatever reason and this is an opportunity to make those inauthority squirm. After all, hospital administrators report their vaccinationlevels, and poor vaccination compliance can reflect poorly on thatadministration. In hospitals that have been through upheaval, a refusal to getvaccinated 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 usuallyrepresentative 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 areboth 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 thebenefit of themselves, their families, and their patients, not for the benefitof the administration might just sway their influence. If you can sell thatposition you will still have to work with those employee leaders to convince theother staff members, all the while weaving your influenza vaccine campaign intoevery 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 ofhealthcare workers to protect their patients, then all that you are left with isthreats. What have you got in your arsenal? I make no suggestions. I hate tothink that this might be necessary because it will further poison therelationships 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. Dontargue against this reason. This is a huge issue involving religious freedom anddiscrimination and its not up to us to disagree. If your facility is struckwith the flu, it is up to the administrators and hospital lawyers and evenlegislators to decide the best course of action. Our role is to maintain therelationship and open communication with those staff members who refuse forreligious reasons.
Surely this is an important root cause of hesitation and refusal to getvaccinated. A study that I heard about, although have not yet seen, stated thatthe single largest obstacle to a successful vaccination program is the fear ofneedles. 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 anddoctors since they get to see so often how others react to the needlesadminister). Find some vaccination specialists, brag about them endlessly, makethem famous for their gentle, painless technique, and give them the thinnestpossible needle. People who have received their injection from these stars needto be coached to spread the word of their skill. All of us fraidy cats willbe lining up.
Fear is also a key influence factor in the power of peer pressure. Target theleader of the pack and do everything possible to get him or her immunized.Alternatively, when you are sending out information directly to your staffmembers, let them know where the community clinics are located and when they areopen 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, thiscan make a big difference. With what do we associate the word shot? In oursociety, 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 getshot down! Shot means a loss I took a real financial shot!Other than a shot of some alcoholic substance, the word carries verylittle but bad karma. And we encourage people to get shot. Does it soundinviting to you? Youll notice that at no time in the writing of this articlehave I used the words flu shot (this paragraph excepted). The soonereveryone stops calling it that, the better our uptake will be.
Have you wondered what other hospitals do to increase their flu vaccinationuptake among their staff? At my request, hospital infection controlprofessionals and occupational health managers sent in descriptions of thestrategies that they employ to promote the influenza vaccine.
I have separated the strategies into three core categories:
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 thethree categories. Thanks to everyone who participated.
Awareness & Visibility Strategies
We have numerous flu clinics to cover all shifts at all of the St-Josephsites (Parkwood, Marion Villa Mt Hope, Grosvenor site RMHC-L RMHC-ST ), pluseducational sessions concerning benefits of taking vaccine; information on ourintranet web sites concerning location of clinics, as well as informationconcerning 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 staffvaccinated as the flu campaign progresses.
Heather Newman, RN, COHN
Staff influenza vaccination programs arepromoted by:
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 avery good response:
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 tothe patients, a film made by public health regarding the vaccine is put on thepatients televisions and staff sees bits and pieces while taking care of thepatients. Inservices conducted by the infection control nurse are provided tothe wards that request information about the flu shot. Handouts, which are madeavailable 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 thatthe vaccine is available in the staff health department. Nurses are hired to goto the wards on off hours so the vaccine is available on evening and nights forthose who want it. Information is put on each table in the cafeteria reminding staff that thevaccine is available. Staff health, infection control nurse and nurse managerspromote the vaccine. We also had a day that is open to staff and the public on the weekend in theauditorium 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, atdifferent times to accommodate all shifts). Even though these are health careworkers they still have some misconceptions about flu vaccine.
Barbara Jones and Peggy Morrison
Each year we start talking aboutthe benefits of influenza vaccine early; we propose it at various committeessuch as infection control and safety, and at departmental and division meetings.Our employee health staff make up a cart and travel to individual units toimmunize the healthcare providers on their own units; they take it to medicalstaff meetings and even wait for some committee meetings to end to catch peopleas 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. Ithink the key is continuous education, both formal and informal and thencontinue to monitor. The approach has to be seen to be of their benefit and thebenefit of patient safety. People today have lots of questions they want to be convinced. Back up your teaching with scientific fact, regulatory guidelines theyrehard to argue with. Most importantly, keep in mind that you will never win everybattle so pick your issues to fight for, accept frustration as a part of lifeand 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 ofdifferent staff in some funny and serious photos that include detailed scheduleon 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 onweekends. Work in conjunction with infection control. It shares the load.
There are no hidden secrets but perseverance! Ihave provided vaccinations to staff for many years and each year the numbersincrease. 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 acouple of weeks (takes about an hour a day), as well as an open-door policy thatallows people to pop in when they can (provided Im available). I makeannouncements over the PA as a reminder. Other things help, likeposters/notices/tent cards/paystub attachments, but accessibility has got to bethe key. Often I hear from staff, I just cant get away so I bring it tothem. In 2001 my goal was to immunize greater than 50 percent of staff and Iended up with 62 percent (165 of 267 staff). Another important point is todispel the myths about I was sicker from the vaccine then I have ever beenfrom the flu. Get those naysayers in a group and debate the issue. Andrecruit 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 flushot immunization program Beer and shots. They provided free root beer toall flu shot recipients. The most effective but most time-consuming strategy forthose giving the shots is to tour your hospital and give the shots in theemployees work area.
We offer drawings for a day off with pay, tickets tosporting events, T-Shirts and sports bags, as well the local health unitoffering prizes.
The best year was a poster that said, Who Wantsto be a Millionaire? Anyone who signed up to come for a flu shot had a $1lotto ticket waiting for them after their shot. The staff were pretty excitedand we had a great turnout. It only cost a dollar per staff member for theticket. Once they got going with their shot and saw that it wasnt so badafter all; then the following years they just came without the bribery.
I have dressed up as a Germbuster and used atraveling cart to go from department to department. This works if you have astrong advocate for immunization in that department but can just as easilybackfire if you have someone who is very vocal against it. Have all participantsenter their name for a daily and weekly and overall draw for prices. Have usedimmunization or infection control promotional materials (mugs, pens, etc.) forprizes. We also bought things like fancy boxes of chocolates/candy and Christmasornaments. A gift certificatefor 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 aspositive reinforcement of the program and a friendly reminder for theircoworkers. One needs the full support of management and some extra funds to makethis program a success.
For the most part, people do not want the flu shotbecause they do not like needles. I use a 25 gauge needle and always changeafter withdrawing from the vial so it is very sharp. Their arms might hurt afterbut if they dont feel the needle going in they are very relieved. Also theneedle is 1.5 inches long (I vary the depth of insertion based on the size ofthe person and the depth of the muscle); some think that a superficial needle would cause less pain but actually ifthe vaccine is distributed properly in the deep muscle tissue it causes muchless pain. Be accessible, be honest and know the correct answers, give a goodneedle (it helps to chatter aimlessly when inserting). Set goals and celebratewhen you reach them; we have cake or donuts, sometimes door prizes. I almostforgot the suckers Lifesaver suckers I think there would be mutiny ifthey didnt get a sucker with their needle!
I try very hard to target a few influential staff atall levels of the hierarchy. I work on these people to convince by reason,education or cajoling, harassment or flattery whatever it takes to gain apositive outlook on immunization. The influential person should be someone other than an ICP or occupationalhealth nurse, someone who is positive about it all, and has a tremendousinfluence for good on their peers. It would seem a lot of people who refuse thevaccine seem to do so just to assert their independence. It is human nature, Iguess. Very few of these people have a good grasp of the real facts aroundimmunization. I have a handful of people who have experienced influenza first hand andthese people are now first in line for their flu shot each year. I gentlycultivate these people. A soft hand and personal testimonial carries a lot ofweight.
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 whenmany people died worldwide.
Mary Lou Martsinkiw
The worst that can happen is for awell-respected nurse/HCW to claim that she got the flu from the vaccine. Thereis much research to prove that it just cant happen and I work hard to dispelthose notions. The best that can happen is for a well-respected nurse/HCW to getthe flu (when they havent received the vaccination) they then become loyalsupporters as they Do not ever want to be that sick again. I also play upthe fact that we do not want to prevent the HCW from getting sick but rather wewant to prevent them from getting sick and then bringing it to the hospitalwhere it will jeopardize the health of their patients. Its not about sicktime, which is what many think its about those who cant fight offinfluenza. Militancy and heavy resistance has been worn down to the point wherethey are the minority and thus much quieter.
We leaned on managers heavily to get their staffimmunized. Managers are accountable during a declared outbreak to have only immunizedstaff 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 WebberTraining, a provider of teleclass education on infection control and publichealth.