Relay for Life

I know many people that have been affected by cancer. I am supporting the American Cancer Society by participating in the relay for life. I hope someone reading or exploring this blog will find it in your heart to donate to this worthy cause. No matter how small or large it will be greatly appreciated. Click here to go to my page and learn more. Thank you.

HGT1 Community Health Nursing

My Practicum can be viewed in my other blog Vickie Views

I choose Disaster Preparedness. Living in Florida and working at a coastal hospital for over 20 years as both a LPN and a RN, I volunteered on our team. We had mock disasters from train derailments, chemical spills, hurricanes, and plane crashes. I had fun practicing setting up decontamination tents and putting on the "zoot suit". Thankfully I never had to use what I learned in real life.
I hope this helps demonstrate the format required in the paper.

EBT1 Task 2 Research Integration

EBT1 Task 2 Research Integration

Victoria Hart

Western Governors University

A. Review of the Sources of Evidence

Name of Source Author	A1. Types of Sources of Evidence	A2. Appropriateness of Sources of Evidence	A3. Classification of Sources of Evidence
In text citation	Classify the type of each source of evidence as either a general information resource, a filtered resource, or an unfiltered resource.	Discuss whether each source of evidence is appropriate for this nursing practice situation.	Classify each source of evidence as primary research, evidence summary, evidence-based guideline, or none of these.
("Diagnosis and management," 2004)	This source is a filtered resource as it identifies a question of whether to wait to treat acute otitis media or to initiate antibiotic therapy immediately.	This source is appropriate for this nursing practice situation. It is peer reviewed and received formal approval by partnering organizations. This study is data 2004 therefore a more current source may be of value to support of dispute the recommendations and opinions of this guideline.	This source is an evidenced based guideline.
(Block, 1997)	This is a filtered resource as the author identifies the problem of resistance to antibiotic therapy and provides a summary of the most effective course to therapy.	This source is inappropriate for this nursing practice. It is dated 1997, the research is not current however the results support the trend of the resistance to antibiotics in causative organisms. There is no research on waiting to initiate treatment	This source includes primary research and an evidence summary
(Kelly, Friedman & Johnson, 2007)	This source is general information as it is from a textbook.	This is an appropriate source for the practice as it provides the background information to explain the practice guideline.	This source is an evidence-based guideline
(McCracken, 1998)	This source is a filtered resource as it contains information that can help decide a course of action in response to a problem.	This is an appropriate source for the practice as it provides research data and information to explain the potential evidence practice guideline.	This source is a primary source.
Interviews	Interviews are general information.	Interviews are appropriate as they provide the current beliefs of the parents of the children being treated in the clinic. It is important to evaluate this source to determine how implementation will be achieved.	This source is a primary. It is research conducted by the clinic staff.

B1. Watchful Waiting

Watchful waiting is an appropriate approach for treating children under certain conditions base on the article “Clinical Practice Guideline”. This article gives the evidence-based statement that allowing 48-72 hours before prescribing antibiotics is an option to be considered by clinicians. Included in this study are children up to age 12. The observation option applies to the children greater than age 2, without other chronic illnesses or anatomic abnormalities. The recommendation was based on placebo controlled trails that spanned 30 years. This article includes results the AHRQ evidence-report, the Dutch College of General Practitioners guidelines, and a randomized trial in the United Kingdom as part of the evidence in making the recommending. In conclusion it is imperative to ascertain the history of acute onset, to identify signs of middle ear effusion or inflammation, the child must be within the appropriate age, the severity of the illness must be considered and an assurance of follow-up obtained ("Diagnosis and management," 2004).

C. Application of Findings

The process of applying the findings in “Diagnosis and management of acute otitis media” into practice would include education of the clinical staff. A team to implement the change should be created, a team leader should be appointed to help educate and gain acceptance of the evidenced-based guideline. This includes education of the entire staff and cliental. The physicians must agree to the change. A pilot group should be formed to implement the new guidelines; this will allow for adjustments or added education to be put into place. Collect benchmarks of current success rates and re-occurrences of acute otitis media (AOM) to compare with the EBG once implemented. Rolling out new treatment recommendations in increments will make it easier for the staff and clients to adjust and accept the change; it will also provide the opportunity to make any necessary adjustments. Communicating the change and the rationale to the parents of the children affected by the practice will gain their support and understanding providing compliancy with follow-up evaluation. A policy outlining criteria to be implemented will solidify the change as a standard of practice within the organization. (Titler, M.G., 2008)

D. Ethical Issues

The three main ethical concerns of research studies are autonomy, beneficence, and justice. Autonomy recognizes the participant is capable of giving informed consent. This includes a thorough explanation of the benefits and risks. Beneficence includes protecting the participant’s privacy and confidentiality, providing information that may arise during the course of the study to protect or prevent harm and maintaining the safety of the participant. Justice provides compensation for the participation in the study in the event they were in a group that did not receive the best treatment or in the event that their condition worsened as a result of the study. (Callahan & Hobbs, October)

D1. Issues

Vulnerable populations include various ethnic groups, the elderly, prisoners, handicapped individuals, mentally ill or handicapped, prisoners, women, poverty stricken and children. It is required that information is presented in a language that is understandable to them. Confidentiality must be guaranteed, they have the right to refuse or withdraw from the study at anytime. Any questions that are asked by them must be answered in a manner that they understand. Under no circumstances may they be harmed or exploited. (Gaines, 2006)

Face flu facts | Nurse.com News

Face flu facts | Nurse.com News

Drug Calculations

http://www.dosagehelp.com/I found this link to be very helpful when studying. I hope it will benefit someone else.

EBT1 TASK 3 Research Integration and Outcome Evaluation

EBT1 TASK 3 Research Integration and Outcome Evaluation

Victoria Hart

Western Governors University

A1. Procedure

 The preoperative procedure of shaving the operative site with a razor has been proven to be a source of surgery site infections. Studies have shown shaving creates micro abrasions that permit bacteria to penetrate the area and infect the wound. The CDC guidelines recommend not removing the hair unless it will interfere with the procedure, if the hair must be removed clipping immediately prior to the surgery is recommended (Segal, C., 2006).

A2a. Basis for Practice

  The basis for changing the method of removing hair at the operative site was due to the results of much research on surgical site infections (SSI) as well as the recommendations from the Center for Disease Control and Prevention (CDC) and The Joint Commission on Hospital Accreditation (TJC). The Hospital Infection Control Practices Advisory Committee published Guideline for Prevention of Surgical Site Infection in 1999. TJC included reducing the risk of healthcare associated infections as one of the national safety goals in 2008 (Waddington, C., 2008).

At the hospital the Infection Control, Performance Improvement, and Patient Safety committees made the recommendation for the change from shaving the patient with razors to only removing hair with clippers and only if necessary. The service line directors of nursing and surgical surgery were responsible for implementing this change after the approval of the hospital administration.

A2b. Rationale

 Antisepsis was introduced in 1860 and resulted in the transformation of surgery. The CDC National Nosocomial Infections Surveillance (NNIS) began tracking nosocomial infections the 1970s. Based on this data more trends were identified. SSIs are responsible for approximately one third of all nosocomial infections (Mangram, Horan, Pearson, Silver, & Jarvis, 1999).

Several characteristics were identified as causative factors that increase the risk of SSIs. Preoperative shaving was identified as one of those causes. Unlike factors that cannot be modified such as the patient’s age changing the way a patient is prepared for surgery can be altered.

A2c. Explanation

 Originally in the early nineteenth century surgeons removed hair to prevent it from falling into the wound or to allow them to visualize the operative area clearly. Later around 1850’s surgeons removed the hair because they believed it caused infection from the bacteria that inhabited the hair. In 1927, Dr. Walter Hughson recognized the risk of shaving with a razor with his description of the condition of the operative site being worse than if the hair remained present (Altman, 1983). The result of a Nigerian study of third world country surgical practices conducted by Adisa, Lawal, & Adejuyigbe in 2010 concluded that depilatory cream is safer than razors. It was concluded by multiple studies depilatory cream can cause skin irritation; therefore the 1999 CDC guideline excluded this method of hair removal. The current recommendation in the United States is for no hair removal or clipping immediately prior to surgery.

A3a. Reference List

Adisa, A., Lawal, O., & Adejuyigbe, O. (2011). Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection. Journal Of Infection In Developing Countries, 5(10), 717-722.

Altman, L. K. (1983, June 21). The doctor's world; shaving area of operation now seems dangerous. The New York Times. Retrieved from http://www.nytimes.com/1983/06/21/science/the-doctor-s-world-shaving-area-of-operation-now-seems-dangerous.html

Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for prevention of surgical site infection. Infection Control Hospital Epidemiology, 20(4), 205-178.

Segal, C. (2006). OR special. Infection control: start with skin. Nursing Management, 37(4), 46-52.

Waddington, C. (2008). Changing behavior: evidence based practice supporting hair removal with clippers. ORL Head Neck Nurs, 26(4), 8-12.

A4. Clinical Implications

Clinical implications of shaving verses clipping may greatly reduce the rate of SSI resulting in improved patient safety, shorter hospital stays and lower costs for care. In each of the studies and literature reviewed the results were significant in the difference between rates of infection with the patients shaved with at razor as opposed to those clipped.

The comfort of the patient with this practice is improved as the risk of micro abrasions are decreased with clippers. The anxiety of the patient is substantially less in cases that require hair removal in vulnerable areas such as the groin with clippers.

The cost to the health care industry will be reduced as the cost of disposable razors is eliminated. The cost of treating infections is reduced as a result of fewer infections. 

Areas of the hospital impacted by this change are significant. The purchasing department must research the cost of clippers; order the correct equipment whether it is reusable or disposable as many patients require preoperative shaving and removal of any kits containing razors. The nursing staff must be educated to the new practice. This includes the operating staff and the surgical care unit staff. Physicians must accept the evidence based recommendation that not all patients have hair removal. Pre-operative printed educational literature for patients must be changed to reflect the new process.

A5. Procedural Changes

By removing the practice of shaving surgical sites with razors infection rates will be decreased. “The infectious rate was significantly higher in the manually shaven than in the electrically clipped patients with an odds ratio of 3.25%” (Ko, Lazenby, Zelano, Isom & Krieger, 1992). By decreasing wound infections, patient discomfort, morbidity and cost of care will decrease significantly (Adisa, Lawal, & Adejuyigbe, 2011). The CDC has recommended hair not be removed unless absolutely necessary (Segal, 2006).

A cited study in the Hospital Infection Control Practice Advisory Committee states SSI rates for hair removal by razor was 5.6% as opposed to 0.6% rate for patients that had hair removed with a depilatory cream or not removed. The timing of hair removal is an important factor in SSI, shaving done greater than 34 hours before surgery increased the rate more than 20%. Additional studies show hair removal by any method increases infection rates. (Mangram, Horan, Pearson, Silver, & Jarvis, 1999)

Based on the research presented, by eliminating preoperative hair removal except when it would interfere with the surgical procedure, we can significantly reduce SSI. This will provide a greater safety to the patient, a cost savings to the organization and increased revenue to the hospital.

A6. Stakeholders

Once administration has approved the evidence based practice recommended change, department managers must be informed and educated to the rationale of changing the procedure. Beginning with the purchasing department, the necessary equipment must be obtained. They must understand the desired practice change to identify the proper equipment and help establish a time line and what education may be necessary. The education department will provide educational in-services to explain the change to the nursing staff. They will need all of the evidence to create the necessary education to the staff. The staff must understand and accept the change. The front line staff is the one educating and helping patients understand their surgical care. The medical staff director will provide education and buy-in from the physicians and surgeons. Infection Control nurses can be influential in providing up to date statistics of our SSIs with easy to read graphs and posters in strategically located places. By showing the trend of lower SSIs acceptance of the change will be increased.

B1. Translation of Research

Shaving the operative site has been a practice in hospitals as far back as the nineteenth century. It has been noted by many great practitioners that bacteria inhabit the hair and has a role in causing infection. This particular practice is clearly understood and the theory has been proven in many medical studies. What may be difficult is explaining to others why the practice of not removing the hair is the best method of infection prevention. A PowerPoint presentation with statistics, photos, and references will be the best method of translating the research to others. Creating a multidisciplinary team to disseminate the information to other departments will assist synthesizing the conclusions and recommendations into our organizational procedure. By creating a team to institute this change the understanding at difference levels and in various departments will be more effective.

B2. Barriers

Possible barriers to instituting this change based on the evidence-based study are physician refusal to accept the change in practice. Shaving the hair from a surgical site has been done for centuries, beginning with a straight razor. Physicians that have a routine may be resistant to change believing it may hinder their outcome or impair their ability to perform the operation. Nursing staff may be hesitant to accept the change due to lack of understanding the research and evidence fearing they may impair their patient’s outcome. Operating room staff may be concerned with delays due to the surgical site possibly needing to be clipped.

In any situation involving change people can be resistive; in the operating room confidence in the accuracy of the research is paramount to accepting new procedures. 

B3. Strategies.

Communication, understanding and education are the key strategies to help institute a change. A gradual transition by providing old and new methods of hair removal and recommendations to avoid hair removal if at all possible will make the change easier to implement. Department champions are able to gain acceptance within departments as they are trusted peers.

B4. Application of Findings

              SSIs are responsible for approximately one third of all nosocomial infections (Mangram, Horan, Pearson, Silver, & Jarvis, 1999). The CDC guidelines recommend not removing the hair unless it will interfere with the procedure, if the hair must be removed clipping immediately prior to the surgery is recommended (Segal, C., 2006). TJC included reducing the risk of healthcare associated infections as one of the national safety goals in 2008 (Waddington, C., 2008). By decreasing wound infections, patient discomfort, morbidity and cost of care will decrease significantly (Adisa, Lawal, & Adejuyigbe, 2011). Based on the evidence presented over the last couple of decades it has been shown the age old practice of shaving hair from the operative site has a direct impact on SSIs. Current practice recommendation guidelines written 1999 from Hospital infection Control Practices Advisory Committee have been implemented by the accreditation committee TJC. “The Center for Medicare and Medicaid Services (CMS) MS will continue to work collaboratively through consensus processes, such as those of the Hospital Quality Alliance(HQA), National Quality Forum (NQF), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), to coordinate measures and implementation of the Value Based Purchasing (VBP) program” (CMS Hospital Pa y-for-Performance Workgroup , 2007).

References

Adisa, A., Lawal, O., & Adejuyigbe, O. (2011). Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection. Journal Of Infection In Developing Countries, 5(10), 717-722.

CMS Hospital Pa y-for-Performance Workgroup U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services. (2007). Medicare hospital value-based purchasing plan development (1st Public Listening Session). Retrieved from website: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/downloads/hospital_VBP_plan_issues_paper.pdf

Freshwater, D. (2003). Understanding and implementing clinical nursing research. Blackwell Publishing, Ltd., Retrieved from http://www.icn.ch/images/stories/documents/networks/Research/48751_4th_proof.pdf

Ko, W., Lazenby, W., Zelano, J., Isom, O., & Krieger, K. (1992). Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. The Annals Of Thoracic Surgery, 53(2), 301-305.

Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for prevention of surgical site infection. Infection Control Hospital Epidemiology, 20(4), 205-178.

Segal, C. (2006). OR special. Infection control: start with skin. Nursing Management, 37(4), 46-52.

Tanner, J., & Khan, D. (2008). Surgical site infection, preoperative body washing and hair removal. Journal Of Perioperative Practice, 18(6), 232.

Influenza Vaccination EBT1 Task 1

Influenza Vaccination EBT1 Task 1

Victoria Hart

Western Governors University

Critique of a Nursing Research Article

A1. Article

Friedl, A. A., Aegerter, C. C., Saner, E. E., Meier, D. D., & Beer, J. J. (2012). An intensive 5-year-long influenza vaccination campaign is effective among doctors but not nurses. Infection, 40(1), 57-62. doi:http://dx.doi.org/10.1007/s15010-011-0193-6

A2. Graphic

(A2)  Background Information	The stated purpose of the article was to increase vaccination rates among physicians and nurses in the hospital setting. Specific interventions, education and availability, were put in place for five years. Vaccination rates were tracked for a targeted group, physicians and nurses. The study was conducted in a teaching hospital for the intervention time frame, 2003-2007, and for a follow-up time period, 2008-2009. During the study there was an avian influenza threat, 2005, and the H1N1 pandemic in 2009, the data showed an increase in vaccination in both groups, significantly higher with physician vaccination.
(A2) Review of Literature	Multiple reputable references provide statistics and facts during the time period of this study. Influenza risks, as well as the risks and benefits of influenza vaccination are well presented as evidence of the problem in the introduction; however there is not a separate review by the author after the introduction and before the methodology. The researches in this article reference material spanning when the collection of data began in 2003 and concluded in 2009 providing current supportive information.
(A2) Methodology	This longitudinal quantitative descriptive study of the sample group compared annual rates between physicians and nurses. The statistics analyzed included the number of individuals vaccinated and the rationale for the staffs’ decision to either accept or decline the vaccination.
(A2) Data Analysis	The researchers started with a quantitative study using a descriptive design and expanded this into a more complex correlational design by expanding the analysis of the data from the effectiveness of interventions to the effect of the Avian Influenza and H1N1 out breaks during the study. The researchers further analyzed the data to determine which group of staff vaccination increased with interventions and rated the arguments given for non-responding nurses.
(A2) Conclusion	Results were summarized and the overall conclusion was clearly stated. The vaccination rate did not significantly increase with the interventions overall, there were higher vaccination rates during the avian and H1N1 outbreaks. The study showed the vaccination rate for the physician group did increase with the intervention; however it did not increase the rate with nurses. There was a flaw in the design of the study; staff that may have been vaccinated elsewhere were not accounted in the total vaccination rate. The number one reason nurses gave for not receiving the vaccination was a fear of the side effects. The main reason given for vaccination was perception of severity of illness as evidenced by the rate increase for the years of the Avian and H1N1 Influenza outbreaks.

A 3. Analysis of Five Areas

Based on the data collected and presented in this study, an accurate conclusion by the researchers has been made. This conclusion is further supported in their referenced literature from similar studies in Europe. In addition to the intended study, vaccination data from the Avian and H1N1 Influenza outbreaks during the study period provided supplementary information regarding motivating factors for vaccination, and a comparison of vaccination rates. It is feasible the lack of data about the staff that may have received their vaccination from other providers skewed their results; this possibility was stated in the research literature. Taking into account the possibility the data did not include all of the vaccinated staff the results still correlate with other similar studies in the region. Unfortunately the data does support their hypothesis; it does however support their conclusion.

A 4. Ethical Issues

Consent was obtained from the Internal Review Board (IRB) of the hospital by the research team for this study. Both clinical and non clinical staff were offered the influenza vaccination with the same interventions therefore the opportunity to protect one’s health was not discriminatory. Education, opportunity, and availability provided were unbiased, financial disclosure of a grant to fund the study to Jurg H Beer by the Swiss National Foundation of Science (SNFS) was provided. Statistical analysis of the study was performed by an independent professor that was not part of the research team thus eliminating bias.

A 5. Type of Research

Descriptive statistical methods were listed as the primary method of research by the researchers. The rationale for this method provided by the researchers was due to the lack of individual data and the fact that some individuals were included in more than one campaign. This was a retrospective, longitudinal study. There were seven identified periods of time included in the research period that data was collected, analyzed and compared for the final conclusion.

The data gathered was primary. This included actual number of individuals vaccinated as well as survey questionnaires to identify reasons the vaccine was declined and motivational factors leading to their acceptance of the vaccination.

a. Appropriate type of research? The type of research was appropriate for this study. Other similar studies utilized this method of research. A control group that was not offered the incentives may have provided a comparative end result to determine if the interventions instituted were impactful in the decision of the group to accept vaccination.

B. Literature Search

B 1. Identification of a Nursing Problem

Influenza infection is a significant risk to patient safety in the care setting. Unvaccinated healthcare staff can be a source of nosocomial influenza infection to the patients and can create a healthcare provider shortage if the healthcare provider becomes ill. One or more interventions may provide an increase in the rate of vaccination among healthcare providers.

B 2. Matrix

Evidence Matrix of 10 pieces of Primary Research on one Topic related to Nursing
Author	Source	Date	Research Type	Population Sample Size	Outcome Measures	Pertinent Results Data	Suggested Conclusions	Comments
(Aegerter, Beer, (Friedl, Meier, & Saner, 2011)	Infection, CINAH	2011	Descriptive statistical, longitudinal study	1687 participants; From a 400 bed teaching hospital in Switzerland	Annual vaccination rates for intervention period and observational follow-up period	Non-significant increase during periods measured, doctors increased more that nurses	Vaccination rates did not improve over the 7 year period study despite interventions. Doctors slightly more receptive. Vaccination rates were higher during the H1N1 outbreak	This article provides data about the success of interventions to improve vaccination rates of healthcare providers
(Center for Disease Control and Prevention, 2012)	Morbidity and Mortality Weekly Report, CINAH	2012	Quantitative descriptive study	2,348 healthcare personnel; from an internet survey	Vaccination rates by occupation and location and reasons for not receiving vaccination	Increased rates for those provided free vaccines, higher among doctors, main reasons for not being vaccinated	Education, promotion and easy access are need to increase vaccination rates among HCP	CMS to require hospital vaccination rates beginning January 2013
(Fox, Harper, Lin, Nowalk, Raymund, Tanis, Willis, & Zimmerman, 2009)	Infection Control and Hospital Epidemiology, Medline	2009	Quantitative, controlled longitudinal study	26,000+ non physician hospital employees from 11 acute care facilities in a large health system	Efficacy of interventions for improve vaccination rates among HCP	Interventions differ among type of worker	Different interventions are required to increase vaccination rates depending on the position of the worker.	Accessibility and incentives in controlled groups
(Osman, 2010)	Australian Journal Of Advanced Nursing, CINAH	2010	Cross-sectional study	63 Emergency Department staff in Australia	Reason for or against vaccination, intention of vaccination in the following year	The main reason to receive the vaccine is to protect self, main reason to decline vaccine is belief it will make them ill, main reason intend to receive vaccine next season is to protect patients	Education is needed to explain influenza and the vaccine benefits	Rationale and likelihood of vaccination
(Johansen, Stenvig, & Wey, 2011)	Public Health Nursing, CINAHL	2011	Descriptive correlation, random  sample	193 RNs from North and South Dakota Board of Nursing	Mail survey of nurses’ decision of vaccination or declination	False beliefs were prevalent	Education and marketing and employer’s support may increase vaccination rates	Nurses decision making rationales
(Abramson, Avni, Levi, & Miskin, 2010)	Annals of Family Medicine, Medline	2010	longitudinal, quantitative, descriptive and controlled	344 healthcare workers with direct patient contact in a community clinics	Control group of 13 clinics with no intervention, 14 clinic with interventional measures	Vaccination rates of clinics with interventions were significantly greater than the control clinics	Interventions such as education and promotion are effective	Educational effects on vaccination
(Brusaferro, Calligaris, Farneti, Faruzzo, Fiappo, Panariti, & Turello, 2009)	Infection, Medline	2009	Retrospective quantitative, longitudinal design	473 Healthcare workers in a northern Italy 286 bed teaching hospital	Education and information of where to receive vaccination mailed	Intervention significantly increase vaccination rates	Providing easy access is helpful but other interventions are necessary	Media influence of vaccination rates
(Hubble, Richards, & Zonteck, 2011)	Pre-Hospital Emergency Care, Medline	2011	Cross sectional survey	601 EMS professionals in North Carolina	Vaccination status and beliefs about the virus and vaccine	Vaccination rates poor due to lack of education about misconceptions and lack of employer requirements	Employers should promote and educate staff and possibly have policies on vaccination	Facilities with policies have increased rates of vaccination
(Moore, 2009)	Business and Leadership, CINAHL	2009	Nonexperimental, retrospective survey	Sample size was 2971 employees that declined the influenza vaccine	Reasons healthcare workers declined the influenza vaccine	Major of staff that declined listed the reason as “it will make me sick”	Education is necessary to increase acceptance of vaccination	Implementation of measures to increase vaccination based on reasons for declinations
(Ofstead, Poland, Rhudy, & Tucker, 2010)	Worldviews on Evidence-Based Nursing, CINAHL	2010	Qualitative descriptive interviews	14 RNs indicating would not or undecided about being vaccinated in following year	Major variable being measured were the view points of the nurses and factors influencing their decision on vaccination	The author concluded these nurses viewed vaccination as a low priority for prevention of influenza	The nurses felt that vaccination is a personal choice not an evidence based intervention	Mandatory education

B3. Review of Research Articles

B3a. Annotated bibliography.

Abramson, Z., Avni, O., Levi, O., & Miskin, I. (2010). Randomized trial of a program to increase staff influenza vaccination in primary care clinics. Annals of Family Medicine, 8(4), 293-298. doi:http://dx.doi.org/10.1370/afm.1132

In this article the authors identified a lack of healthcare workers to accept seasonal influenza vaccination despite the recommendations. This is a well documented worldwide problem in the health care industry. The authors implemented interventions in a random selection of 13 primary care community clinics in Jerusalem, Israel. They collected data on all 27 community clinics. The interventions were a lecture by a family physician, e-mail literature, reminders, and personal contact. They conclude the interventions were successful in increasing vaccination. The method of research was longitudinal, quantitative, descriptive and controlled. This article is a credible source and has current references to substantiate the information and recommendations. It is concluded vaccination outreach programs can increase vaccination rates. It is suggested more interventions than accessibility is required with specific interventions required for targeted groups (Abramson, Avni, Levi & Miskin, 2010).

Brusaferro, S. Chittaro, M., Turello, D., Calligaris, L., Farneti, F., Faruzzo, A., & Fiappo, E. (2009). Impact of vaccinating HCWs on the ward and possible influence of avian flu threat. Infection, 37(1), 29-33. doi:http://dx.doi.org/10.1007/s15010-008-8002-6

This article evaluates the effectiveness of a vaccination program in an acute care hospital in northern Italy. The longitudinal quantitative method included the year Avian Flu was a threat. This inclusion provided additional insight into the reasons healthcare providers opt for or against vaccination. A perception of self protection was identified as a motivation with the increased media coverage. Further data shows physician vaccination was significantly increase as compared to nurses and ancillary workers. This study was credible and provided current references to facts and other research (Brusafero, Calligaris, Chittaro, Faruzzo, Fiappo, Panariti, & Turello, 2009).

Friedl, A. A., Aegerter, C. C., Saner, E. E., Meier, D. D., & Beer, J. J. (2012). An intensive 5-year-long influenza vaccination campaign is effective among doctors but not nurses. Infection, 40(1), 57-62. doi:http://dx.doi.org/10.1007/s15010-011-0193-6

This article is a descriptive statistical, longitudinal study of vaccination rate in a Switzerland teaching hospital. A period of 7 years that include the Avian and H1N1 influenza outbreaks were within this time period allowing for the inclusion of additional data. Various methods of incentives were applied during the first 5 years of the study followed by a follow up of 2 years. This was not an optimal study as the same groups studied were not included in the entire study. The results however of the effectiveness of the interventions instituted did show an increase in the rate of physician accepting vaccination. Reasons for declination analyzed are similar to other referenced research that was current with this study (Friedl, Meier, Saner, 2011).

Hubble, M. W., Zontek, T. L., & Richards, M. E. (2011). Predictors of influenza vaccination among emergency medical services personnel. Prehospital Emergency Care, 15(2), 175-183. doi:http://dx.doi.org/10.3109/10903127.2010.541982

This article studies the vaccination rates of emergency medical services personnel (EMS) in North Carolina (NC). The study was a retrospective, cross-sectional survey of EMS personnel in NC. The reference material in the article was current with the period of the study. The design by authors of this study is very inclusive and thorough. The conclusions drawn were similar to other studies of subject, education and promotion is necessary to improve vaccination rates (Hubble, Richards, & Zonteck, 2011).

Influenza vaccination coverage among health-care personnel - 2011-12 influenza season, United States. (2012). MMWR: Morbidity & Mortality Weekly Report, 61753-757.

This article is published on the Center for Disease Control and Prevention (CDC) website. The CDC has determined that vaccination of healthcare personnel (HCP) can reduce influenza. The CDC surveyed a variety of HCP, physicians, nurses, dentists, ancillary staff, such as food service, environmental and laboratory staff via the internet for a quasi-experimental quantitative methodological designed study. The conclusion drawn is the overall coverage of vaccination is greatest among physicians. The rate of vaccination was higher in organizations that promoted vaccination and the most popular reason for declination of the vaccine was “the belief that they did not need it” (CDC, 2012).

Johansen, L., Stenvig, T., & Wey, H. (2012). The Decision to Receive Influenza Vaccination Among Nurses in North and South Dakota. Public Health Nursing, 29(2), 116-125. doi:http://dx.doi.org/10.1111/j.1525-1446.2011.00966.x

In this article the authors describe the rational of the decision to accept or decline influenza vaccination by nurses in North and South Dakota. The design used was a descriptive correlational design with a random sample of registered nurses taken from the licensing board. This is a credible study with ample current references. The conclusion drawn is similar to other studies of this subject, education and promotion does help improve vaccination rates (Johansen, Stenvig, & Wey, 2011).

Moore, B. (2009). Why health care workers decline influenza vaccination. AAOHN Journal, 57(11), 475-478. doi:http://dx.doi.org/10.3928/08910162-20091027-02

This is a non-experimental, retrospective methodological designed study to determine the reason why staff declined the influenza vaccination. This is a credible study with current reliable references. The purpose of this study was to identify methods to improve the vaccination rate. The study included all 8,537 adult employees of all positions in a Texas hospital for the influenza vaccination 2007 - 2008. Based on the results of the data, interventions were implemented to increase vaccination. It was concluded that despite efforts to provide education, availability and promotion only 52% of the staff accepted the vaccination. The employer mandated the vaccination in August of 2009. Only exemptions were for health contra-indications signed by a physician, or religious restrictions (Moore, 2009).

Osman, A. (2010). Reasons for and barriers to influenza vaccination among healthcare workers in an Australian emergency department. Australian Journal of Advanced Nursing, 27(3), 38-43.

The author of this article used a cross-sectional study to review attitudes and beliefs of staff in an Australian emergency Department. The references were current to the time of the study. The references in this article were creditable, among those referenced were the Center for Disease Control and the World Health Organization. The author concludes education and promotion does help combat reasons staff decline as evidenced by the intentions reported by the respondents. The reasons cited in this study are similar to the other studies on this subject (Osman, 2010).

Rhudy, L., Tucker, S., Ofstead, C., & Poland, G. (2010). Personal choice or evidence-based nursing intervention: nurses' decision-making about influenza vaccination. Worldviews on Evidence-Based Nursing, 7(2), 111-120. doi:http://dx.doi.org/10.1111/j.1741-6787.2010.00190.x

This article focuses on the reason nurses’ vaccination rates are among the lowest worldwide. The authors of this study conducted interviews of RNs either undecided or declining vaccination. Out of 170 invited to participate only 14 nurses actually participated. The resulting reasons for declining began with feelings that vaccination was not a priority; overall good health and hand washing were sufficient protection against the flu. “Autonomy, choice, and skepticism of the effectiveness” were reasons for not being supportive of mandatory vaccination. The conclusion drawn by the researchers was the view of the nurses does not view influenza vaccination as a patient safety issue but rather a personal choice issue. References used for this study are current and support the conclusion given by the authors. Education is extremely important to help change the viewpoint of the nurses that are declining vaccination (Ofstead, Poland, Rhudy, & Tucker, 2010).

Zimmerman, R., Nowalk, M., Lin, C., Raymund, M., Fox, D., Harper, J., &. Willis, B. (2009). Factorial design for improving influenza vaccination among employees of a large health system. Infection Control & Hospital Epidemiology, 30(7), 691-697. doi:http://dx.doi.org/10.1086/598343

This article describes a large factorial design study with a baseline and group specific interventions. Based on surveys obtained from staff and rates from databases interventions were tailored to target specific groups, clinical and non clinical and different geological locations. This study was published in the Infection Control and Hospital Epidemiology Journal. The literature and articles referenced by the authors were both current and relative to the study. The conclusion is similar to other studies of this subject (Fox, Harper, Lin, Nowalk, Raymund, Tanis, Willis, & Zimmerman, 2009).

B3b. Efficacy.  The researchers presented a very reliable case for the necessity of interventions by the employer to increase vaccination among health care workers (HCW). It is well documented and accepted through the research and references the importance of seasonal influenza vaccination to reduce hospital acquired infection by both the patients and HCW, to prevent or reduce the transmission to family and community members by HCW, and to reduce lost time of staff within the healthcare setting. All of the research reviewed included measures to increase awareness, education the staff, and increase availability of the vaccine by the employers. Despite these efforts vaccination rates still remain low. The research shows this problem is not limited to the United States, it is a worldwide issue.

The researchers have collectively taken into account the reasons for declination and addressed those with interventions in following years. Education, availability, promotional efforts, and policies have shown effective in increasing vaccination rates in subsequent years. However unless the organizations adopt a mandatory vaccination policy it is doubtful that significant increases can be achieved.

B3c. Tools. The primary tool the researchers used were surveys for the reasons the vaccine was declined. Actual vaccination tallies were used for all but one of the studies for the rates of vaccination. Statistics were analyzed by position and location for most of the articles.’

B3d. Effect on results. The surveys the researchers used could have an effect on the results. If the survey had a limited amount of selections there may not have been an accurate representation of the reasons for declinations. Data that was self reported for vaccination will not be as accurate as the data that was obtained from actual vaccination records.

B4. Evidence Summary

All of the articles reviewed concluded interventions by the employer are necessary to increase vaccination among HCW. Promotion by the employer by posters, e-mails, letters in paycheck mailings, one on one invitation by key supervisory personnel, education by the use of literature, lectures by experts in infection control, financial incentives such as bonuses, free vaccinations, drawings or lotteries, and increased availability by providing the vaccine to every area during all hours every day have increased coverage. The primary intervention concluded by all of the articles reviewed was education is needed to improve vaccination coverage. The results of the articles that provided a breakdown by position revealed highest vaccination coverage was of physicians. This supports the conclusion increased education is an importation incentive in increasing vaccination rates.

The use of declination forms allows organizations to analyze and devise a strategy to address those rationales by the staff declining. By the use of education to dispel misconceptions and misunderstandings it may be possible to meet the goal of the Healthy People 2020. The objective is to require all health care employers (HCE) to have 90% of HCW vaccinated by 2020. Based on the recommendation of the National Vaccine Advisory Committee, if healthcare organizations are not able to achieve this goal they may need to consider vaccination required by the employer (National Vaccine Advisory Committee, 2012).

B5. Recommendation

Based on all of the reviewed literature education has been effective in increasing the vaccination rates of HCW. One of my recommendations for a nursing strategy to improve vaccination rates is to mandate educational programs ((Ofstead, Poland, Rhudy, & Tucker, 2010). This includes initiatives that emphasize patient safety, prevention of transmission of the flu and misconceptions of the vaccine. Active promotion by the organization with emphasis on the importance of vaccination (Skourti & Stathopoulou, 2010) will increase awareness and address beliefs that the vaccination is not important. Accessibility of the vaccine is another cited barrier. Making the vaccine available to all HCW during their hours of work and at their location can overcome this barrier (Fox, Harper, Lin, Nowalk, Raymund, Tanis, Willis, Zimmerman, 2009)

B6. Theoretical Models

Theory is a means of understanding a situation and explaining that perception to others. The theoretical framework used in creating evidenced practice is effective by utilizing evidence from a variety of research studies. In nursing the use of theoretical models has been effective in guiding evidenced based practices. The ten articles reviewed could be used to create a theoretical model by presenting the combined concepts of these studies and interventions. My review of the results of the research studies repeatedly reveals HCW vaccination rates are disappointingly low worldwide. All of the research studies reviewed provides references that validate the risk of nosocomial influenza infection within the healthcare setting. Surveys of attitudes, beliefs, and reasons of those that decline vaccination are repeated in each of the research studies. The conclusions repeatedly result in recommendations for an increase in education, promotion, and availability as means to increase vaccination among HCW. As a nursing measure to protect patients this research could be used to create a theoretical framework to change core beliefs or perceptions from viewing vaccination as unimportant or ineffective to a means of providing patient safety through education. By eliminating barriers such as availability, health care employers could adopt a best practice of vaccination.

References

Abramson, Z., Avni, O., Levi, O., & Miskin, I. (2010). Randomized trial of a program to increase staff influenza vaccination in primary care clinics. Annals of Family Medicine, 8(4), 293-298. doi:http://dx.doi.org/10.1370/afm.1132

Brusaferro, S. Chittaro, M., Turello, D., Calligaris, L., Farneti, F., Faruzzo, A., & Fiappo, E. (2009). Impact of vaccinating HCWs on the ward and possible influence of avian flu threat. Infection, 37(1), 29-33. doi:http://dx.doi.org/10.1007/s15010-008-8002-6

Friedl, A. A., Aegerter, C. C., Saner, E. E., Meier, D. D., & Beer, J. J. (2012). An intensive 5-year-long influenza vaccination campaign is effective among doctors but not nurses. Infection, 40(1), 57-62. doi:http://dx.doi.org/10.1007/s15010-011-0193-6

Hubble, M. W., Zontek, T. L., & Richards, M. E. (2011). Predictors of influenza vaccination among emergency medical services personnel. Prehospital Emergency Care, 15(2), 175-183. doi:http://dx.doi.org/10.3109/10903127.2010.541982

Influenza vaccination coverage among health-care personnel - 2011-12 influenza season, United States. (2012). MMWR: Morbidity & Mortality Weekly Report, 61753-757.

Johansen, L., Stenvig, T., & Wey, H. (2012). The Decision to Receive Influenza Vaccination Among Nurses in North and South Dakota. Public Health Nursing, 29(2), 116-125. doi:http://dx.doi.org/10.1111/j.1525-1446.2011.00966.x

Moore, B. (2009). Why health care workers decline influenza vaccination. AAOHN Journal, 57(11), 475-478. doi:http://dx.doi.org/10.3928/08910162-20091027-02

National Vaccine Advisory Committee. (2012, February 08). Recommendations on strategies to achieve the healthy people 2020 annual influenza vaccine coverage goal for health care personnel. Retrieved from http://www.hhs.gov/nvpo/nvac/influenza_subgroup_final_report.pdf

Osman, A. (2010). Reasons for and barriers to influenza vaccination among healthcare workers in an Australian emergency department. Australian Journal of Advanced Nursing, 27(3), 38-43.

Rhudy, L., Tucker, S., Ofstead, C., & Poland, G. (2010). Personal choice or evidence-based nursing intervention: nurses' decision-making about influenza vaccination. Worldviews on Evidence-Based Nursing, 7(2), 111-120. doi:http://dx.doi.org/10.1111/j.1741-6787.2010.00190.x

Stathopoulou, H., & Skourti, I. (2010). Health care workers' participation in influenza vaccination programs. Application of the PRECEDE- PROCEED mode. Health Science Journal, 4(3), 142-148

Zimmerman, R., Nowalk, M., Lin, C., Raymund, M., Fox, D., Harper, J., &. Willis, B. (2009). Factorial design for improving influenza vaccination among employees of a large health system. Infection Control & Hospital Epidemiology, 30(7), 691-697. doi:http://dx.doi.org/10.1086/598343