Vickie - My Journey: March 2013

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).

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

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

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.

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

Vickie - My Journey

Thursday, March 28, 2013

Influenza Vaccination EBT1 Task 1

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