Abstract
This four-phase evidence-based practice initiative was designed to determine preliminary contextual characteristics of collegian nursing students in receiving, or their lack of receiving, the flu vaccine. Subsequently, strategies were developed to improve and maintain the students’ participation in flu vaccines.
This study relates to the welfare of student nurses and patients in their care. Students perform patient care in hospitals, clinics, and other settings where patients in compromised health are especially vulnerable to influenza. The Centers for Disease Control and Prevention reported that the 2009 H1N1 pandemic resulted in more than 12,000 influenza-related deaths in the US. The Joint Commission requires hospitals and long-term care facilities to provide on-site access to influenza immunisation to staff and licensed independent practitioners; however, no provisions for student nurses are specified. Employer-mandated influenza immunisation as a term for employment was associated with a significant increase in healthcare employees receiving the flu vaccine, but, in the main, students are currently not mandated to receive the flu vaccine. A one-day reduction of influenza-like illness for every two college and university students vaccinated has been reported. Therefore, improving influenza immunisation rates may have academic and performance benefits for nursing students.
Keywords
Introduction
Despite the fact that student nurses are expected to be knowledgeable about the influenza (flu) illness, as well as being aware of the vaccine to prevent it, many students are reluctant to be immunised. Student nurses perform patient care in hospitals, clinics, and other settings where patients in compromised health are especially vulnerable to the flu (Centers for Disease Control and Prevention (CDC), 2010). Undergraduate nursing students must fulfil specific clinical hours to provide direct nursing care to meet the requirements for the baccalaureate nursing programme. While the school of nursing strives to ensure the safety of students and their patients in the clinical practice sites, the flu vaccination is not a mandatory requirement for clinical practice. If the students are ill, they are discouraged from attending their clinical work; however, the period for flu contagion begins one day before symptoms are apparent (CDC, 2010). An informal inquiry by a clinical nursing instructor revealed that none of the eight nursing students in her clinical group had been immunised for the flu in 2010. This finding, as well as similar findings by another instructor, prompted the idea of examining the flu vaccine rate among undergraduate nursing students and assessing their knowledge about the vaccine and barriers to them receiving the vaccine. Findings from this study will be used for planning appropriate interventions to improve immunisation rates among nursing students and perhaps achieving a long-term goal of changing policy to improve flu immunisation among nursing students.
Purpose
The purpose of this study was to identify contextual characteristics related to participation or lack of participation of undergraduate nursing students in influenza immunisations.
Literature review
The prevalence of influenza immunisation among college students, and specifically student nurses, is less than 31% (Ali et al, 2007; Nichol et al, 2008; Wilson and Huttlinger, 2010). As reported by the Centers for Disease Control and Prevention (CDC, 2010), the 2009 H1N1 pandemic resulted in more than 12,000 influenza-related deaths in the United States. The Joint Commission requires hospitals and long-term care facilities to provide on-site access to influenza vaccine to staff, licensed independent practitioners, and volunteers; however, the Joint Commission remains relatively silent regarding student influenza immunisation (Joint Commission, 2011). The Joint Commission is an independent non-profit accrediting agency that evaluates more than 15,000 healthcare organisations in the US (Donatelle, 2010). The Society for Healthcare Epidemiology (SHEA) maintains that healthcare personnel have a professional and ethical responsibility to comply with yearly influenza immunisation to protect their patients (Talbot et al, 2010); however, to date SHEA has not addressed the responsibility of student nurses and the influenza immunisation. Employer-mandated influenza immunisation as a term for employment was associated with a 98.1% compliance in healthcare employees receiving the influenza vaccine (CDC, 2011a). It is also noteworthy to mention that Healthy People 2010 and 2020 propose to increase the national influenza vaccination rate from 60% to 90% (Shefer, 2010). Healthy People is a US nationwide health promotion and disease prevention agenda administered by the US Department of Health and Human Services (US Department of Health and Human Services, 2012).
Methods
The research design is a cross-sectional design. After obtaining approval from the university institutional review board (IRB), a convenience sample of 225 undergraduate nursing students (sophomores, juniors, and seniors) from this private university in the Pittsburgh area were recruited to complete a paper-and-pencil questionnaire based on the design of the CDC National Flu Survey Questionnaire (CDC, 2011b). The National Center for Health Statistics, a subdivision of CDC, reports approval for this survey through the CDC’s IRB and administered this survey to 5,000 US adults in a six-month period in 2010 (National Center for Health Statistics, 2011). The measure consisted of seven items, which were either multiple choice questions or short answer questions, based on whether the students received the flu vaccine or did not receive the flu vaccine during the period of August 2010 through to May 2011. An additional item was added to determine the students’ current grade level, but no other identifying information was requested. The questions addressed students’ reasons for receiving or not receiving the flu vaccine. Additionally, students were asked if they had experienced flu-like symptoms between September 2010 and May 2011 and whether they had missed any clinical days (required course work) or lecture days (related to course work) due to flu-like symptoms during that time period.
A graduate assistant administered the questionnaire rather than faculty to prevent students from feeling pressured to participate. She did so prior to regularly scheduled classes to gain access to the most students. Written informed consent was obtained from the students before their participation in the study. To maintain anonymity, the consents were placed in an envelope and were not reviewed by the researchers. The whole process took approximately 25 minutes, and participants were given a US$5 gift card to the university bookstore in appreciation for completing the survey. Questionnaire responses were reviewed and aggregated using SPSS software, and chi square was used to analyse the association between the class of nursing students and their responses to the survey.
Results
Of the 225 nursing students surveyed, 224 surveys were filled out correctly and were usable (see Table 1). Of these, 83 (37%) were sophomore nursing students, 63 (28%) were junior nursing students, and 78 (35%) were senior nursing students. As shown in Table 1, Responses to Flu Questionnaire by Grade Level, 97 (43.1%) nursing students reported having received the flu vaccine, while 128 (57%) had not. Of the three levels of nursing students, 56.3% of the junior nursing students received the flu vaccine compared with 39% in the senior level, and 37% in the sophomore level. The top five ‘main’ reasons reported by the 98 students who received the flu vaccine were ‘Did not want to get sick’ (37%), ‘Parents suggested it’ (16%), ‘Did not want to give flu to others (besides relatives)’ (15%), ‘Did not want to give to relatives’ (13%), and ‘Healthcare provider suggested it’ (11%). The top five ‘main’ reasons reported by the 128 students who did not receive the flu vaccine were, ‘Concerns about side effects’ (23%), ‘No time’ (19%), ‘Concerns about getting the flu’ (17%), ‘I never get the flu’ (16%), and ‘Flu is not a very serious illness’ (5%).
Responses to Flu Questionnaire by Grade Level (n=224)
The chi square results were statistically significant for the proportion of students with the following reasons for receiving the flu vaccine: ‘Healthcare provider suggested it’ χ2(4, n=224)=12.4, p=0.015, Ph =0.24, ‘Parents suggested it’ χ2(4, n=224)= 20.1, p=0.001, Phi=0.30, and ‘Felt moral obligation’ χ2(4, n=224)=10.4, p=0.034, Phi=0.22. The chi square results were statistically significant for the proportion of students with the following reasons for not receiving the flu vaccine: ‘Flu is not a serious illness’ χ2(4, n=223)=11.2, p=0.024, Phi=0.22, ‘Underlying condition/other health condition’ χ2(4, n=223)=10.7, p=0.031, Phi=0.22, ‘Vaccine not available’ χ2(4, n=223)=11.5, p=0.022, Phi=0.23, ‘Because I already had the flu’ χ2(4, n=223)=11.2, p=0.024, Ph =0.22, ‘Vaccine costs too much’ χ2(4,n=223)=15.0, p=0.005, Phi=0.26, ‘Allergic to flu shot’ χ2(4, n=223)=10.0, p=0.041, Phi= 0.21, and ‘No contact with anyone who has the flu’ χ2(4, n=223)=10.1, p=0.039, Phi=0.21.
Discussion
With the lack of studies on student nurses and the flu vaccine, our study is one of the few that have evaluated the various reasons student nurses either receive the flu vaccine or do not receive the flu vaccine. In this sample of nursing students, only 43% received the flu vaccine, which is much lower than the 2010 CDC estimate of 63.5% in healthcare personnel, and Healthy People 2020’s target of 90% (CDC, 2011b). The CDC (2011b) reported that vaccination of healthcare providers against influenza has been shown to reduce illness and absenteeism as well as transmission of influenza to healthcare providers and their families and patients. Our findings indicate that student nurses misunderstand the facts about flu, especially those who reported a lack of concern about contracting the flu and the belief that flu is not a serious illness. These results indicate the necessity of a programme to educate students about the effectiveness of the flu vaccine and the potential serious impact of the flu on their patients. Aside from the lack of education about the flu vaccine, our students also reported that lack of time was a main reason they did not receive the flu vaccine. By sending the students reminders about receiving the flu vaccine, as well as making the flu vaccine available and accessible to the students, we may be able to increase the number of students who receive the flu vaccine.
Limitations
Findings from this study should not be generalised to other populations of student nurses. This study included only sophomores, juniors, and seniors. Freshmen and graduate students were not included.
Conclusions
Healthy People 2020 proposes a target of 90% for flu immunisation for people less than 65 years of age (Shefer, 2010). This study indicates that the immunisation rate for student nurses in this university setting falls considerably below this goal. When considering factors identified in this study, the following strategies would improve that outcome. Faculty must provide education to dispel myths about getting the flu from the flu vaccine and improve students’ understanding of the seriousness or threat of the flu on their own health as well as that of their patients, families, and fellow students. A sense of moral obligation as a healthcare professional must be conveyed by identifying the risk of exposing compromised patients, even inadvertently, to the flu. The flu vaccine must be easily accessible to student nurses. Regulatory and government agencies should clearly specify student nurses among healthcare workers, requiring healthcare institutions to extend immunisation to include student nurses who use their facilities for clinical assignments. Recent policy change to mandate flu immunisation as a condition for employment may also be considered to include student nurses.
Footnotes
Funding: This study was supported by a Nursing Faculty research grant (grant number: 110010 505095).
Conflict of interests: None declared.