Evidence-based initiative to improve influenza immunisation participation among undergraduate nursing students

Abstract

This evidence-based practice study presents the outcome of specific intervention strategies that have been implemented to improve the immunisation status among undergraduate nursing students in a local university. These interventions included education about the importance of the influenza vaccine, email reminders about convenient times and influenza clinic locations, raffles, and an appeal to the moral responsibility that healthcare personnel have to their patients to increase immunisation. Despite these strategies, the overall percentage of nursing students receiving the influenza immunisation only slightly improved: from 43.1% (influenza season 2010–2011) to 46.3% (influenza season 2011–2012). Similar outcomes have been found with employers who have sought to improve employee influenza immunisation rates without mandating immunisation. Given the clinical settings where students are engaged, schools of nursing, regulatory agencies, and clinical sites should not overlook the impact of students on patients regarding influenza. In order to promote patient welfare, while employer-mandated influenza immunisation as a condition for employment becomes more prevalent, perhaps a similar approach may be required to promote influenza immunisation among nursing students.

Keywords

Evidence-based practice flu immunisation infection control nursing influenza influenza vaccination patient safety prevention students vaccine uptake monitoring

Introduction

Influenza immunisation has recently gained considerable attention, especially among healthcare personnel (HCP) to prevent the transmission of the influenza virus, reduce the disease burden, and lower health costs. The Centers for Disease Control and Prevention (CDC) (2011) reported an overall influenza vaccination rate of 63.5% for the 2010–2011 influenza season among HCP. To date, data related to the immunisation rate among undergraduate nursing students are very limited. Determining how many undergraduate nursing students received the influenza vaccination during the influenza season 2010–2011 was part of a four-phase evidence-based practice initiative conducted at a local university school of nursing in a city in the Commonwealth of Pennsylvania, USA. As previously reported, the influenza immunisation rate found among those nursing students for the influenza season 2010–2011 was only 43% (Koharchik et al, 2012). The initial phases of the study (Phases one and two) revealed barriers that students reported for not being immunised, and the motivation other students experienced to receive the influenza vaccine.

Purpose

Based on the findings of Phases one and two, this current study focussed on the development of strategies to improve the influenza immunisation rate among nursing students for the influenza season 2011–2012.

Literature review

Over 67% immunisation rates have been reported among HCP when employers use strategies such as offering free immunisations, personal reminders for immunisation, and more than one-day availability of the vaccine (CDC, 2011). Employer-mandated influenza immunisation as a condition for employment has been successful in achieving more than 90% employee influenza-immunisation (CDC, 2011).

While the literature is replete with information regarding influenza immunisation among healthcare employees, reported research on immunisation among college students is sparse. Wilson and Huttlinger (2010) reported 25.7% of the students surveyed in a New Mexico university received influenza immunisation for the 2009 season; 54.8% of the students reported a belief that influenza immunisation was safe, while 42.5% reported a belief of possibly getting influenza from taking an influenza shot. Ali et al (2007) provided free immunisation over a three-day period to health professionals, health profession students, and other staff at a university hospital. Of those receiving immunisation, 53% were health profession students, and 22% of the enrolled nursing students were immunised.

Despite healthcare training, student nurses have been shown to have misconceptions regarding influenza. Yonge et al (2007) evaluated student nurses’ general knowledge and risk perception of pandemic influenza. Although 80% of the student nurses correctly identified transmission modes for influenza, perception of personal risk for getting influenza was low. Recommendations to increase vaccination rates include discussing the concept of professional obligation with students as well as educating students about the critical role they may play in an influenza pandemic. Shahrabani et al (2009) studied factors that influence the decision of whether or not to receive the influenza vaccine among nursing students in both a master’s and a bachelor’s degree programme. Their study revealed that those who were vaccinated for influenza had, on average, more knowledge regarding the vaccine and influenza, and a main factor prompting undergraduate nursing students to receive the influenza vaccine was the presence of internal or external stimuli, such as information from the media or physicians’ recommendation to take the vaccine. The investigators recommended a comprehensive approach to increase influenza immunisation rates, including education about the benefits and the potential health consequences of influenza for the nurses, their families, and their patients. Trainee nurses were specifically identified as an important target audience for education.

Methods

Assuring ethical considerations, the University’s Institutional Review Board approved the study. Although the initial phases (Phases one and two) of the study were previously published (Koharchik et al, 2012), below is a brief summary of the four-phase process improvement plan.

Phase one: The investigators gathered information from local universities, from clinical sites where students practice, from the university student health service regarding influenza policies, and from the county health department regarding the cost and availability of influenza vaccine.

Phase two: A paper-and-pencil survey was administered to a convenience sample of 225 sophomore (second-year), junior (third-year), and senior (fourth-year) nursing students. Since freshmen (first-year) students do not practise in clinical environments, they were excluded from the study. The survey was based on the design of the CDC National Flu Survey Questionnaire (CDC, 2012), which in 2010 was administered to 5,000 US adults in a six-month period (National Center for Healthcare Statistics, 2011). We revised this measure to consist of seven items, which were either multiple choice or short answer, addressing whether the student had or had not received an influenza immunisation during the previous influenza season (August 2010 to May 2011). Additionally, the survey requested the students’ current grade level, but requested no other identifying information. The questions addressed students’ reasons for receiving or not receiving the influenza immunisation. Additionally, the surveys were used to identify the number of students that may have experienced any influenza-like symptoms between September 2010 and May 2011, and whether they missed any clinical days or lecture days due to influenza-like symptoms. A research assistant administered surveys to the students during regular class time so that students would not feel pressure from a professor to participate. Students were informed that completion of the survey was voluntary; would not impact their grades or progression in the programme, and completed surveys would be kept in a locked file and destroyed when the study was complete. Students were told they would receive a $5 gift card in gratitude for participating. Data were entered into statistical package for social sciences (SPSS), where it was aggregated and analyzed for trends.

Phase three: Based on the findings in Phase two, multiple strategies were designed to increase students’ rate of immunisation for the 2011–2012 flu season. An amendment to the original Institutional Review Board submission specifying the implementation plan was filed and granted. Several strategies were introduced to the undergraduate nursing students: posters from the CDC urging immunisation were displayed throughout the school of nursing; information related to influenza facts was provided to clinical faculty to be used in post-clinical conferences; students were sent emails reminding them of dates and convenient locations of influenza clinics offered throughout the university; and a drawing for gift cards to the university bookstore was held for those who obtained an influenza vaccine.

Phase four: A follow-up survey was repeated in March 2012, the end of the 2011–2012 influenza season. The survey was administered to the same groups of students, using the same questions as asked on the initial survey used in Phase two. The same research assistant administered the survey and entered the data into SPSS software. The data were aggregated and analyzed for trends.

Results

During Phase two a total of 225 undergraduate nursing students completed the August 2011 influenza surveys. The results from Phase two have been previously published (Koharchik et al, 2012) (Table 1). During Phase four, a total of 218 undergraduate nursing students completed the March 2012 influenza surveys (Table 2). Of the 218 nursing students in Phase four, 101 (46.3%) reported having received the influenza vaccine, while 117 (53.7%) had not. Of the three levels of nursing students receiving the influenza vaccine, 55.6% of the sophomore class had received the vaccine, compared to 49.3% of juniors, and 34.7% of seniors. Table 3 shows the comparison of results from the August 2011 surveys to the March 2012 surveys. The superscripts shown on Table 3 indicate the top five “main” reasons reported by the students who did and did not receive the influenza vaccine.

Table 1.

Responses to August flu questionnaire by grade level (n = 225)

Have you had the flu vaccine?	Sophomore(n=83)		Junior(n=64)		Senior(n=78)
Have you had the flu vaccine?	n	%	N	%	n	%
Yes	31	37.3	36	56.3	30	38.5
No	52	62.7	28	43.8	48	61.5
Main reason received flu vaccine
Did not want to get sick	26	31.3	30	46.9	27	34.6
Did not want to give to relatives	10	12.0	11	17.2	8	10.3
Did not want to give flu to others (besides relatives)	10	12.0	14	21.9	10	12.8
Healthcare provider suggested it	13	15.7	7	10.9	4	5.1
Parents suggested it	20	24.1	11	17.2	5	6.4
Felt a moral obligation	6	7.2	1	1.6	4	5.1
Main reason did not receive flu vaccine
Concerns about SIDE effects	19	22.9	13	20.3	20	25.6
Concerns about GETTING the flu	17	20.5	7	10.9	14	17.9
Think vaccines do NOT work	4	4.8	2	3.1	3	3.8
I NEVER get the flu	16	19.3	7	10.9	14	17.9
Flu is NOT a very serious illness	7	8.4	3	4.7	2	2.6
Vaccine COSTS too much	—	—	1	1.6	5	6.4
ALREADY had the flu	4	4.8	2	3.1	—	—
NO time	17	20.5	10	15.6	16	20.5
Between Sep 2010 and May 2011, did you have signs of the flu?	—	—	1	1.6	2	2.6
Yes	57	68.7	37	57.8	43	55.1
No	22	26.5	22	34.4	33	42.3
Did you miss clinical days between Sept 2010 and May 2011
Yes	8	9.6	6	9.4	14	17.9
No	72	86.7	57	89.1	64	82.1

Table 2.

Responses to March flu questionnaire by grade level (n = 218)

Have you had the flu vaccine	Sophomore (n=72)		Junior (n=71)		Senior (n=75)
Have you had the flu vaccine	n	%	N	%	n	%
Yes	40	55.6	35	49.3	26	34.7
No	32	44.4	36	50.7	49	65.3
Main reason received flu vaccine
Did not want to get sick	30	41.7	31	43.7	18	24.0
Did not want to give to relatives	13	18.1	15	21.1	11	14.7
Did not want to give flu to others (besides relatives)	11	15.3	16	22.5	10	13.3
Healthcare provider suggested it	10	13.9	12	16.9	5	6.7
Parents suggested it	20	27.8	13	18.3	5	6.7
Felt a moral obligation	5	6.9	9	12.7	3	4.0
Main reason did not receive flu vaccine
Concerns about SIDE effects	13	18.1	13	18.3	11	14.7
Concerns about GETTING the flu	8	11.1	9	12.7	9	12.0
Think vaccines do NOT work	3	4.2	—	—	5	6.7
I NEVER get the flu	13	18.1	10	14.1	18	24.0
Flu is NOT a very serious illness	—	—	—	—	1	1.3
NO contact with anyone who has flu	—	—	1	1.4	1	1.3
ALLERGIC to the vaccine	1	1.4	—	—	2	2.7
Vaccine COSTS too much	2	2.8	1	1.4	5	6.7
ALREADY had the flu	1	1.4	—	—	1	1.3
NO time	6	8.3	14	19.7	29	38.7
Between Sep 2011 and Mar 2012, did you have signs of the flu?
Yes	27	37.5	38	53.5	27	36.0
No	41	56.9	33	46.5	45	60.0
Did you miss clinical days between Sep 2011 and Mar 2012?
Yes	6	8.3	19	26.8	12	16.0
No	65	90.3	50	70.4	61	81.3

Table 3.

Comparison of responses between August and March Flu Questionnaires

	AUGUST (n = 225)		MARCH (n = 218)
Have you had the flu vaccine?	n	%	n	%
Yes	97	43.1	101	46.3
No	128	56.9	117	53.7
Main reason received flu vaccine
Did not want to get sick	83	36.9¹	79	36.2¹
Did not want to give to relatives	29	12.9⁴	39	17.9²
Did not want to give flu to others (besides relatives)	34	15.1³	37	17.0⁴
Healthcare provider suggested it	24	10.7⁵	27	12.4⁵
Parents suggested it	36	16.0²	38	17.4³
Saw advertising about importance	9	4.0	8	3.7
Felt a moral obligation	11	4.9	17	7.8
Main reason did not receive flu vaccine
Concerns about SIDE effects	52	23.1¹	37	17.0³
Concerns about GETTING the flu	38	16.9³	26	11.9⁴
Think vaccines do NOT work	9	4.0	8	3.7⁵
I NEVER get the flu	37	16.4⁴	41	18.8²
Flu is NOT a very serious illness	12	5.3⁵	1	0.5
Vaccine COSTS too much	6	2.7	8	3.7⁵
ALREADY had the flu	6	2.7	2	0.9
NO time	43	19.1²	49	22.5¹
AFRAID of needles/shots	7	3.1	8	3.7⁵
Between Sep 2010/2011 and Mar 2011/2012, did you have signs of the flu?
Yes	137	60.9	92	42.2
No	77	34.2	119	54.6
Did you miss clinical days between Sep 2011 and Mar 2012?
Yes	28	12.4	35	16.1
No	193	85.8	179	82.1

Superscript identifies the order of “main”

The chi square results were statistically significant for the proportion of students with the following reasons for receiving the influenza vaccine: “Healthcare provider suggested it”.

χ² (4, n= 224) = 12.4, p = .015, Phi = .24, “Parents suggested it” χ² (4, n = 224) = 20.1, p = .001, Phi = .30 and “Felt moral obligation” χ² (4, n = 224) = 10.4, p = .034, Phi = .22. The chi square results were statistically significant for the proportion of students with the following reasons for NOT receiving the influenza vaccine: “Flu is not a serious illness” χ²(4, n = 223) = 11.2, p = .024, Phi = .22, “Underlying condition/other health condition” χ²(4, n = 223) = 10.7, p = .031, Phi = .22, “Vaccine not available” χ²(4, n = 223) = 11.5, p = .022, Phi = .23, “Because I already had the flu” χ²(4, n = 223) = 11.2, p = .024, Phi = .22, “Vaccine costs too much” χ²(4, n = 223) = 15.0, p = .005, Phi = .26, “Allergic to flu shot” χ²(4, n = 223) = 10.0, p = .041, Phi = .21, and “No contact with anyone who has the flu” χ²(4, n = 223) = 10.1, p = .039, Phi = .21.

Comparisons were made between the August 2011 (Phase two) and March 2012 (Phase four) classes of students. The only class of students with a statistically significant difference in receiving the influenza vaccine was the sophomore class, with an increase from 37.3% in Phase two to 55.6% in Phase four [χ²(1, n = 155) = 5.2, p =.023, Phi = –.18]. For the students in the sophomore class who did not receive the influenza vaccine the chi-square result was statistically significant for the proportion of students with the following reason, “Flu is not a very serious illness” with a decrease from 8.5% in Phase two to 0% in Phase four [χ² (2, n= 154) = 8.4, p =.015, Phi = .23]. For the students in the junior class who received the influenza vaccine, the chi-square result was statistically significant for the proportion of students with the following reason, “Felt a moral obligation” with an increase from 1.6% in Phase two to 12.7% in Phase four [χ²(2, n= 134) = 8.0, p =.018, Phi = .25]; however, the chi-square result was statistically significant for the proportion of junior class students in Phase two and Phase four, in the category of missing clinical days, 9.5% and 26.8%, respectively [χ²(1, n= 133) = 7.6, p =.006, Phi = .24]. For the students in the senior class who did not receive the influenza vaccine, the chi-square result was statistically significant for the proportion of students with the reason “No time”, with an increase from 20.5% in Phase two to 38.7% in Phase four [χ²(2, n= 153) = 6.8, p = .034, Phi = .21]. When comparisons were made between the combined classes of students completing the survey in Phase two and those completing the survey in Phase four, the chi-square results were not statistically significant for the proportion of students who received the influenza vaccine in Phase two (43.1%) to the students in Phase four (46.3%), [χ² (1, n= 443) = .46, p = .496, Phi = .03]. However, the chi-square result was statistically significant for the proportion of students with the reason for not receiving the influenza vaccine of “Flu is not a very serious illness” with a decrease from 5.3% in Phase two to 0.5% in Phase four [χ²(2, n= 442) = 9.3, p = .009, Phi = .15].

Discussion

Compared to the data in Phase two, the data in Phase four indicates a statistically non-significant increase in the percentage of students who received the influenza vaccine. The five top “main” reasons students gave for receiving the influenza vaccine in Phase four were not different from their reasons in Phase two; however, distinctly different “main” reasons are identified by students who did NOT receive the influenza vaccine from Phase two to Phase four, with the largest difference in the percentage of students who felt that influenza was not a very serious illness; indicating that the students have realized that influenza infections are serious.

Our findings from Phase two indicated that our student nurses had a misunderstanding regarding influenza facts. Students who did NOT receive the influenza vaccine were concerned about the side effects of the influenza vaccine, getting influenza from the vaccine, and feeling as if the vaccine does not work. Implementation of Phase three, with an educational component, did not improve the outcome for students receiving the influenza vaccine. Aside from education, one of the top “main” reasons reported in Phase two and Phase four by the students for NOT receiving the vaccine was a lack of time, despite the availability and accessibility of the influenza vaccine.

Interestingly, if we look at the results by class (sophomore, junior, and senior), the class with the largest increase in receiving the influenza vaccine from Phase two to Phase four were the sophomore students, whereas the class with the least improvement were the senior students. In our nursing programme, sophomore students learn to give injections by hosting influenza immunisation clinics, and therefore have more access to receiving the influenza vaccine. Our junior students, being exposed to their first acute care clinical setting, were the only class to report a statistically significant increase in having missed the most clinical days due to illness with influenza-like symptoms. Our senior students reported having no time to receive the influenza vaccine, having more demands on their time and fulfilling a large number of hours with their preceptors.

Limitations

There are several limitations to our study. First, our study included only sophomore, junior, and senior nursing students; therefore, the results should not be generalised to other populations. In addition, our study derived its subjects from students attending a university, which may have added bias to our findings. Next, our study relied on self-reported influenza-like symptoms and immunisation rates from the participants, and lastly, having a mild influenza season may have attributed to the lack of motivation for students to receive the influenza vaccine.

Conclusions

Current recommendations for influenza immunisation are specified by government and healthcare-regulating agencies, but provisions for student nurses are sometimes not addressed. For example, The Joint Commission (2011) Standard IC.02.04.01: Influenza Vaccination for Licensed Independent Practitioners and Staff (Hospital Accreditation Program) recommends that hospitals establish an annual influenza vaccination program that is offered to licensed independent practitioners and staff. To date, inclusion of students who work on-site in hospital facilities are not included among those groups to whom hospitals must provide influenza vaccination.

The Association for Professionals in Infection Control and Epidemiology (APIC) has recommended “that acute care hospitals, long term care, and other facilities that employ healthcare personnel require annual influenza immunization as a condition of employment unless there are compelling medical contraindication” (Greene et al, 2011, p.1). APIC has specified that the term “healthcare personnel” is inclusive of “all paid and unpaid persons working in health-care settings who have the potential for exposure to patients with influenza…might include…students and trainees…” (Greene et al, p.3).

Divisions of the CDC, The Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee, “recommend that all U.S. health-care personnel (HCP) be vaccinated annually against influenza” (CDC, 2011, p.1). The CDC recommends employers offer all workers annual flu immunisation, but does not address extending flu immunisation access to students.

In 2010, the Society of Healthcare Epidemiology of America (SHEA) updated its position on influenza vaccination of healthcare personnel. SHEA recognised a professional and moral responsibility of all HCP to be immunised annually for influenza, and recommended that employers make flu immunisation a condition for employment. Additionally, SHEA identified students as among those who should be required to be immunised for the flu (Talbot et al, 2010).

Our study indicated that a variety of strategies to improve nursing student immunisation rates for influenza were not significantly helpful. If the Healthy People 2020 goal of 90% influenza immunisation for HCP is to be attained, perhaps mandating immunisation is necessary (U.S. Department of Health and Human Services, 2012). Nursing students comprise a large group of HCP who are in close contact with patients, and our results indicate that regulatory agencies should specifically address nursing students in recommendations for influenza immunisation.

Footnotes

Funding

This work was supported by the School of Nursing Center for Nursing Research Faculty Research Grant [grant number: 110010 505095].

Conflict of interests

None declared.

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