Vaccinating healthcare workers (HCWs) against seasonal influenza is recommended to reduce the risk of nosocomial infection between patients and HCWs (European Council, 2009; Fiore et al, 2010; World Health Organization (WHO) 2012a; National Immunisation Advisory Committee, 2017). Each year, epidemics of seasonal influenza contribute to a significant increase in mortality and morbidity among high-risk groups, especially older people (Iuliano et al, 2018), with rates of serious illness and death highest among those aged ≥65 years, children aged <2 years and any person with an underlying medical condition (WHO, 2012b).
Internationally there has been substantial interest in addressing the issue of poor vaccine uptake among HCWs (European Centre for Disease Prevention and Control (ECDC), 2018). In the interests of patient safety, vaccinating HCWs against seasonal influenza is recognised as a key public health measure with coverage rates of ≥75% recommended by the WHO since 2003 (WHO, 2003). HCWs influenza vaccine coverage rates for three consecutive seasons (2015–2016, 2016–2017 and 2017-2018) were reported by 12 European member states and ranged from 15.6% to 63.2%. The highest vaccine uptake rates were reported by Belgium, the UK-England and the UK-Wales (2016–2017), with vaccine uptake increasing in Greece, Ireland and the UK; however, coverage rates remained below the goal of 75% (ECDC, 2018).
Since 2004, some healthcare facilities and local health departments in the US require certain HCWs to be vaccinated against influenza as a condition of employment and, since this, many other facilities in the US have implemented similar policies (Stewart and Cox, 2013). These mandatory vaccination programmes have been more effective at increasing vaccine coverage rates (Hollmeyer et al, 2013; Lytras et al, 2016) with some US health systems reporting coverage rates up to 99.3% (Keller, 2010; Rakita et al, 2010; Feemster et al, 2011; Karanfil et al, 2011). Despite this, mandatory vaccination remains a controversial topic among different health professional groups and also among different countries (Karnaki et al, 2019). Although this strategy is advocated by many health professionals who consider it to be ethically justifiable (Helms and Polgreen, 2008; McLennan et al, 2008; Galanakis et al, 2013; Dubov and Phung, 2015), others argue that it infringes HCWs' autonomy (Isaacs and Leask, 2008; Quinn, 2014; Pless et al, 2017).
With the exception of some US states, vaccination programmes remain voluntary but, although some voluntary multifaceted interventions have been found to be successful at increasing HCWs influenza vaccination uptake rates, others have been found to be less successful (Lam et al, 2010; Hollmeyer et al, 2013; Rashid et al, 2016; Bechini et al 2020). The low vaccine uptake as a result of voluntary policy has fuelled debate about whether mandatory vaccination programmes should be implemented in the UK and the Republic of Ireland (Carter and Yentis, 2018; Royal College of Physicians of Ireland (RCPI), 2018). In 2018, the Faculties of Occupational Medicine, Pathology and Public Health Medicine of the RCPI in Ireland recommended introducing mandatory seasonal influenza vaccination for certain categories of HCWs using a risk assessment framework (RCPI, 2018). They highlighted that the health of the patient population as a whole takes priority over the personal choice of the individual HCW (RCPI, 2018). Although recognising that mandating influenza vaccination for HCWs increases vaccine rates, the decision to introduce a mandatory programme needs to recognise the challenges that will accompany it (Quach et al, 2013). It is highly likely that influenza will coincide with the current coronavirus (COVID-19) pandemic in the coming influenza season (2020–2021) and increasing HCWs influenza vaccine uptake will be a major priority to reduce the pressure on health services. Although high HCW influenza vaccine uptakes would be ideal, implementing mandatory vaccination could have the opposite effect to that intended.
Methods
This qualitative study formed phase two of a sequential explanatory mixed-methods study reported elsewhere (Flanagan et al, 2020). A self-selected sample of qualified nurses participated in five homogenous focus group discussions between September and October 2018. Nurses attending mandatory training courses (cardiopulmonary resuscitation (CPR) and manual handling) at two hospital sites (referred to as site A and site B), where medical and surgical services are provided, were invited to consent to participate. This ensured a wide variety of nurses were recruited from a range of clinical settings within the two hospitals. An information leaflet was provided to all nurses at the start of each mandatory training session, which provided detailed information about the study. A separate paper-based consent form was also provided and, although the risk of unconscious bias was possible, nurses were advised that they would receive a €25 voucher as an honorarium for attending the focus groups before consenting. These vouchers were posted to participants a number of weeks after all the focus groups were undertaken. Contact information was requested from the nurses who provided written consent so a suitable date and time could be arranged to conduct the focus groups. A text message or email was sent to each nurse and for those who did not respond to the initial invite, one reminder message was sent. The focus groups were held shortly after recruitment and took place in a training room in the hospital site where the nurses were employed allowing for comfort, convenient access and minimal distractions.
The researchers were cognisant of possible social desirability bias, which can result in ‘questionable appearance of consensus’ (Bergen and Labonté, 2020:784). Therefore, before each focus group, all nurses were reminded about the aim of the study, confidentiality of the discussions and assured of their anonymity in the reporting of the findings. They were also advised that they could stop participating and leave the focus group at any stage. Each focus group lasted approximately one hour and light refreshments were provided.
A sample size in qualitative research is usually determined based on information needs. A guiding principle is data saturation (Lincoln and Guba, 1985). Although the number of participants needed to reach data saturation depends on many factors, using multiple focus groups allows the extent to which saturation has been reached to be assessed (Lincoln and Guba, 1985; Onwuegbuzie et al, 2009), with three to six focus groups consisting of an average of six to eight participants adequate (Morgan, 1997; Kreuger and Casey 2015). One potential challenge when arranging focus group discussions is the lack of guarantee that those recruited would attend on the day. To overcome this, there was over-recruited of participants for each focus group (Rabiee, 2004).
A topic guide was developed and informed the focus group discussions. This was pre-tested on two nurses from a different healthcare setting in advance of the focus groups to ensure clarity of the questions. At the focus groups, nurses were asked their views on mandatory vaccination policy in general and also their views if mandatory vaccination were implemented for seasonal influenza in the Republic of Ireland. The first author served as the moderator and an assistant moderator also attended each focus group and took field notes. Neither were employees of either hospital site and were not known to the participants. The topic guide assisted in managing the discussion, although it was not rigidly adhered to. It also ensured there was consistency across the different focus groups. All questions were open ended. Immediately after each focus group, debriefing took place between the moderator and assistant moderator to discuss observations noted, such as how the focus group progressed and if all nurses in attendance were given an opportunity to share their views.
The focus group interviews were audio recorded and transcribed verbatim by the first author. Pseudonyms were assigned to maintain participants' confidentiality. Braun and Clarke's framework, which is widely used in the analysis of focus group interviews (Lauri, 2019) guided thematic analysis in NVivo v12 (a qualitative data analysis application) (Braun and Clarke, 2006). The transcripts were read multiple times and notes were taken by the first author (PF) to ensure familiarisation with the data. Initial codes were then generated from the data and codes with a similar meaning were combined to form overarching themes. These themes were reviewed to ensure they represented the data. The final report consisted of data from the transcripts which supported the final themes. All transcripts, codes and themes were validated by the second author (MD).
Ethical approval
Ethical approval was obtained from the two hospital sites. Written consent was provided by each nurse before participating in the focus groups.
Results
A total of 35 nurses took part in the five focus groups. Three focus groups were conducted in site A and two in site B. The majority of participants were female (91.4%, n=32) and had been vaccinated against seasonal influenza in the previous 12 months (57%, n=20) (Table 1). Two themes were identified: duty of care and invasion of personal autonomy.
| Vaccinated | Unvaccinated | Intend to vaccinate | ||||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Focus group 1 (n=6) | 4 | 66.6 | 2 | 33.3 | 0 | 0 |
| Focus group 2 (n=7) | 3 | 42.9 | 4 | 57.1 | 0 | 0 |
| Focus group 3 (n=11) | 7 | 63.6 | 1 | 9.1 | 3 | 27.3 |
| Focus group 4 (n=7) | 6 | 85.7 | 0 | 0 | 1 | 14.3 |
| Focus group 5 (n=4) | 0 | 0 | 4 | 100 | 0 | 0 |
| Total (n=35) | 20 | 57.1 | 11 | 31.4 | 4 | 11.4 |
Theme one: mixed views on mandatory vaccination
Overall, the idea of mandatory vaccination was criticised by nurses and their views were clearly divided among those vaccinated and unvaccinated. Although some vaccinated nurses agreed with implementing mandatory vaccination policy for influenza, the majority strongly disagreed with it.
‘No, not [mandatory] for flu.’
‘Personally I don't. I think there's better buy-in from people.’
Nurses in favour of mandatory vaccination were more likely to have been vaccinated against influenza in the previous 12 months.
‘I would be in favour of it [mandatory vaccination].’
‘Yes, it should be [mandatory].’
The participants said that they had a duty of care and a professional responsibility to protect their patients by accepting the vaccine.
‘I suppose again, I'm talking as an advocate for my patients, our patients are our frequent visitors or current visitors. They're very high risk for infections, and flu could, you know, actually potentially kill them very, very quickly, so if I don't protect myself and I come in with early stages of flu and I give it to someone who's just, literally, out of HDU or transplant and they're on my ward, the flu could potentially kill them so, yeah, I think that, you know, I have to take responsibility to protect myself and them.’
‘There's a responsibility on us to get vaccinated.’
Nurses were also aware of the impact influenza had on vulnerable patients and the role that vaccinating HCWs played in offering indirect protection to patients in healthcare facilities.
‘By mandating it I feel I am protecting myself and my family, yes … I am protecting my patients.’
‘Yeah [to mandatory vaccination], I think if you're working with patients that are vulnerable and they're immunocompromised—all patients that come into hospital are sick.’
In contrast, nurses who did not agree and who were not in favour of mandatory influenza vaccination policy cited multiple concerns, including the fact that the seasonal influenza vaccine needs to be administered annually.
‘I think it shouldn't be mandatory for that reason, because someone has to do it every year’
‘No, simple reason is that it's new every year, it's a different strain you're getting, you're not getting the same strain every year.’
Other nurses also voiced safety concerns as a justification for not implementing mandatory vaccination.
‘I think it's dangerous ground by making it mandatory, because it changes every year and how safe is it every year.’
Theme two: leave nurses to make their own choice on vaccination
Nurses in the focus groups said that implementing mandatory vaccination policy for influenza would invade their personal autonomy and take away their choice to decide to accept the vaccine or not.
‘It's taking away your choice as well, isn't it?’
The participants expressed the view that choice is vital for vaccine acceptance and, by having a choice, they believed vaccination uptake rates would be higher. In addition, they did not agree with being forced to get vaccinated.
‘I think you'd find the uptake will be higher if people have a choice.’
‘If someone doesn't want to take a vaccine for whatever reason, then really I don't agree with forcing them to take it, I really don't.’
Participants also said that they should be more informed about the influenza vaccine and that being informed should be mandatory because this would afford them the opportunity to make an informed decision to accept or reject the influenza vaccine.
‘I think being informed should be mandatory as a healthcare professional should be and I think after that, you should be offered [the chance] to make your own decision.’
Nurses viewed themselves as intelligent professionals who were highly capable of making an informed decision whether to accept the vaccine or not.
‘I think we are professionals and we are intelligent enough to make our own decision whether we want it or not, or whether it's good for us or not, you know.’
It was the opinion of most nurses that implementing mandatory vaccination for influenza would contribute to a significant increase in resistance among staff. They felt this would have a negative impact on vaccine uptake rates.
‘If you push people one way they will definitely dig in their heels and go the other.’
‘There'd be uproar.’
‘There would be huge issues with it in Ireland.’
Other nurses expressed the view that, if the vaccine were made mandatory, there should be an ‘opt-out’ option for HCWs.
‘An “opt-out” option so everybody gets it unless you categorically sign something and say “I am not having this for whatever reason”.’
‘I think maybe the “opt-out” option is fairer, for everybody.’
Discussion
This study found nurses' views varied in relation to mandatory vaccination policy. Although a minority supported introducing it based on patient safety and duty of care, the majority did not and thought it would be a violation of their autonomy and choice. This finding has also been reported elsewhere (Looijmans-van den Akker et al, 2009; Rhudy et al, 2010; Pless et al, 2017; Quinn, 2014; Stead et al, 2019).
Implementing mandatory influenza vaccination policy infringes HCWs' autonomy (Isaacs and Leask, 2008; Quinn, 2014; Pless et al, 2017). The present study supported this view because the majority of nurses considered that implementing mandatory vaccination for seasonal influenza would negatively impact on vaccine acceptance and cause ‘uproar’. This finding was also reported in a recent UK study which found that mandatory vaccination would antagonise those who currently accept the vaccine and also create ‘absolute uproar’ (Stead et al, 2019).
Despite some US states having successfully implemented mandatory influenza vaccination policy for HCWs, multiple ethical issues have been raised, including the infringement of HCWs' autonomy, freedom of choice and damage to staff morale (Stewart, 2009; Hollmeyer et al, 2013; Wang et al, 2017). A recent study conducted in the Netherlands found that measures that give nurses some decisional autonomy such as signing a ‘declination’ form were more acceptable than measures that are merely decreed (Pless et al, 2017). The present study found that giving nurses the option to sign a form and ‘opt out’ of having the vaccine would be more acceptable because they would still be given some choice regarding vaccine acceptance. This indicates that enforced measures such as the use of declination forms might be accepted among nurses within the Irish context. However, according to Stead et al (2019) if declination forms are adopted in the UK, they should be used in a constructive intelligence-gathering manner that avoids stigmatising HCWs.
Although nurses' influenza vaccination uptake rates have increased slowly over the years since national reporting first began (O'Lorcain et al, 2019) implementing an enforced measure such as mandatory vaccination might reverse this and have a negative impact on vaccine acceptance. In addition, it is evident that mandatory vaccination policy raises several ethical issues. According to van Delden et al (2008), if voluntary vaccination programmes are able to increase vaccine uptake to over 50% of the relevant HCWs, mandatory vaccination programmes are not necessary. This was observed in two randomised controlled trials (Carman et al, 2000; Hayward et al, 2006) where vaccination in the intervention facilities varied between 43.2% and 50.9%, indicating that even a moderate increase in HCWs vaccine uptake may have a significant impact on patient outcomes (van Delden et al, 2008). In addition, a recent UK systematic review also reported low-quality evidence that a mandatory influenza policy was associated with an increase in vaccine uptake (National Institute for Health and Care Excellence, 2018).
Vaccination of HCWs plays an important role in preventing nosocomial transmission of influenza in healthcare facilities and, although mandatory vaccination policy has the potential to increase vaccination rates, concerns remain about its acceptability. This year, health services will face a significant challenge, with COVID-19 and seasonal influenza potentially occurring at the same time. To improve HCW influenza vaccine uptake rates, in the absence of mandatory vaccination policy, it is essential to tailor interventions to the needs of different categories of HCWs. In the Irish context, mandatory vaccination policy for seasonal influenza is not favoured by frontline nurses and the potential for resistance is evident. Mandatory training or access to high-quality evidence for HCWs about influenza and the vaccine may also result in an increase in vaccination uptake without a mandatory policy (Carter and Yentis, 2018; Flanagan et al, 2020).
Despite years of intensive voluntary vaccination campaigns, persistently low vaccine rates in nurses have been observed and, for the previous influenza season, uptake rates were reported to be 50.4% for nurses employed in acute hospitals in Ireland (O'Lorcain et al, 2019). Although improvements in vaccination coverage have been observed since national reporting first began, challenges exist in reaching the target of 75%.
Limitations
There are several limitations to qualitative methods and especially focus group discussions due to the small sample sizes. Although five focus groups were undertaken in this study, this was limited to two hospital sites only. Therefore, the generalisability of the findings is limited by the self-selected sample of nurses recruited at two hospital sites. However, a substantial number of nurses participated in the focus groups in this study, which ensured data saturation was reached. The majority of nurses participating in this study had been vaccinated against influenza in the preceding 12 months, which may also be a limitation.
Conclusion
This study provides information for policymakers on nurses' views in relation to mandatory vaccination for influenza. Nurses in this study regarded influenza vaccination as an individual choice despite being aware of the evidence and rationale supporting HCW vaccination on patient safety. Although nurses are currently given the freedom to decide whether or not they wish to accept or reject the influenza vaccine, uptake rates remain disappointingly low.