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American Journal of Infection Control 41 (2013) 737-9

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American Journal of Infection Control

journal homepage: www.aj ic journal .org

American Journal of Infection Control

Brief report

Influenza vaccination knowledge and perceptions among Veterans Affairs nurses

Andrea R. Jennings DrPH, RN a,*, Christopher J. Burant PhD b

aGeriatric Research, Education, and Clinical Center, Louis Stokes Department of Veterans Affairs Medical Center, Cleveland, OHbCase Western Reserve University at the Frances Payne Bolton School of Nursing, Cleveland, OH

Key Word:Nurses’ flu vaccination knowledge

* Address correspondence to Andrea R. Jennings, DEducation, and Clinical Center, Louis Stokes DepartmeCenter, 10701 East Blvd 111C (W), Cleveland, OH 4410

E-mail address: andrea.jennings2@va.gov (A.R. JenConflicts of interest: None to report.

0196-6553/$00.00 - Published by Elsevier Inc. on behhttp://dx.doi.org/10.1016/j.ajic.2013.01.005

Flu vaccination among nurses in the Veterans Health Administration system is crucial in the preventionof influenza. Nurses working at a Veterans Administration Medical Center completed the InfluenzaVaccination Knowledge and Perceptions Survey. The findings from this survey suggest the need foradditional education for nurses as it relates to flu vaccination.

Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control andEpidemiology, Inc.

Influenza is a highly contagious disease and is associated withpotentially high rates of morbidity and mortality in the VeteransHealth Administration (VHA) system. It is projected that thenumber of veteran patients older than age 65 years is expectedto reach 2,437,000 by 2020 with a disproportionate rate of thispopulation utilizing inpatient and outpatient services as a result ofhaving multiple chronic conditions causing immune systems to befurther compromised if the influenza virus is contracted.1 Accord-ing to the Centers for Disease Control and Prevention, influenzacases on average result in approximately 226,000 hospital admis-sions and 36,000 deaths annually.2 VHA employees are atan increased risk of acquiring influenza due to the exposure ofhospitalized and outpatient veterans who have influenza. More-over, health care personnel could be potential reservoirs fortransmitting the disease from patient to patient.3 Achieving theVeterans Affairs vaccination goal of 85% for VHA employees isa work in progress and educational efforts emphasizing theimportance of VHA personnel receiving the influenza vaccinationshould continue throughout the VHA system.4 The Association forProfessionals in Infection Control and Epidemiology, the InfectiousDiseases Society of America, the Advisory Committee on Immuni-zation Practices, and the Society for Healthcare Epidemiology ofAmerica have all alerted health care organizations to developstrategies to increase influenza immunization rates among healthcare professionals. VHA employees had a 54% documentation ofseasonal influenza vaccination during the 2010-2011 influenzaseason compared with a vaccination rate of 77% in 2009-2010.During the 2009-2010 season, Veterans Affairs physicians reported

rPH, RN, Geriatric Research,nt of Veterans Affairs Medical6.nings).

alf of the Association for Professio

the highest rates of vaccination at 88.7%, followed by nursingassistants and licensed practical nurses at 71%, and health careworkers younger than age 50 years had the lowest rates of vacci-nation.4 The National Health Interview Survey documented thenation’s health care personnel vaccination for the 2010-2011season rate at 63%. Results from this survey illustrated that physi-cians had a vaccination rate of 77.6% and nurses had a vaccinationrate of 75.7%. Influenza vaccination rates varied by age, with healthcare professionals in the 18-29 group at 56.2% and those aged60 years and older at 67.8%. In addition, influenza vaccination ratesvaried by work setting, with health care professionals workingin the hospital at 77.8% and those working in a longeterm-carefacility at 45.1%.5 Thus, in this study knowledge and perceptionsof Veterans Affairs nurses as it relates to the influenza vaccinationwere assessed.

METHODS

For this study, the Influenza Vaccination Knowledge andPerceptions Survey was utilized and administered by the nurseresearcher to nurses at 1 Veterans Affairs medical center over a4-month period. The questionnaire took approximately 10 minutesto complete. The nurse researcher explained the purpose of thequestionnaire to the nurses and obtained their verbal consent toparticipate in this study, which was approved by the InstitutionalReview Board at the Veterans Affairs medical center.

Survey

The knowledge questions from the Influenza VaccinationKnowledge and Perceptions Survey were based on the NationalFoundation for Infectious Disease InformationMyth and Fact sheet.6

The content from this resource was utilized to develop the multiplechoice questions for this study. TheMyth and Fact sheet specifically

nals in Infection Control and Epidemiology, Inc.

Table 1Correct answers from the Influenza Vaccination Knowledge and Perceptions Surveycorrelated with number of nurses who received vaccination (N ¼ 203)

QuestionPearson

correlation

1. Which of the following statements are true regarding nurseswho are at risk for getting influenza?

.099

2. Which of the following statements are true regarding influenzasymptoms and the transmission of the influenza virus?

.204*

3. Which statement is correct regarding influenza vaccination? .193*4. Which statement is true regarding the types of influenza

vaccine?.136

5. The influenza vaccine can be expected to reduce influenzaillness by approximately?

.272*

6. Which statement is true regarding antibiotics and the influenzavaccine?

.115

7. Which statement is true about when to get the influenzavaccine?

�.042

8. If you do not regularly receive the influenza vaccine,state the reason why you do not:

Personal beliefs �.197*Afraid of getting ill �.143y

Feel that you do not need it �.153y

9. Do you believe that the flu vaccination should be mandatoryfor nurses?

�432*

10. Do you agree that the influenza vaccination remains the bestway for nurses to protect themselves, their families, and theirpatients during the annual influenza season?

�.544y

*Correlation is significant at the .01 level (2 tailed).yCorrelation significant at the 0.5 level (2 tailed).

A.R. Jennings, C.J. Burant / American Journal of Infection Control 41 (2013) 737-9738

targets health care workers and focuses on common misconcep-tions of influenza. There are a total of 10 questions (ie, 7 knowledgequestions and 3 perception questions) on the survey. The survey hasnot yet been evaluated for testeretest reliability; however, it hasface validity because the questions can be reasonably expected toelicit information about the respondent’s perceptions and knowl-edge about the influenza vaccination. Before utilizing this survey, itwas piloted to 4 nurses at the medical center. One of the 4 nursesspecialized in the field of infection control. The nurses gave theirfeedback about the survey and revisionswere done by the author. Inthe original survey, some of the questions were presented as fill-in-the-blank questions. The nurses all agreed that multiple choicequestions would be a more acceptable format and less timeconsuming for their colleagues to complete. Thus, the questions onthe survey were formatted as multiple choice questions.

Sample

The study consisted of 203 nurses working on different shiftsand units at a single VAMC. No one refused to participate in thestudy; thus, the nonresponse rate was 0. Convenience samplingwas utilized in this study. One hundred twenty-eight (63%) nursesin the study were registered nurses 128, 39 (19%) were licensedpractical nurses, and 36 (18%) were nursing assistants/students. Interms of level of education, most had a bachelor’s degree 67 (33%),63 (31%) had an associate’s degree, 49 (24%) did not have a degree,and 24 (12%) had a master’s degree or higher. The majority (n¼ 114[56%]) of nurses worked on a medical surgical unit or medicalintensive care unit/surgical intensive care unit, 29 (15%) worked inother administrative/research units, 25 (12%) worked in long-termcare units, 21 (10%) worked in emergency departments, and 14(7.0%) worked in ambulatory care. Most nurses (n ¼ 93; 41%) had>10 years of experience, 72 (35%) had >5 years of experience, and48 (24%) had 1-5 years of experience. Themajority of nurses did notget the flu vaccination in 2009-2010: 109 (54%) compared with 94(46%) who did get the flu vaccination.

RESULTS

Percentages for each of the questions are described and thequestionnaire is available to readers upon request from the authors.Pearson correlational analyses were done to illustrate the rela-tionship between the correct answers for each question in thesurvey with those nurses having received the flu vaccine (Table 1).To the knowledge question, “Which of the following statements aretrue regarding nurses who are at risk for getting influenza?” 7%chose the response, “You are healthy and there is no need to worryabout getting influenza,” 14% chose, “As someone who works ina health care environment, you have been exposed to germs thatmade you immune to influenza,” 64% chose “Health care workerscan have an increased risk of exposure to influenza due to thenature of the job,” (this is the correct answer), and 15% chose, “All ofthe above.” To the question, “Which of the following statements aretrue regarding influenza symptoms and the transmission of theinfluenza virus?” 15% chose the response, “Even if you do not showsymptoms of having influenza yet, the virus is unable to be trans-mitted to patients,” 20% chose the response, “Health care workersinfected with influenza are unable to transmit the highly conta-gious virus to patients in their care,” 51% chose the response,“Preventing the incidence of influenza virus protects patients andmay save lives” (this is the correct answer), and 14% chose theresponse, “All of the above.” To the question, “Which statement iscorrect regarding influenza vaccination? 19% chose the response,“Vaccination of health care workers can prevent the incidence ofinfluenza in health care settings,” 15% chose the response, “The

influenza vaccination is the most effective method for preventinginfluenza virus infection,” 6% chose, “Health care worker vaccina-tion is important for influenza prevention and control,” 18% chosethat only the first and third options were correct, and 42% chosethat all of the options were correct (this is the correct answer). Tothe question, “Which statement is true regarding the types ofinfluenza vaccine?” 36% chose the response, “Trivalent inactivatedinfluenza vaccine contains killed viruses and thus cannot causeinfluenza, 21% chose the response, “Live attenuated influenzacontains live, attenuated viruses and therefore does have thepotential to produce mild signs or symptoms related to attenuatedinfluenza virus infection,” 34% chose that the both the first andsecond options were correct (this is the correct answer), and 9%responded that none of the options were correct. To the question,“The influenza vaccine can be expected to reduce influenza illnessby approximately.,” 20% chose 100%, 56% chose 70%-90% (this isthe correct answer), 19% chose 50%, and 5% chose 20%-30%. To thequestion, “Which statement is true regarding antibiotics and theinfluenza vaccine?” 18% chose the response, “Influenza is a bacterialinfection and cannot be treated by antibiotics,” 57% chose, “Takingantibiotics when they are not needed contributes to the seriousproblem of antibiotic resistance (this is the correct answer), 14%chose, “Antibiotics are a substitute for the influenza vaccine,” and11% chose that all of the options were correct. To the question,“Which statement is true about when to get the influenza vaccine?”19% chose the response, “By January, it is too late to get the influ-enza vaccine, 66% chose, “The CDC recommends that the influenzavaccination begin as soon as health care providers have the vaccinein stock and should continue through April,” 10% chose, “Vaccina-tion in January is medically beneficial and necessary to protect asmany people as possible” (this is the correct answer), and 5% chosethat none of the options were correct.

The perception questions from the survey included, “If youdo not regularly receive the influenza vaccine, select the reasonwhy you do not.” Response options were, “Too time consuming”(31.5% [yes] and 68.5% [no]), “Personal beliefs” (37.9% [yes] and62.1% [no]), “Afraid of getting ill” (21.1% [yes] and 78.8% [no]), and“Feel that you do not need it” (21.7% [yes] and 78.3% [no]). To the

A.R. Jennings, C.J. Burant / American Journal of Infection Control 41 (2013) 737-9 739

question, “Do you believe that the flu vaccination should bemandatory for nurses?” 16.9% agreed, 27.1% were neutral, and 56%disagreed. To the question, “Do you agree that the influenzavaccination remains the best way for nurses to protect themselves,their families, and their patients during the annual influenzaseason?” 38.5% agreed 27.0% were neutral, and 34.5% disagreed.

Results of the correlational analyses revealed that nurses whoreceived the flu vaccinationwere more likely to provide the correctanswer to the questions, “Which of the following statementsare true regarding influenza symptoms and transmission of theinfluenza virus?” (P ¼ .004), “Which statement is correct regardinginfluenza vaccination?” (P ¼ .006), and “The influenza vaccinecan be expected to reduce influenza illness by approximately.”

(P ¼ .000).Those participants who did not get the flu vaccine were more

likely to claim personal beliefs for not doing so (P ¼ .005), wereafraid of getting ill from the vaccine (P ¼ .042), and believed thatthey did not need it (P ¼ .029). Nurses who received the flu vaccinewere more likely to agree that the flu vaccination should bemandatory for nurses (P ¼ .000) and were more likely to agree thatthe influenza vaccination remains the best way for nurses to protectthemselves and their patients (P ¼ .000).

Limitations

A larger sample size of Veterans Affairs nurses from otherhospitals would have provided a broader understanding of fluvaccination knowledge and perceptions. The age of the studyparticipants was not asked in this study. Including age as a demo-graphic variable would have provided additional insight about thepotential relationship between age and nurse vaccination. None-theless, the data from the study provides for continuing discussionon how to better educate Veterans Affairs nurses about flu vacci-nation knowledge.

IMPROVING INFLUENZA VACCINATION RATES AMONG HEALTHCARE PERSONNEL IN VHA: CURRENT EFFORTS

The Veterans Affairs Influenza Manual 2011-2012 outlinesseveral strategies to improve vaccination rates among VHA healthcare personnel and encourages quality improvement activities totrack the progress of these strategies.4 The strategies includevaccination access issues, documentation and tracking, educationalprogramming, and team oriented/organizational approaches. Oneinitiative addressing access is making the vaccine available for staffearlier in the influenza vaccination season. Having infection controlnurses and volunteer nurses assigned to mobile carts to administerthe vaccine on all units throughout the influenza season is key inboosting vaccination rates. Having extended hours for the occu-pational health clinic so that the vaccine is easily available to healthcare personnel will also address the access issue.

Infection: Don’t Pass It On7 is an initiative that encouragesVeterans Affairs facilities to train all employees responsible fordocumentation on the correct procedures for entering vaccinationdata in the Occupational Health Record-Keeping System. Thisinitiative will reduce the underreporting of vaccination rates and

allow for a tracking system to identify which health care personnelwere vaccinated. Using postcards to remind health care personnelwhere and when to get vaccinated may be helpful.

To dispel the many myths associated with the influenza vacci-nation, continuous educational efforts must take place throughouteach Veterans Affairs facility. Educational training on the impor-tance and effectiveness of the influenza vaccine must occur ata variety of venues in each facility (eg, grand rounds, staff meetings,health fairs, and journal clubs). Adding an influenza vaccinationmodule to the standard curricula of training requirements for allhealth care personnel may boost knowledge about the vaccination.

Forming an interdisciplinary team consisting of representativesfrom nursing, occupational health, infection control, pharmacy,medicine, and public relations departments to oversee an influenzavaccination campaign tailored toward health care professionalsshould be encouraged. The team members need to meet ona consistent basis throughout the year to develop creative strate-gies to boost influenza vaccination rates among health careworkers. Involving the facility director, service chiefs, and nursingadministration to help lead a campaign to increase influenzavaccination rates among health care personnel is essential inillustrating that there is a real commitment to this issue.4

CONCLUSIONS

Based on the results of our study, personal beliefs are a majorfactor to consider when discussing influenza vaccination ratesamong nurses. When considering personal beliefs, the principlesof the Health Belief Model (ie, perceived susceptibility, perceivedseverity, perceived barriers, and perceived benefits) should bediscussed with nurses as an educational strategy in hopes ofshedding light about why vaccination is or is not probable. Onerecent study illustrated that those employees who had experiencewith influenza as an illness and those who chose to get vaccinatedover a period of time resulted in a change of health beliefs in favorof vaccination.8

References

1. Geriatrics and extended care strategic plan. Patient care services. VeteransHealth Administration, Department of Veterans Affairs web site. Available from:http://vaww.geriatrics.wss.va.gov/stratplan/default.aspx. Accessed October 31,2012.

2. CDC. Prevention and control of influenza: recommendations of the advisorycommittee on immunization practices (ACIP). MMWR Morbid Mortal Wkly Rep2008;57:1-60.

3. Influenza immunization among health care personnel. National Foundationfor Infectious Disease web site. Available from: http://www.nfid.org/pdf/publications/healthcarecta08.pdf. Accessed December 28, 2011.

4. How to improve vaccination rates in VHA health care personnel. The VA influ-enza manual 2011-2012. Available from: http://www.publichealth.va.gov/flu.Accessed January 24, 2012.

5. Health care personnel flu vaccination. Available from: http://www.cdc.gov/flu/professionals/vaccination/health-care personnel.htm. Accessed March 1, 2012.

6. Healthcare workers and influenza: fact sheet on common misperceptions ofinfluenza. Available from: http://www.nfid.org/idinfo/influenza/give-factsheet.pdf. Accessed February 7, 2012.

7. Infection: don’t pass it on. Available from: http://www.publichealth.va.gov/InfectionDontPassItOn. Accessed March 1, 2012.

8. Shahrabani S, Benzion U. How experience shapes health beliefs: the case ofinfluenza vaccination. Health Educ Behav 2012;39:612-9.