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Methods

The study design and methods are described elsewhere.⁹ Briefly, the data were derived from a survey that was offered to a random sample of 1,000 inpatient registered nurses (RNs) employed at Mayo Clinic. The 93‐item survey included 7 questions that evaluated RNs' preferences with respect to participation in an influenza prevention program and assessed their receptivity to mandatory influenza vaccination policies, as well as mandatory policies for several other vaccines (see Table 1) (no RNs saw all survey items because of skips). Specific questions of high importance asked RNs to indicate whether they believed that mandatory vaccination of HCWs was appropriate with respect to the following conditions: hepatitis B, influenza, measles, rubella, and varicella (chickenpox). The survey also included an item that asked “Would you support a policy that required all healthcare workers with direct patient contact to receive annual influenza vaccination (a flu shot or the nasal spray influenza vaccine) unless there is a medical or religious contraindication or a signed, informed declination?” The survey also included questions related to information receipt, knowledge, and behaviors related to vaccination and influenza‐like illness.⁹ Responses for these items were used to evaluate the relationship between various factors and HCWs' opinions about influenza prevention programs and policies.

Table 1.  Preferred Mode of Participation in Influenza Prevention Among 513 Registered Nurses at Mayo Clinic

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The survey was administered using a secure internal Web site, and data were automatically entered into a database (SurveyTracker E‐Mail/Web 4.5 Survey Software for Web Surveys; SurveyTracker). Descriptive statistics, the χ² test, and the Fisher exact test were used. P values less than .05 were considered statistically significant.

Results

The demographic characteristics of survey respondents have been described elsewhere.⁹ The response rate was 51.8% ( ), and 490 (95.5%) of the RNs reported having regular work contact with infants, elderly persons, or persons who are chronically ill or have compromised immune systems. Only 331 (64.5%) of the respondents reported that they intended to receive influenza vaccination during the upcoming season.

Respondents were much more likely to favor receiving some form of influenza vaccination (426 of 513 [83.0%]), compared with any other option for helping to prevent influenza (Table 1). The majority of RNs reported that mandatory vaccination policies were appropriate with regard to hepatitis B (457 [89.1%]), rubella (431 [84.0%]), measles (428 [83.4%]), varicella (316 [61.6%]), and influenza (283 [55.2%]). More than half of respondents (304 [59.3%]) reported that they would support a policy that required annual influenza vaccination for all HCWs with direct patient contact unless there was a medical or religious contraindication or the HCW provided a signed, informed declination. Many of the respondents who did not support mandatory vaccination responded that they were “not sure” about such policies, rather than stating that they opposed such policies (eg, 11.1% reported that they were not sure whether mandatory vaccination was appropriate for influenza).

The χ² test was used to evaluate the impact of other factors on respondents' opinions about mandatory influenza vaccination. There was no association between most of the factors tested and RNs' opinions about mandatory policies (Table 2). However, there was an association between past receipt of influenza vaccination and opinions about mandatory vaccination. Specifically, of 512 RNs, 290 (65.3%) who had received influenza vaccination in the past also supported mandatory vaccination, whereas only 14 (20.6%) of 68 RNs who had never been vaccinated supported mandatory vaccination ( ). RNs who felt that they had received all the information they needed to make good decisions about influenza vaccination were more likely to believe that a mandatory vaccination policy was appropriate (253 of 431 [58.7%]), compared with those who felt they had not received enough information (16 of 32 [50.0%]) or those who were not sure whether they had received enough information (14 of 42 [33.3%]; .

Table 2.  Association Between the Factors Tested and Registered Nurses' Support for Mandatory Influenza Vaccination for Healthcare Workers (HCWs)

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Discussion

Given the low rates of influenza vaccination among HCWs and our finding that only 64.5% of RNs intended to receive vaccination during the upcoming season (despite working at an institution with widespread education and convenient access), we were surprised that the majority of RNs at our institution (304 of 512 [59.3%]) were in favor of requiring influenza immunization (while allowing informed declination). We believe it is in our best interests, and our patients’, to institute measures that improve patient safety and quality of care. Influenza vaccination requirements may be increasingly accepted as part of a comprehensive employee health and patient safety program. Similar requirements are in place to prevent rubella, measles, mumps, varicella, and hepatitis B, and to screen for tuberculosis,¹⁰ and mandatory requirements for HCWs to receive these vaccinations seem to be well‐accepted by RNs at our institution, as indicated by our survey results.

Other researchers have concluded that mandatory influenza vaccination or policies requiring informed declination are appropriate. Lester et al.¹¹ found that 44% of 670 physicians surveyed believed that influenza vaccination should be mandatory, including 29% of those who had chosen to not receive vaccination. A recent survey of HCWs at 2 tertiary care teaching hospitals revealed that 46% of 1,042 HCWs were in favor of mandatory influenza vaccination.¹²

CDC investigators have concluded that vaccination requirements “that are properly implemented and enforced should be an effective tool in future efforts to reduce healthcare‐associated infections and increase overall quality of care.”^13(p465) However, they cautioned that vaccination recommendations are not likely to be fully adopted without legal requirements.¹³ Recently, influenza vaccination requirements have been codified by professional standards of care,^7,8 Joint Commission standards,⁴ and state laws.¹³ A full list of organizations that have codified such requirements can be found at the National Influenza Vaccine Summit Web site.¹⁴

In 2005, the Virginia Mason Medical Center in Seattle, Washington, implemented a requirement that required all employees to receive annual influenza vaccination unless there was a medical or religious contraindication. Declination for other reasons was not allowed. For the 2006‐2007 season, this institution reported a 98.5% overall influenza immunization rate among employees. Unionized nurses were not required to accept the vaccine, but almost 90% did so when requirements were put into place for the other employees (P. Crome, personal communication, March 2007).

HCWs are regularly exposed to and frequently become infected with influenza.² Healthcare institutions have an ethical obligation to prevent HCW‐to‐patient transmission of the influenza virus, given that safe and effective methods to do so exist. This prevention is particularly important because the majority of RNs in our study reported going to work when ill with influenza‐like illness.⁹ Instituting policies that require annual influenza vaccination for HCWs also protects other HCWs and ensures a healthy workforce in healthcare facilities while simultaneously protecting the health of both patients and the public. This concept of protecting the patients for whom HCWs are privileged to care sits well with professional, legal, and ethical standards of care.