Overall, 29 of the 34 invited stakeholders (85.3%) participated in the study. Three identified stakeholders refused to participate and another two could not be contacted. The remaining 29 participants were responsible for or involved with the delivery of occupational influenza vaccination in 82 responding hospitals out of 92 hospitals of interest from the three states. These hospitals were classified, as per the Australian government’s myhospitals website, into the following categories: 54 general, 25 tertiary, and 3 specialist. Sixteen participants represented single sites, 8 represented 2–5 sites, 3 represented 6–9 sites, and 2 represented more than 9 sites. The vaccine was provided freely to employees at all sites.
Structure and resources associated with the campaigns
When asked about the existence of a formal written policy regarding employee influenza vaccination, a reference was generally made to a policy published by the state health department, which states that the uptake of the influenza vaccine by HCWs is “highly recommended.” Only one participant reported that influenza vaccination of the staff at their site is “essential,” and that their site requires employees who refuse vaccination for any reason to discuss with their manager the risk of being unvaccinated and of possible exposure to a patient with influenza. At this site, any staff member who declines to receive the influenza vaccine (because of an allergy, illness, or non-medical reason) is required to complete a declination form.
In order to make the influenza vaccine easily accessible at their hospitals, numerous strategies to deliver the vaccine have been utilised. These range from having permanent “drop in” staff health clinics to temporary clinics (within wards or the staff cafeteria) and using mobile carts. However, not all sites have the capacity to run a fixed clinic; those that do not rely on mobile carts to deliver the vaccine. At one hospital, the wards are responsible for vaccinating their own staff, while at other sites, temporary vaccine clinics are set up to vaccinate staff en masse over two days. The importance of using mobile carts was highlighted, as it was felt that going to the staff members in their own settings indirectly placed “pressure” on them, which resulted in higher uptake rates.
"We run two 12-hour flu vaccination days over two days. … We have five to six vaccination stations and a triage section … We have people checking the consents and then people just flow through so it’s very, very quick when we have, you know, six vaccination stations going and they have their vaccine and then go back to work. (Tertiary hospital, 500 beds)."
In most instances, the vaccine campaigns also target non-clinical staff such as volunteers, students, laboratory staff, ancillary staff, and the health service childcare centre staff.
Staffing and resource issues
The need for surge staff to assist with the initial weeks of the campaign was not uncommon, while in other instances staff had to be “rationed” so that all sites were serviced. The capacity to increase the number of clinics run or the hours they are open for was deemed to be limited because of these staffing constraints.
"I think we would probably get higher compliance if we had more time, like we can only spend so much time…(Tertiary hospital, 200–500 beds)."
Aside from being responsible for organising general staff health activities, staffing the vaccine clinics, and promoting and educating, participants are also involved in other infection control activities, such as exposure management. The vastness or relentlessness of the “task” each year was often mentioned, while the lack of support or resources available from within the hospital setting was highlighted. One participant went as far as to say that during “the six weeks of the flu campaign, all of our other work goes on hold.”
"It’s hard work given it’s quite a negative environment and poorly resourced.(Tertiary hospital, 100–200 beds)."
It was not uncommon for participants to spread their time over multiple sites, with one participant even reporting that they are responsible for staff vaccination at 19 sites. Participants who estimated that their coverage rates were above 50% were generally only responsible for a single site, and often commented on the considerable amount of resources available to them.
Informing and educating staff
The need to continually promote the importance of getting vaccinated at every opportunity was a common theme, with many participants relying on the resources produced by the drug companies to promote the vaccine. A wide range of methods were utilised to inform staff about the availability and need for influenza vaccination, with multiple strategies often being adopted. Emails were the most common method, followed by newsletters or flyers. Other approaches mentioned included posters, payslips, pop-up screen reminders, letters from hospital directors, and setting up booths in the cafeteria. Some indicated that they provided information and education at orientation days and at grand rounds (medical and nursing).
"As we see people, we’ll say “we’ll see you next year at flu season time”, and if there’s any reluctance then we’ll discuss matters with them out of season. The education is ongoing. (Tertiary hospital, >500 beds)"
"We put posters around everywhere. I sent out letters to all heads of department, and you know, and these are all round the hospital, but it doesn’t seem to make any difference, really, for the uptake. The only time the uptake really increases is if there’s a, like swine flu, like in bird flu, SARS, you know, like when SARS was around, when people are really scared, when the media kind of starts to kind of scare everybody to come. (Tertiary hospital, >500 beds)."
Less common approaches included providing an eight-minute DVD to staff, produced by one of the main vaccine distributors, which challenges staff to consider whether “they can afford the flu.” Last, one group highlighted that they had instigated an “ask the expert” helpline so that staff members could get their questions about the disease and the vaccine answered by a medical staff member located at the hospital.
"A letter goes out from the general manager as well as the director of clinical services, strongly advising that staff have the vaccination. We present at grand rounds, the medical grand rounds and nursing grand rounds. There’s an email reminder and flyers and we’ve tried an “ask the expert” kind of strategy so people that have got questions about flu vaccination ring someone that is an expert in that so we have a doctor that agreed to participate in that. It’s in all the newsletters and all that kind of stuff. (Tertiary hospital, 500 beds)."
"As soon as the vaccine arrives, they start walking around a lot with their high visibility vests on that have got the flu bug on the back. (General hospital, 200–500 beds)"
Motivators driving vaccination
The use of incentives was a common factor, with many relying on the products provided by the vaccine manufacturer (often a lollipop). Participants highlighted that it was common for staff not to turn up at the vaccine clinic if they found out the incentives were not available or had run out. Not all incentives were targeted at the individual, with some sites awarding a monetary prize (partly donated by the vaccine manufacturer) to the ward that had the highest overall levels of influenza coverage. However, the ability to routinely provide this type of incentive was not ubiquitous. In many instances the hospitals were unable or reluctant to provide any incentives, with one participant saying that they had used gifts donated by volunteers, and unwanted “Christmas” presents, to make up raffle prizes, or had dipped into their own department budget to buy chocolates as incentives. Due to funding issues, most of the perks (such as morning teas for staff during the vaccine clinics) had ceased.
"If we didn’t actually have the lollipop I think we’d have less people being vaccinated, because whenever we run out there’s a mass walkout. (Tertiary hospital, >500 beds)."
"Can we get a coffee thing to get people to come down? There’s no money in it. The hospitals have no money and … so nothing more than giving the lollipop works. (Tertiary hospital, 100-200 beds)."
The positive effect of having champions within the hospital system actively promoting the need for staff to get vaccinated, or “rolling up their sleeve” and getting vaccinated as an example, was spoken about. On the flipside, others commented on the negative impact of having managers or senior hospital staff who did not support influenza vaccination.
"We lost our CEO … he was an absolute wonderful, wonderful support. Every year he used to have his photo taken whilst we gave him his flu vaccine … But this year, he actually left at the end of last year, and our new (CEO) … they just weren’t interested. They didn’t want to do it. (General hospital, 200–500 beds)"
"There are a lot of clinical people and people in senior clinical roles who are anti influenza vaccination, which just amazes me … We have one in (a high risk) department and it’s a very senior level, and that person loves to tell them all every year it’s a waste of time. You know, it’s just gonna make you sick. You’re gonna get the flu from it, you’re gonna be ill. (General hospital, 200–500 beds)."
While declination forms had been implemented in some sites, the practice was deemed to be resource intensive and associated with staff animosity and other problems. Participants believed that the problems stemmed from the fact that receiving the vaccine was not “mandatory,” so there was no governance behind the action. They could not “force” the staff members to complete the form, and too many thought it was a “pointless activity in the end,” and had abandoned the use at most sites within a season.
"We have tried to do that in the past. This year we didn’t because it always creates a lot of animosity. (General hospital, 100–200 beds)."
"Yeah, it was a problem in terms of staff relations. They felt they were being forced to do something they didn’t believe in and yeah, so we haven’t used a declaration, an opt-out policy. Not again anyway. (Tertiary hospital, >500 beds)."
"You need more staff members … You need extra resources for all of this and for arguing and if you had to explain why they didn’t have it … you’d just need more resources. Until people fund this, it’s not possible. (Tertiary hospital, 100–200 beds)."
Difficulties of keeping vaccination records
While some form of record keeping was done at most sites to document on-site staff influenza vaccination, not all hospitals had the capacity to maintain electronic databases and instead relied on hard copy consent forms as evidence of uptake. Many commented on the enormity of the task of manual entry for the coverage data each year. Generally, there were no organised mechanisms for recording off-site vaccination or for keeping records for personnel not directly employed by the hospital (agency staff, volunteers, students, etc.) due to resource constraints and feasibility issues.
"It’s an extremely resource intensive job. So you know, if you’re looking at 1,200 staff, putting that data into the database every year, we don’t have the resources to do it. (General hospital, 100–200 beds)."
"We did have an intranet database for the last two seasons, so we were able to have online graphs which drilled down to hospital, you know, department, and category of staff. That wasn’t able to be supported. It was linked to the payroll, so they actually gave an accurate record of who was vaccinated or who received vaccination from the staff clinic, but yeah, it wasn’t supported this year so we’re just back to doing our own by staff category, hospital graphs in an Excel kind of format. (Tertiary hospital, >500 beds)."
The problems associated with not having databases ranged from not being to track staff members who were unvaccinated through to not being able to identify wards and departments with overall low uptake rates. Participants spoke of the frustration of not being able to appropriately target areas with low uptake with the appropriate resources or education.
"It’s a bit difficult for us because the real denominator is not that accurate. We always get problems with getting the real denominator … staff are on leave, temporary staff, bank staff to filter through that. (Tertiary hospital, >500 beds)."
While the available vaccine coverage data (or estimates) were conveyed back to either the ward managers or the hospital board, the information was neither being strategically utilised as patient safety indicators nor being made available to staff.
Future directions: need for a culture change
When asked to comment on whether they felt their hospital and/or staff would support a mandatory influenza vaccination policy, the response was extremely mixed. For the participants who stated that there would be outright hospital support, the main reason provided was that the policy would promote patient protection and would reduce personal risk and sick leave among staff. One participant felt that it was the only way to increase coverage figures among their staff. Others felt that it would be supported if the policy or directive came from the state health department. However, numerous comments were made about the problems associated with implementing this type of policy, with most remarking that the difficulties lay in not having enough infrastructure and resources to provide a vaccine that needs to be administered on a yearly basis. One participant stated that there needed to be a “culture change” around vaccination support before they could implement a mandatory vaccination policy.
"How can you make it compulsory? Are you saying people can’t start their shift? I just can’t imagine how, you know, I’d be standing at the front door, [saying], “You can’t go to your shift until I’ve jabbed you. (General hospital, 50–100 beds)."
When asked to comment on whether staff would support a mandatory vaccination policy, it was felt that there would be little support among staff. Some stated that they felt their staff would see it as a violation of their rights. However on the flipside, others felt that if there were consequences associated with not complying, or if the policy were instigated from the state or national health department, then it would be accepted and complied with.
"But you know, if they’re told, “well, you take it, or you don’t come to work,” they tend to take it. (Tertiary hospital, >500 beds)."
"I know the ones that will never have the influenza vaccine and I don’t think anything will change that, unless of course they are definitely told if you’re not going to have it, you can’t work. (Tertiary hospital, 50–100 beds)."