The piece below was first published in a publication called “Connections” by the Australian College of Nursing (then the Royal College of Nursing).
It is a fully referenced article that looks at whether Health Care workers should feel morally obliged to get a yearly flu shot in order to protect their patients. It is an exploration of the moral and ethical issues involved and does not necessarily represent my opinions.
The Flu shot: Is it a nurses a moral obligation?
There is a large collection of evidence demonstrating the efficacy of staff influenza vaccination, yet uptake remains low. Should nurses be considering the seasonal vaccine as a moral obligation? Or should the vaccine be mandatory? If not, what can hospitals do to improve staff vaccination rates?
There is a relatively large evidence base establishing the effectiveness of the influenza vaccine in reducing the morbidity of staff and patients in getting both influenza and influenza like symptoms (amongst some are: Carmen et al 2000, Stewart et al 2002, LaVela et al 2004, M Wu & Abrutyn 2004, Bryant et al 2004, Hoffman 2005, Burls et al 2006, Lugo 2007, Bellei et al 2007, Steckel 2007). That is to say, as staff vaccination for influenza increases so does healthcare associated influenza decrease, infection of staff has been shown to reduce by 88% and patient mortality by 50% (Hoffman 2005), or from 17% to 10% (Carman et al 2000). There has been a demonstrated 43% reduction of staff cough (Lester et al 2003, Steckel 2007) and fever and a reduction of absenteeism (according to Lester et al 2003 63%, according to Steckel 2007, 28%), as well as decreased visits to a health care provider and decreased consumption of antibiotics (Steckel 2007). In spite of this large body of evidence staff uptake of the vaccine remains low, below 50% (Hoffman 2005, King et al 2005), at 36% in the U.S (Nichol 2003, Goldstein 2004, Steckel 2007) and between 20-50% in Australia (anon 2007b).
The discussion of the influenza vaccine is different to that of other vaccines such as hepatitis and pertussis where vaccination and adequate serology levels must demonstrated to avoid work restrictions since work restrictions are not placed on those who decline yearly influenza vaccination (Occupational Assessment Policy Directive NSW 2007). Applying work restrictions on nurses who decline yearly seasonal influenza vaccination is naturally impractical since it would most likely result in a relatively large proportion of the work force being unable to work during the winter months.
Considering we work in an era where best practice should be evidenced based, in the absence of restrictions on those not receiving the influenza vaccine could it be considered that nurses have a moral obligation to get the yearly influenza vaccine? It is not uncommon to find scholars referring to a ‘duty’ towards the patient which for some includes a duty to be vaccinated (Steckel 2007). Rea & Upshur (2001) ask the question to what extent are doctors (or any health care worker), who have a primary commitment to their patients (Olsen 2006), ethically obliged to take personal actions to prevent their (own) infection in the first instance? The issue at stake here is the principle of nonmaleficence, or ‘do no harm’ (Leung 2001) and they conclude that there does indeed exist a duty to protect the patient from an undue risk of infection from diseases such as HIV and hepatitis, and “mundane” infections such as influenza (Rea & Upshur 2001).
However the issues raised here unintentionally stretch to aspects of nurse behaviour beyond the realms of vaccination; for if one is to consider that staff have a duty to their patients to “do no harm” by getting vaccinated, where in theory does this duty terminate? Does it terminate with a needle or does it extend deeper into other areas of the life of the health care worker, that is to say, do staff have an ethical obligation to ‘stay healthy’ (Hughes 2005) and minimize infection by eating the optimum nutrients, by getting enough sleep and by ensuring they get the recommended amount of exercise in order to strengthen their immune systems? Such questions cannot be tackled here.
It is not easier to turn to the question of mandating the influenza vaccines; this too has great ethical complications, compromising an individuals’ right to making autonomous decisions. It must be remembered that no vaccine is without its’ own risk of adverse reactions (Bonhoeffer & Heininger 2007) and in addition is known to have variable efficacy (Lugo 2007).
With such complex ethical arguments surrounding staff influenza vaccination it would benefit hospitals to develop a strong promotional program for the influenza vaccine in order to maximize voluntary staff uptake of the vaccination. Thus evidence based strategies for improving staff vaccination rates must be employed which would include knowledge of motivating and preventative factors affecting vaccine uptake (Roush 2005), staff education (Lugo 2007, Roush 2005) and improved accessibility of vaccine to all staff (Cooper 2002).
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Anonymous Nurses Urged to fight flu (2007b) Australian Nursing Journal 14(9):7
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Occupational Assessment, Screening and Vaccination against Specified Infectious Diseases, Policy Directive NSW Health (2007)
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_006.pdf (accessed 16/3/10)
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Stewart S, Murray S & Skull S (2002) Evaluation of Healthcare worker vaccination in a tertiary Australian hospital Internal Medicine Journal 32:585-592