We continue to be beset with misinformation that undermines uptake of the annual flu vaccine, and that may explain why almost one-third of homecare nurses report that they think the shot is unsafe.
The attitudinal survey did not assess whether the workers were actually immunized, but few likely were because attitudes were generally predictive of compliance with infection control measures.
“Only 70% of the sample felt that the influenza vaccine was safe,” said lead author of the study David Russell, PhD, a sociology professor at Appalachian State University in Boone, NC. “I worked with an agency on their influenza vaccine, and this was a constant battle. There are a lot of misperceptions. People think they could get sick from the vaccine or that it is ineffective. It’s exactly those kinds of attitudes we are going to have to change to move the needle on infection control.”
This study’s flu shot finding follows similar discouraging trends, including previously reported findings that long-term care workers have very low immunization rates, misinformation about vaccinating pregnant women, and reports that social media trolls target vaccine safety to stir controversy.
For example, the CDC recently clarified that it was not instructing pregnant women to consult with their doctors before getting the flu shot, although they are advised to get the traditional shot and not the live attenuated mist version. For the record, pregnant healthcare workers also should be vaccinated, says a nurse who continued to work for much of her pregnancy.
“I absolutely received the flu shot last year, and every year,” says Laura Kinsella, BSN, RN, CEN, an emergency room nurse in Washington, DC. “Getting a flu shot is one of the most important ways a pregnant woman can protect herself and her baby. Infants cannot receive the flu shot until they are six months old, so they rely on passive immunity from their mothers. It is completely safe for a woman to get a flu shot while she is pregnant.”
The flu shot finding in homecare came out of the initial phase of an ongoing study on nurses’ knowledge, attitudes, and compliance with infection control.
The second phase, in which homecare nurses were observed delivering care, is under analysis and expected to be published this year. The next phase of the study also will include a tool developed by a biostatistician to predict which patients discharged to homecare are more likely to develop infections, Russell says.
Homecare is an increasing infection control issue, as patients are being rapidly discharged after the briefest of hospital stays.
“You have a lot of people coming home from hospitals with wounds, potentially with an existing infection,” Russell says. “There is a lot of responsibility placed on homecare. Almost one out of five rehospitalizations that occur among homecare patients is due to an infection. It is one of the leading causes of why homecare patients go back to the hospital.”
The study analyzed survey responses from 369 nurses working at two certified home healthcare agencies. A series of questions assessed self-reported compliance with infection control measures, knowledge of infection control, and their attitudes toward recommended practices.
Most homecare nurses reported a high level of infection control compliance, correct knowledge, and favorable attitudes. However, “in addition to gaps in knowledge for some [infection control] precautions,” the authors “observed unfavorable attitudes toward certain infection prevention practices,” such as flu vaccination and not reporting to work if sick.
“Given the strong association observed between infection control attitudes and compliance, these results suggest that home healthcare agencies may benefit from offering their staff educational programs on influenza vaccination and employee sick leave policies,” the authors concluded.
In general, attitudes toward practices were more predictive of compliance than knowledge, meaning in part that even if nurses knew the core information they were unlikely to comply with measures if they perceived them as unimportant or unnecessary. This finding was somewhat surprising.
“We thought knowledge — how much nurses knew about infection control — would be the main driver of how well they complied with all the practices,” Russell says. “But, interestingly, it wasn’t. It was their attitude toward infection control. We found that appropriate attitudes toward infection control were predictive of greater compliance. That is consistent with the theory of planned behavior, which suggests that it is not so much what we know about something, but how strongly we feel about it.”
While a knowledge question could include correctly naming a recommended practice, an attitudinal question, for example, was “How serious a problem do you think infection control is in homecare?”
On a scale of zero to 10, with the latter being the highest level of importance, homecare nurses generally answered in the seven to eight range, he said. Lower scores were less likely to comply, and vice versa.
Adding another twist, self-reported compliance with recommended measures typically runs higher than behavior in actual practice, thus the follow-up study of nursing observations, says co-author Jingjing Shang, PhD, assistant professor of nursing at Columbia University School of Nursing in New York City.
The percentage of home health nurses who self-reported compliance with infection control practices exceeded 90% for most of the measured behaviors. “Self-reporting overestimates the true effect,” she says. “I think that the main message from this paper is we find that the knowledge does not translate to the self-reported compliance. We find that their attitude is more important. If they believe infection control is important, it is more likely to translate to action.”
A caveat to that is that knowledge is easier to change than attitudes, she adds.
Questions on PPE revealed, as has been well documented in hospital workers, lack of compliance with eye and face protection was frequently reported. A mere 6% said they wear goggles or an eye shield when there is a possibility of exposure to bloody discharge or fluid. Only 9% said they wear a disposable face mask “whenever there is a possibility of a splash or splatter.” However, 79% said they “wear a gown if soiling with blood or bodily fluids is likely.” Almost one-third of respondents did not know “that hand hygiene should be performed after touching the nursing bag” homecare givers bring into house.
“They carry all of their supplies into the home in the nursing bag, so that can be a potential source of transmission,” Shang says. “The policy is to put a barrier down to make sure the bag is not touching the patient environment. Every time they touch the bag they should clean their hands.”
While compliance with most measures was self-reported as high, the findings in the new in-home observation study are confirming that self-assessments have some bias that can inflate results.
“When we go in with nurses to a patient’s home and observe what they do, the infection control compliance rate is much lower than what they self-reported,” Shang says.
In this unpublished portion of the study, researchers followed 50 nurses working with eight patients each, resulting in 400 care observations.
“We also interviewed the nurses after the observations to ask them questions,” Shang says. “What can help them improve compliance? What are the barriers? It is fascinating to know what nurses are doing in patients’ homes in terms of infection control,” she adds, noting that some of these new data are slated for presentation at the 2019 conference of the Association for Professionals in Infection Control and Epidemiology.
“In hospitals, the environment is more controlled, so that way it means the homecare environment can pose more risk to patients for infections,” she says. “On the other hand, hospitals have a lot of antibiotic-resistant bacteria, so they also pose a different risk to patients. The hospital is a supervised setting, but in homecare usually only one nurse goes to see the patient and their family members. It is easier not to follow the rules.”
- Russell D, Dowding DW, McDonald MV, et al. Factors for compliance with infection control practices in home healthcare: findings from a survey of nurses’ knowledge and attitudes toward infection control. AJIC 2018;46(11):1211-1217.