When a nurse midwife recommended delaying the administration of the hepatitis B vaccine (typically given within 48 hours after an infant’s birth), Michael J. Deem, PhD, took the advice, and the family’s pediatrician accepted the decision.

Years later, the family was establishing themselves as new patients at a different pediatric practice. There, staff asked if they planned to delay or refuse any vaccines, explaining that vaccine-refusing families are automatically dismissed without further discussion. “It struck me how different the approach was,” says Deem, an assistant professor at the Duquesne University School of Nursing and the Center for Healthcare Ethics in Pittsburgh.

The realization of how widely disparate practices’ policies were regarding vaccine refusal sparked an interest in exploring whether the same was true of nursing staff. Usually, nurses are the first to learn a family is hesitant or opposed to vaccines. “Nurses often are the ones who counsel families about vaccines. Yet their views are not typically solicited,” Deem observes.

Researchers surveyed 488 primary care nurses in 2018 on their attitudes toward dismissal of vaccine-refusing families, and found significant polarization. Some key findings:

  • 28% of nurses agreed or strongly agreed they would support a decision to dismiss families who refuse all vaccines, and 39% disagreed or strongly disagreed with this practice.
  • 12% supported dismissal for refusal for some, but not all, vaccines; 50% disagreed or strongly disagreed with this practice.

Researchers also asked nurses, “Do you think it’s ethical to dismiss vaccine-refusing families?”

“That is where we found deep polarization,” Deem reports. “We think their voices need to be heard, given this polarization.”

Vincent Staggs, PhD, another of the study’s authors, did not expect to see so many respondents stand clearly on one side or the other of the issue. Many nurses reported feeling “strongly” one way or the other.

“This can become an ethical issue for nurses if their practice has a dismissal policy that conflicts with their strongly held convictions about the right response to vaccine-refusing families,” says Staggs, an associate professor of pediatrics at Children’s Mercy Kansas City and the University of Missouri-Kansas City School of Medicine.

There also were some interesting regional differences in nurses’ attitudes. Respondents from the South reported more positive attitudes toward dismissal than respondents from the Midwest and West. Respondents who practice in rural areas held less favorable attitudes toward dismissal.

“It’s important to note, however, that negative attitudes toward dismissal don’t necessarily coincide with a belief that vaccines are any less important,” Staggs cautions.

For example, nurses serving rural areas did not rate vaccines as any less important than nurses serving urban areas. Nurses from the West, where attitudes toward dismissal were least favorable, scored the same on perceived vaccine importance as nurses from the South.

Notably, a significant portion of nurses find the practice of dismissal unethical or inappropriate. “Physicians may assume that because it’s my practice and nurses are working for me, that nurses just have to go along with whatever I decide,” Deem says. Some practices dismiss all families who refuse vaccines, while others consider it on a case-by-case basis. “If nurses are expected to adhere to a dismissal practice, but their opinion wasn’t solicited, there is a breakdown in professional ethics,” Deem notes.

The issue is perhaps even more important for practices to sort out, considering the anxiety over an anticipated COVID-19 vaccine. “Families who are otherwise on board with vaccines might be hesitant. There are safety concerns since it is being rushed through the process, and we don’t know the long-term risks,” Deem says.

This is an excellent time for physicians to consider their interprofessional obligations to nurse colleagues, according to Deem. “While one would hope that the full burden of addressing vaccine hesitancy would not fall entirely on the nurses, nurses nonetheless might be particularly well-disposed to handle objections to vaccines and build trust with families,” Deem offers.

Ultimately, the physician still might decide to dismiss the vaccine-refusing family. “But getting nursing input would go a long way toward recognizing that nurses have a real stake in a situation that has significant effects on their professional relationships with families,” Deem adds.


  1. Deem MJ, Kronk RA, Staggs VS, Lucas D. Nurses’ perspectives on the dismissal of vaccine-refusing families from pediatric and family care practices. Am J Health Promot 2020;34:622-632.