The Behaviors of Nurses Who Immunize Children

1. The Behaviors of Nurses Who Immunize Children Principal Investigator: Thomas E. Stenvig, RN, PhD, MPH, CNAA Associate Professor South Dakota State University College of Nursing Thanks to Nurses in South Dakota

2. The Problem • Specific vaccines • Simultaneous vaccine administration • False contraindications • Vaccine schedule changes • Declining disease incidence rates • Vaccine safety concerns • “Missed opportunities” • Where are the nurses?

3. Study Objectives • Purpose: to gain insight into behaviors of nurses who immunize children • Aim: understand, explain, and predict these behaviors • Long term goal: Improve childhood immunization coverage levels

4. Thoeretical Framework - Ajzen’s Theory of Planned Behavior External Variables ____________ Demographic and Personality Characteristics e.g Age Education Certification etc. Behavioral Beliefs X Outcome Evaluation Attitudes Normative Beliefs X Motivation to Comply Behavioral Intention BEHAVIOR Subjective Norms Control Beliefs X Perceived Control Perceived Behavioral Control

5. Research Questions • Q1: Do attitudes, subjective norms, perceived behavioral control, and intention influence immunizing behavior? • Q2: Does behavior differ by age, educational level, licensure, certification, public vs. private, and parental status? • Q3: What influence do facilitators have on intention and behavior? • Specific hypotheses.

6. Other Questions • Q1. What interventions do nurses use to deal with discomfort caused by giving vaccines? • Q2. To what extent can nurses identify age appropriate vaccines? • Q3. Is there a positive correlation between level of education and knowledge of age-appropriate vaccines?

7. METHOD • Mail survey of randomly selected nurses in South Dakota (N=316) who immunize children • Drawn from estimated population of 720 at 215 vaccine sites

8. Instrument:Nurses’ Childhood Immunization Belief Questionnaire (NCIBQ) • Derived from literature sources • 12 page booklet format • Questions for each variable • 7-point semantic differential • Open ended questions • Scenarios (case studies) • Pilot study

9. PROCEDUREDillman’s Total Design Method (TDM)for Mail Surveys • Contents • Cover letter • NCIBQ booklet • Immunization schedule • Postage-paid business reply envelope • Golden “Sacajawea” dollar incentive • Reminders and follow-up mailings

10. RESPONSE • 261 useable surveys returned • Response rate = ____useable returns____ number sent (-) ineligibles (-) undelivered • The response rate was estimated at about 85%

11. Average age - 45 years (21 to 66 years) Overwhelmingly female (99%) Years in nursing - 21 years (>1 to 54 years) Education: LPN 27% AD/Diploma 41% BSN 23% post BSN/ MS Doctorate 9% Setting Private 62% Public/Federal/ Tribal 38% Respondent Profile

12. Item Analysis • 94% consider immunizing children extremely important • 80% report an extremely favorable attitude toward immunizing • 27% report it to be extremely rewarding • 58% considered it extremely safe

13. Item Analysis (continued) • 26% strongly agreed it causes minor side effects • 6% strongly agreed it causes major side effects • 5% feel extremely bad over one injection • 12% feel extremely bad over four injections • 62% strongly agreed hepatitis B should be required • Only 30% strongly agreed varicella should be required!

14. Dealing with parents • Most agreed they can assess parents’ educational needs • 82% agreed giving multiple shots on the same visit causes some degree of stress for the parents • Only 27% strongly agreed they have control in overcoming parents’ objections

15. Significant Findings • Behavioral intention, perceived behavioral control, and belief-based perceived behavioral control explain nearly 50% of variance in behavior • Attitudes and subjective norms and their belief-based determinants were not good predictors of behavior

16. Hypotheses • A positive correlation was demonstrated between: • Perceived behavioral control and intention (p = .000) • Perceived behavioral control and behavior (p = .001) • Intention and behavior (p = .000) • Subjective norms was not a predictor of intention

17. Other Findings Older nurses were more likely to immunize appropriately (p = .042) Nurses with higher levels of education were more likely to immunize appropriately (p < .001)

18. Licensure and Certification • RNs were more likely than LPNs to immunize appropriately (p = .043) Certified nurses were more likely to immunize appropriately than those who were not (p < .015)

19. Public or Private • Nurses in public settings were more likely to immunize appropriately than nurses in private settings (p < .01) • (but mistakes were common in both)

20. Facilitators • Nurses were more likely to immunize appropriately if any of the following were present (p < .05) : • Immunization audits • Standing orders • AAP “RedBook” • SPIP • WIC Linkage

21. Interventions for Discomfort Before and After Giving Vaccines • (Open-ended responses) • 1. Pharmacologic • 2. “TLC” • 3. Distraction • 4. Specific techniques • 5. Cognitive

22. Identification of Age-Appropriate Vaccines

23. Probability of Immunizing with all age-appropriate vaccines NOW

24. Inappropriate Vaccines

25. Most Important Finding • Nurses who felt they had more control over their own vaccine decisions were more likely to immunize appropriately • Other tenets of the model were not supported

26. Implications for Practice, Education, Research • Variable adherence to recommendations • Questions of education and competence and who makes vaccine decisions • Information sources - textbooks are not adequate • Protocols to reduce errors • Larger study comparing disciplines • Other studies – approaches to dealing with discomfort

27. Conclusion: • Improving health care provider practices and behavior can contribute to improving immunization coverage levels • Nurses are important vaccine providers • BUT • Lots of bad habits!