Running head: MANDATORY VACCINATIONS FOR NURSES 1

Ethical Issues Surrounding Mandatory Vaccinations for Nurses

91772

NUR 335

Cedar Crest College

Abstract
MANDATORY VACCINATIONS FOR NURSES 2

In the ever-changing healthcare system, organizations had begun implementing many require-

ments for their nurses to improve patient and employee safety. In previous years, vaccinations

were viewed as a voluntarily received treatment. The current ideology stated that mandatory im-

munizations should be required for all healthcare workers, including nurses. This movement was

initiated with the support of evidence-based practice research. Nurses and other healthcare pro-

viders across the Unites States questioned the ethics of this new implementation. Benefits, as

well as, disadvantages had be identified within each viewpoint. The significance to nursing re-

quired one to inspect the American Nurse Association Code of Ethics for Nurses as well as other

key ethical principles.

Keywords: nurse, vaccine, immunization, mandatory, requirement, ethics, research

Ethical Issues Surrounding Mandatory Vaccinations for Nurses

MANDATORY VACCINATIONS FOR NURSES 3

The transition from voluntary to mandatory vaccinations for nurses was primary seen af-

ter the H1N1 epidemic of 2008 through much promotion and strategic campaigning done by the

employer. Although, the United States Center for Disease Control(CDC), the Advisory Commit-

tee on Immunization Practice, the Society for Healthcare Epidemiology, the Association for Pro-

fessionals in Infection Control, and the Infectious Disease Society of America had been recom-

mending this requirement since the early 1980's (Babcock, Gemeinhart, Jones, Dunagan, &

Woeltje, 2010). Controversy arose amongst nurses, as well as other healthcare workers (HCW),

regarding the ethics of the immunization requirement. Both the CDC and the employers viewed

mandatory vaccinations as a means to improve patient and HCW well-being. Mandates of this

nature were based on the concept that a properly immunized nurse was crucial for public safety

as communicability of a disease was affected by the decrease in carriers (American Public Health

Association, 2010).

On an annual basic, 200,000 United States patients were hospitalized with vaccine-

preventable seasonal influenza resulting in over 36,000 mortalities. Patients were at risk for con-

tracting other illnesses, such as measles, via a HCW that was not properly vaccinated. Prior to

2008, only half of the nursing population was voluntarily vaccinated against the seasonal influ-

enza. This statistic increased to 65% of the nursing population, after the H1N1 epidemic with

much push from the employer (Quan et al., 2012). Nurses were the most reluctant population to

be vaccinated but the ones who had the most direct patient contact. Thus, nurses had the highest

chance of passing life-threatening viruses to patients (Zhang, While, & Norman, 2014). It was

apparent that the voluntary vaccination rate, especially amongst nurses, was not sufficient for the
MANDATORY VACCINATIONS FOR NURSES 4

healthcare setting. After assessing the practical issues of mandatory vaccinations, the ethical di-

lemmas that arose with the immunization requirement shall be depicted thoroughly, fully expos-

ing both the positive and negative attributes and the significance to nursing.

Practicality of Mandatory Vaccinations

In congruence with the ethical issues, nurses across the United States had concerns re-

garding the practicality of the new immunization policy. Nurses and their employers alike ana-

lyzed the effectiveness, necessity, cost, and potential harm that accompany the newly instated re-

quirement. Direct evidence of vaccine effectiveness, especially in regards to influenza, was diffi-

cult to assess. Although, a study completed by a Bioethics Program showed an increase in dis-

ease outbreaks in geographic areas where too many nurses, and other HCWs, had opted out of

recommended vaccinations implying indirect proof of vaccine efficacy (Galanakis, Jansen,

Lopaico, & Glesecke, 2013). In 2013, a group of qualified nurses attending educational courses

at a large London university were surveyed regarding voluntary seasonal influenza vaccination

uptake; results showed that 44.9% reported to had never been vaccinated in the last five years

(Zhang, et al., 2014). These results proved there was a necessity for mandatory vaccinations.

From a financial standpoint, vaccinations for nurses had economic benefits for the em-

ployment organization. The cost of the vaccinations and education was immensely less than the

financial deficits that were seen in both staff replacement related to sick leave (Zhang, et al.,

2014) and the medical fees for a patient who acquired a vaccine-preventable disease (American

Public Health Association, 2010). The potential physical harm component of mandatory vaccina-

tions shall be fully depicted within "Risks of Vaccinations." To decrease emotional and situa-

tional harm to nurses, employers had modified the immunization requirement policy to allow
MANDATORY VACCINATIONS FOR NURSES 5

medical or religious exemptions. In one hospital setting, religious exceptions required an ap-

proved letter from Human Resources. Whereas medical exemptions required a formal statement

from a licensed physician stating there was a specific medical contraindication to the vaccine in

question (Babcock, et al., 2010).

Other factors that prevented nurses from participating in voluntary vaccinations was the

barriers such as availability and education (American Public Health Association, 2010). This

posed to be extremely important as the nurses within the quantitative study from London self-

reported their rationales for being unvaccinated as both the concern of personal safety and lack

of knowledge on the immunization (Zhang, et al., 2014). Employers had begun providing educa-

tional flyers and seminars, mobile vans for vaccinations, declination tools, and a good-standing

budget allocation to decrease negative response in the future (Quan et al., 2012).

Benefits of Vaccinations

Galanakis, et al. stated that in the United States, mortality rates relating to seasonal influ-

enza was equivalent to that of breast cancer and triple that of human immunodeficiency/ acquired

immunodeficiency syndrome (HIV/AIDS) (2013). Immunizing HCW's had been known to de-

crease the prevalence of preventable diseases in the healthcare setting (American Public Health

Association, 2010). Vaccine-preventable diseases may be transmitted before symptoms develop

and often were spread to at-risk patients without the awareness of the carrier. At- risk popula-

tions included those with diabetes, cardiovascular disease, chronic lung/renal/liver disease in ad-

dition to immunocompromised and chemotherapy patients. The American Public Health Associ-

ation stated that hospitalized patients who develop a nosocomial infection had high mortality

rates (2010). Diseases such as seasonal influenza could be spread through respiratory droplets,

such as a cough or sneeze of an unvaccinated person. Therefore, barrier precautions such as

MANDATORY VACCINATIONS FOR NURSES 6

masks must be implemented to protect patients from those who were not immunized (American

Public Health Association, 2010). The previous Bioethics Program provided evidence that

showed when five in eight healthcare workers were vaccinated, one case of influenza-like illness

and one death could be prevented in a residential setting (Galanakis, et al., 2013).

Risks of Vaccinations

Similar to most other medical treatments, vaccinations had posed as a hazard to the recip-

ient. All nurses who were required to abide by the mandatory immunization policy had the right

to know of all contraindications and adverse reactions. All series of the seasonal influenza vac-

cine were contraindicated in pregnant women, immunosuppressed persons, adults with an egg

allergy of any severity, and adults who had taken any influenza antiviral medications. In addi-

tion, the influenza vaccine was to be used cautiously in adults with a history of Guillian-Barre

syndrome (GBS) within six weeks of any previous influenza vaccine (Kim, Bridges, &

Harriman, 2016). GBS was the most common cause of acute flaccid paralysis although it was

considered rare. The annual incidence rate of GBS was 0.4-4.0 cases out of 100,000 with the

most susceptible population being school-aged children (Vellozzi, Iqbal, & Broder, 2014). GBS

was described as a potentially debilitating disease in which the ones immune system creates an-

tibodies against his/her own nerves resulting in loss of muscle function (Ward & Hisley, 2016).

Reported adverse reactions of the Measles, Mumps, and Rubella (MMR) vaccination in-

cluded anaphylaxis, myocarditis, GBS, and arthritis. It should be noted though that of the 3175

reports in which these adverse reactions were reported, there were 131 contraindicated pregnan-

cies identified (Sukumaran et al., 2015). This implied that the primary care provider should be

providing more in-depth vaccination education. Another popular vaccination, varicella, was con-

traindicated in those who were severely immunocompromised, pregnant, or anyone who was a
MANDATORY VACCINATIONS FOR NURSES 7

recent recipient of antibody containing blood products as it had caused moderate to severe ill-

ness, with or without fever (Sukumaran et al., 2015). Both the MMR and varicella vaccination

had been accompanied by the risk of febrile seizures (MacDonald, Dover, Simmonds, & Sven-

son, 2014). Nurses who had medical contraindication of any of the above should have had appro-

priately filed for medical exemption.

Ethical Considerations

The paternalism exhibited by the employers who were initiating the mandatory vaccina-

tion policies along with the potential harm to the vaccine recipient pose as an moral and ethical

dilemma. Ethical dilemmas had be described as an intra- or interpersonal conflict where two or

more unwanted options were being contemplated. In this case, a patients or nurses potential for

harm. Two major ethical frameworks, the teleological and deontological theory, contracted an

array of principles to outline ethical dilemmas. These principles originate from the basic stand-

ards of human interaction (Marquis & Huston, 2012). Predominantly, the disagreement of man-

datory immunizations for nurses was between the individual good and the common good

(Moodley et al., 2013).

Autonomy

In its most natural form, autonomy was one's personal freedom of choice or accepting the

responsibility for one's choice. For an employee, autonomy warrants that he/she had the choice

meet the employers expectations or not. In the same sense, the employer must take responsibil-

ity for declining to meet the organizations standards even if that meant being terminated (Mar-

quis & Huston, 2012). This specific principle happened to be the most prominently discussed in

regards to mandatory vaccinations for nurses.

MANDATORY VACCINATIONS FOR NURSES 8

American Public Health Association presented that mandatory vaccinations could isolate

workers, damage staff morale, and produce resentment towards the organization thus diminish-

ing the nurse's autonomy (2010). Another qualitative journal by a Bioethics Program stated that

any sort of mandatory policy, especially one forcing medication or treatment, was an infringe-

ment on liberty and one's personal freedom. To continue, that same article exposed that those

supporting required immunizations for nurses often use non-maleficence as a bargaining wage

against autonomy; it should be noted, ethical principles were not created to be used against one

another, yet congruently for the common good. From the opposing standpoint, autonomy shall

remain but with restrictions when implementing required vaccination treatment if harm to the

public was preventable (Galanakis, et al., 2013).

Beneficence

Healthcare teams across the globe took actions to implement beneficence in daily tasks.

Beneficence had be interpreted as the unconditional and continuous endeavor to promote good

(Marquis & Huston, 2012). The duty of care by a nurse according to beneficence included the

uptake of vaccines as the government created them to prevent the most contagious diseases.

Actions of this sort should be taken to prevent avoidable deaths (Moodley et al., 2013). To coun-

teract that statement, Galanakis, et al. questioned whether the interpretation of beneficence was

acceptable if only promoted by causing harm to the nurse (2013). The specific rationale used by

these authors inquired about influenza vaccines in which the strain within the vaccine does not

match the circulating strain thus causing unneeded harm to nurse.

Non- Maleficence

Associated closely with beneficence, non- maleficence was often described as, "if one

cannot do good, then one should at least do no harm" (Marquis & Huston, 2012, p.76). Moodley,
MANDATORY VACCINATIONS FOR NURSES 9

et al, perceived non- maleficence under the impression that the risk to the recipient must justify

the good; this statement was also directed towards seasonal influenza vaccinations and unneces-

sary immunizations (2013). The authors quantified the risks of contagion into four variables: the

characteristics of the illness in relation to geographic and biological factors, the probability of

transmission, the severity of the disease, and the disease duration. In addition, although the nurse

attending to the patient may be vaccinated, the patient could had other exposure to the disease

leading to illness regardless of HCW contamination (Galanakis, et al., 2013).

Contradictory to that statement, Galanakis, et al. expressed that any means of patient pro-

tection should be explored by healthcare professionals (2013). As a basic human standard, the

spread of infection from one person to another was not acceptable; this holds especially true for

those in healthcare. Regardless of additional exposure to vaccine-preventable diseases, the trans-

missions of a disease from a non-immunization nurse to any patient would be intolerable as well

as highly unprofessional (Galanakis, et al., 2013).

Justice

In regards to mandatory immunizations, justice of the employee must be clarified. Mar-

quis & Huston defined justice as the ethical principle that treats individuals equally and others

unequally according to their differences (2010). Galanakis, et al. reviewed the patients perspec-

tive when addressing justice; it was going against both beneficence and non- maleficence to put a

patient at risk who were unable to receive immunizations, such as newborns and those who were

immunocompromised (2013). To advance the discussion further, the author stated that non-im-

munized healthcare workers should be required to state their vaccination status to the patients.

Due to the exceptions allowed within the mandatory immunization policy for nurses, jus-

tice for the employee was maintained by ensuring that the unequal were treated accordingly.
MANDATORY VACCINATIONS FOR NURSES 10

Medical and religious exception examples were previously discussed; a quantitative study de-

picted that 321 (1.24%) employees received medical exception while 90 (0.35%) employees re-

ceived religious exceptions or accommodations.

Significance to Nursing

Nursing professionals across the United States looked towards the American Nurse Asso-

ciations (ANA) Code of Ethics for Nurses for guidance. "It is essential for healthcare environ-

ments to balance virtues and values central to the nursing profession to support nursing practice."

The original code was established in 1950 with core principles to support the ethical duty of

nurses. Constant changes were made by the ANA to coincide with the modernized healthcare

system (American Nurses Association,2015a).

An updated statement regarding vaccinations for nurses was published on 07/21/2015 by

the ANA. Previous statements supported immunizations from high contagious and deadly dis-

eases with a push for mandatory vaccinations for healthcare workers and nurses under certain

circumstances. The recent events including the remarkable measles outbreak urged the associa-

tion to edit the provision once again. The newest statement reads, "To protect the health of the

public, all individuals should be immunized against vaccine-preventable diseases according to

the best and most current evidence outlined by the Center for Disease Control and Prevention

(CDC) and the Advisory Committee on Immunization Practice (ACIP)." To conclude, the ANA

allows medical contraindications and religious beliefs as a means of exception (American Nurses

Association,2015b).

Author's Viewpoint
MANDATORY VACCINATIONS FOR NURSES 11

After thorough examination of the practical and ethical issues surrounding mandatory

vaccinations for nurses, the author had created her own opinion on the matter. The author be-

lieved that mandatory vaccinations should be implemented, given the current measles outbreak

along with the increased seasonal influenza illnesses resulting in mortality (Sukumaran et al.,

2015). The author took into consideration all ethical principles. Although the nurses autonomy

may be at risk, one must look at the greater good that arose from this mandate. The author felt as

though protection of the public's well-being outweighs the negative attributes that had occurred

with mandatory vaccinations including adverse reactions (Marquis & Huston, 2012).

Conclusion

The implementation of mandatory vaccinations revolved around the ideology that a

fully-vaccinated employee was essential for maintaining the populations well-being. Regardless

of other health measures in which nurses were taking, the choice of vaccinations had

detrimental impacts on at-risk populations (American Public Health Association, 2010). This

would not be an issue if the voluntary immunization rates of nurses was at an acceptable level.

Regardless of the numerous recommendations, voluntary vaccination rates stayed around 40-

50% of HCWs only rising to 60-70% after extreme promotion and the H1N1 outbreak (Galana-

kis, et al., 2013). Amodio et al. concluded that a fifth of HCWs developed seasonal influenza

each year causing an increased number of nosocomial outbreaks and staff shortages (2014).

Many times, nurses were not blatantly ignoring healthcare recommendations but had not made

vaccinations a priority (Quan et al., 2012. Mandatory immunizations for nurses closed the gap

between those who were and were not properly vaccination thus increasing patient and employee

health through one of the most effective prevention techniques (Amondio, et al., 2014).
MANDATORY VACCINATIONS FOR NURSES 12

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MANDATORY VACCINATIONS FOR NURSES 13

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