Digital Repository Doctoral Projects Fall 2021 Improving Future Provider Confidence in Vaccination Discussions Through Simulation Experiences Laura Clyde Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Clyde, L. (2021) Improving Future Provider Confidence in Vaccination Discussions Through Simulation Experiences. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Improving Future Provider Confidence in Vaccination Discussions Through Simulation Experiences by Laura Clyde A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: IMPROVING VACCINATION DISCUSSIONS 1 Improving Future Provider Confidence in Vaccination Discussions Through Simulation Experiences Laura Clyde Weber State University Annie Taylor Dee School of Nursing IMPROVING VACCINATION DISCUSSIONS 2 Abstract The World Health Organization (WHO) listed vaccine-hesitancy as one of the top ten threats to global health in 2019. Provider recommendation is the leading indicator for vaccine acceptance, and effective communication is critical to establishing patient trust and confidence in the provider. The purpose of this Doctor of Nursing Practice (DNP) project was to enhance Weber State University (WSU) Family Nurse Practitioner (FNP) students’ vaccination knowledge and communication skills through education and simulation experiences to improve provider knowledge and to increase vaccination rates. Eighteen WSU DNP-FNP students attended a class focusing on vaccine-preventable diseases, vaccine mechanisms, and recommendation strategies. Students then participated in a vaccination discussion simulation event using written scripts and an algorithm designed by the student DNP leader. Pre- and post-tests, including multiple choice and short answer questions, were used to evaluate participant knowledge and confidence levels. The mean scores on content knowledge increased 6.5% from pre-implementation to post-implementation, while the mean scores for perceived confidence/self-efficacy and knowledge regarding effective vaccination recommendation practices increased 23%. Every patient-provider contact is an opportunity to discuss and recommend vaccination. It is crucial for future providers to feel competent and confident in their knowledge and communication skills to increase patient-provider trust and effective vaccination recommendations. Healthcare providers who routinely recommend vaccinations could benefit by having opportunities to practice essential vaccination communication techniques and skills. Keywords: vaccination, communication, provider recommendation, vaccine hesitancy, future provider, confidence, simulationIMPROVING VACCINATION DISCUSSIONS 3 Improving Future Provider Confidence in Vaccination Discussions Through Simulation Experiences In Utah, vaccination rates are well below the national average. According to the Utah Department of Health (UDOH) Immunization Coverage Report (2019), only 23.7% of children 18-34 months old had received the influenza vaccine, with other age groups demonstrating low coverage across the state as well. Only 14% of males aged 18-34 months, and 18.6% of females reported ever having the pneumococcal vaccine. Human papillomavirus (HPV) vaccination rates in Utah are well below the Healthy People 2020 goal of 80% vaccination of all vaccine eligible males and females ages 11 through 26. Disparities exist between sexes and HPV vaccination completion rates, and 94% of exemptions for vaccination were categorized as personal, as opposed to medical or religious (UDOH, 2019). Not being vaccinated leads to the resurgence of vaccine-preventable diseases such as HPV and decreased herd immunity resulting in increased cancer rates, increased healthcare costs, and increased years of life lost due to disability and death (Ylitalo, Lee, & Mehta, 2013). This Doctor of Nursing Practice (DNP) project incorporated a vaccination discussion simulation into the Family Nurse Practitioner curriculum at Weber State University’s Annie Taylor Dee School of Nursing aiming to increase future providers’ confidence and comfort in discussing vaccinations, improve patient-provider communication, and potentially influence patient vaccine acceptance. Search Strategies A search was conducted of bibliographies of the identified clinical practice guidelines, systematic reviews, and relevant journal articles using Google Scholar, CINAHL, MEDLINE, PUBMED, and Research Gate databases. Date criteria included sources from 2007 to 2020. Searches were limited to articles in English. Articles were selected by title searching for the IMPROVING VACCINATION DISCUSSIONS 4 keywords: vaccine, vaccination, vaccine-hesitancy, barriers, access, future providers, advance practitioners, mid-level providers, nurse practitioners, clinicians, recommendation, simulation, vaccine preventable disease, herd immunity, HPV, education, vaccine uptake, communication, nursing education, provider role, immunization, confidence, competence, vaccine for children. Literature Review Vaccination Description. Establishing immunity to certain infections is important to avoid serious diseases and their deleterious outcomes. Most often, this is accomplished by either experiencing the disease or being vaccinated to prevent it. Vaccination is a method to introduce a viral pathogen into the body producing a small scale immune response prior to exposure of the wild virus to avoid an unpleasant or deadly infection (McCance & Huether, 2019). Vaccines utilize weakened or dead viruses, deactivated bacterial toxins, bacterial polysaccharide coatings, viral DNA, and protein from viral coatings as a means to present the different antigens to the immune cells (National Institutes of Health, 2019). Vaccine introduction of the antigen causes the body’s immune cells to recognize it as a foreign pathogen and mount a response. White blood cells see the antigen as harmful and create antibodies with memory to fight future infections (Centers for Disease Control and Prevention [CDC], 2018). It is estimated that vaccination saves one life every five minutes worldwide (CDC, 2016). Benefits. Vaccination has many proven benefits besides lifelong immunity to potentially fatal diseases. Herd immunity is also made possible because of vaccination. Herd immunity is the overall benefit observed in a population when the number of individuals immune to a specific disease can break the chain in the transmission of infection (HHS, 2020). People who are unable to be vaccinated due to an immunocompromised status or allergy, or those in whom the vaccine IMPROVING VACCINATION DISCUSSIONS 5 is not effective, are protected because there are not enough diseased individuals to continue the spread of infection. Disease outbreaks are also significantly decreased (HHS, 2020). However, a substantial number of individuals need to be immunized to realize the benefits of herd immunity. For example, a contagious disease such as measles has a basic reproductive number of 12-18, which means that for every case of measles, 12-18 more cases can be expected through disease transmission. In order to establish appropriate herd immunity for measles, 90-95% of the population must be vaccinated. For a disease much less contagious, like polio, at least 80% of the population must be vaccinated, and for non-infectious diseases, such as tetanus, herd immunity does not apply (Oxford Vaccine Group, 2016). Another beneficial outcome of vaccination is reduced disease burden and cost to society. Vaccines are inexpensive compared to the relative cost of treating a vaccine-preventable disease, and most are covered by insurance. Children that contract vaccine-preventable diseases are not allowed to attend school, which often means missed days of work for parents/caregivers. Some diseases result in disability and increased medical bills or death, which places a significant burden on a family and community (HHS, 2020). Outcomes. The practice of vaccination has drastically reduced disease transmission of many vaccine-preventable diseases (CDC, 2020). However, vaccine hesitancy has led to gaps in protection and the resurgence of diseases like measles, whooping cough, and tetanus. The CDC (2020) reported 1,282 cases of measles in the United States in the year 2019. The majority of individuals infected were unvaccinated. The 2019 report is the highest number of measles cases reported since 1992. Previously, measles had been declared eradicated from the United States in the year 2000 (CDC, 2020). Experiencing the disease leads to increased hospitalization rates, IMPROVING VACCINATION DISCUSSIONS 6 increased complications, and increased costs. The reappearance of vaccine-preventable diseases also puts vulnerable populations at risk (CDC, 2020). Obstacles. Despite the advantages gained with vaccination and evidence of vaccine safety and efficacy, many barriers to routine vaccination remain. Vaccine-hesitancy is defined as the decision to refuse or delay vaccination based on beliefs and attitudes often related to the vaccine's real and perceived side effect profile. A vast majority of individuals believe that vaccination demonstrates utility in disease prevention, but express concern over vaccine safety (Olowo, Hasan, & Wirza, 2020). Although no studies have proven that vaccines cause diseases like autism spectrum disorder, many individuals still avoid vaccination due to that belief (American Academy of Pediatrics, 2018). Some people have also voiced concern over the safety of ingredients and preservatives used in vaccines, such as thimerosal and mercury additives (United States Department of Health and Human Services [HHS], 2020). Many social media activist groups are broadcasting antivaccination messages using personal and emotionally compelling stories about the danger of vaccination. It is easy for the lay or non-medical individual to relate to antivaccination groups' stories and experiences. Medical facts and studies are full of jargon and statistics, are difficult to access, and challenging to understand (Johnson et al., 2020). Johnson et al. (2020) looked at antivaccination and pro-vaccination Facebook groups and found that although fewer antivaccination Facebook groups existed, they had a more substantial outreach and are predicted to outnumber pro-vaccination groups within the next ten years. Anti-vaccination Facebook groups were also found to recruit undecided individuals at a rate 300 times that of pro-vaccination groups. One may be inclined to predict that an outbreak of a preventable disease would increase pro-vaccination messages. However, Johnson et al. (2020) discovered that antivaccination IMPROVING VACCINATION DISCUSSIONS 7 Facebook groups experienced their most substantial recruitment rate during the 2019 measles outbreak in the United States. Vaccine-preventable diseases have primarily been eradicated due to the success of many vaccinations. This has left a complacent population that perceives the risk associated with receiving a vaccine much higher than being infected with a vaccine-preventable illness (Bond & Nolan, 2011). In a national online survey of parents with children 17 years or younger, researchers found that 69% of individuals were likely to make the decision to delay vaccination due to parental fears of immune system reactions, severe long-lasting adverse effects, and the belief that vaccines were unwarranted (Freed, Clark, Butchart, Singer, & Davis, 2010). Another barrier to vaccination is missed primary care visits and a lack of access. According to Daley et al. (2014), a vast majority of school-age children and adolescents infrequently attend well visits, and providers regularly miss the opportunity of administering vaccines at sick visits due to a lack of knowledge about guidelines and recommended schedules. HPV Vaccination Exemplar Description. HPV is defined as a double-stranded DNA virus that is transmitted through contact of an infected person’s skin, mucous membranes, or bodily fluids. A break in the epithelium allows the virus to travel to the basement membrane where it can enter the cells’ nuclei and transform proteins that code for unchecked benign or cancerous cellular growth. The HPV infection often occurs months to years before signs and symptoms appear (McCance & Huether, 2019). HPV is the most widespread sexually transmitted infection in the United States, and nearly all sexually active males and females contract the virus at some point in their lives (CDC, 2015a). Because of the prevalent nature of the virus, in most cases, an individual only needs two sexual partners in a lifetime to contract HPV infection (CDC, 2017). HPV prevalence IMPROVING VACCINATION DISCUSSIONS 8 is also likely to be underestimated due to the subclinical nature of the disease (McCance & Huether, 2019). The HPV vaccine contains inactivated protein from the HPV virus and protects against seven oncogenic types of HPV. There is currently only one HPV vaccine on the market, the Gardasil 9-valent vaccine, which also helps to protect against two strands of HPV that cause genital warts (CDC, 2019b). Children under the age of 15 need two doses of the vaccine given 6 to 12 months apart. If the series begins on or after the child’s 15th birthday, the vaccine is given in three divided doses over six months (CDC, 2019b). The Gardasil vaccine is approved by the U.S. Food and Drug Administration (FDA) for males and females ages 9 through 45; however, the CDC and most guidelines only include recommendations for ages 11 through 26 (CDC, 2019a). The vaccine is most often administered by primary care providers at well-child visits, because the HPV vaccine is only useful before viral exposure, and it is believed that individuals have already been exposed to the virus by age 26, suggesting no increased benefit after that time (Saslow et al., 2018). HPV is widely known for its role in causing cervical dysplasia and cervical cancers. However, HPV is also linked to oropharyngeal cancer and cancers of the anus, penis, vulva, and vagina accounting for 630,000 newly diagnosed cancer cases worldwide (Sanjose et al., 2019). Cervical cancer is the only HPV-related cancer that currently has an associated screening method (American Cancer Society, 2020). According to the CDC (2015b), in 2015, there were over three million healthcare visits related to abnormal pap smear tests and colposcopy in the United States. Once other HPV-related cancers are detected, they are often in the later stages and require more aggressive treatments. Cancer treatments are costly and are associated with disability, depression, disfigurement, and malnutrition. Mortality for cancers in late stages is much higher than cancers IMPROVING VACCINATION DISCUSSIONS 9 found with early detection (Sanjose et al., 2019). Cancer is a major public health concern that carries a significant disease burden. Societal costs of cancer are projected to increase due to a growing and aging population (American Cancer Society, 2020). Certain types of HPV also cause genital warts. Genital warts are associated with increased pain, embarrassment, anxiety, and depression. According to the CDC (2015b), genital warts economic burden exceeded 220 million dollars in 2015 in medications and healthcare visits alone. Genital wart infections lasted an average of 95.4 days, prompting an average of 1.9 healthcare visits annually per infection. The national total medical cost burden for HPV infection in 2015 was 8 billion dollars (CDC, 2015b). Diagnosis with HPV affects not only the infected individual but also potentially the partner of that person since HPV is so easily transmitted (Hernandez et al., 2008). Barriers. The 9-valent HPV vaccine protects against seven types of oncogenic HPV, and two non-cancer types related to genital warts. Despite the effectiveness of the vaccine, numbers for vaccinated children and adolescents continues to remain below the goal of 80% set by Healthy People 2020 (Senkomago et al., 2019). As of 2017, the national average rates for HPV vaccination for age-appropriate individuals was only 52.4%, with some states as low as only 12%, and well below the average of other vaccination rates (National Institutes of Health, 2018). In the state of Utah, only 36.3% of age-appropriate individuals have received all recommended doses of the vaccine, and the rate is much higher in females than males (CDC, 2018). Reasons for low rates include complex vaccine schedules, lack of education, and discomfort with the subject of HPV and sexually transmitted infections for both parents and providers. Rates for initiation of the vaccine are much higher than the completion of the two or three-dose series, suggesting that the vaccine schedule of multiple doses may pose a barrier to IMPROVING VACCINATION DISCUSSIONS 10 establishing HPV immunity (CDC, 2019a). Many individuals are unaware of the prevalence of HPV and its associated impact and do not view themselves at high enough risk to receive the HPV vaccination (Thompson, Vamos, Sappenfield, Straub, & Daley, 2016). When Thompson et al. (2016) looked at HPV decision making among young adult women, those who were single or in monogamous relationships were significantly more likely to question the need for the HPV vaccine and decline it. In a follow-up study, Thompson et al. (2019) also discovered that conservative values were correlated with a lower perception of risk. Utah is a state thought to have predominantly conservative views. A large percentage of the population practices organized religion (Jones, 2004). Bodson, Wilson, Warner, and Kepka (2017) found that religious young women in the state of Utah were less likely to have heard about HPV, its transmission, and prevalence, and were less likely to have been vaccinated compared to more liberal and less religious populations. HPV is a sexually transmitted infection and, therefore, often an emotionally charged or uncomfortable subject for providers to discuss with their young patients. Some parents are also uncomfortable with the sexualization of their younger children (Perkins et al., 2014). In order to identify the rationale by parents/guardians and providers for delaying or administering HPV vaccination to girls ages 11 to 17 years old, Perkins et al. (2014) conducted 161 in-depth interviews with providers and parents/guardians. They identified dominant themes, including barriers and successful techniques for HPV vaccination. Providers in the public clinic setting were more likely to offer HPV as a routine vaccination rather than a choice and were less likely to profile patients based on the time the provider believed the patient would become sexually active. Common reasons providers did not offer the HPV vaccine at visits was because they believed the patient still had time before sexual debut and wanted a bargaining item to use with IMPROVING VACCINATION DISCUSSIONS 11 vaccine-hesitant parents. The HPV vaccine was also found to be more of an emotionally charged subject than other vaccines. Parents were more likely to accept the vaccine when providers strongly recommended HPV vaccination and normalized the vaccine with other vaccines' coadministration. One of the most important findings of this study was that providers and parents were mostly not opposed to HPV vaccination, but believed the patient had more time based on assessments of sexual activity. The delay in vaccination most often led to non-vaccination. Providers have also been known to recommend HPV vaccination less often than other vaccines because they do not view the risks as high as some of the other vaccine-preventable diseases (Dempsey et al., 2018). Role of Providers Provider recommendation has proven to be one of the most effective means for increasing vaccine uptake; however, vaccine-hesitant parents and guardians still pose a significant barrier to vaccination recommendation (Ylitalo et al., 2013). Providers often serve as a patient’s first source of knowledge and establish the earliest impressions of vaccines. Communication plays a critical role in the link between vaccine acceptance and rejection (Olowo, Hasan, & Wirza, 2020). Productive communication between the patient and provider can help reinforce positive attitudes towards vaccination in supportive individuals and can influence a vaccine-hesitant individual towards vaccine approval (Leask et al., 2012). Lack of effective communication can lead individuals to lose confidence and trust in their provider, leading to the delay or rejection of vaccination (Olowo, Hasan, & Wirza, 2020). According to Jacobson, Etta, & Bahta (2013), primary care clinic visits are scheduled in as little as approximately 15 minute intervals, making it hard to address vaccine-hesitant patients’ concerns. Providers were found to frequently dismiss the awkward conversations and suggest a delay in the IMPROVING VACCINATION DISCUSSIONS 12 vaccine schedule due to time constraints. A significant number of patients who chose to delay vaccination never scheduled a follow-up appointment resulting in a missed opportunity (Jacobson, Etta, & Bahta 2013). Solutions Patient and Provider Education. Interpreting parental motivation to accept vaccination and increasing parental education is central in establishing successful rates of immunization because they are the ones who decide whether or not to vaccinate. Ault and Reisinger (2007) found that parents were significantly more likely to vaccinate their children once they were adequately educated. The researchers also found that parental perception of their child’s increased risk of contracting a vaccine-preventable disease was another key indicator in parental vaccination approval as well as provider recommendation. Ault and Reisinger (2007) also discussed essential areas of focus regarding parental vaccination education, including vaccine safety and vaccine effectiveness. Because provider recommendation is one of the most influential initiators for obtaining vaccination, it is essential to teach providers to incorporate vaccine endorsement into routine care (Ylitalo et al., 2013). In a cross-sectional observational study, Opel et al. (2015) looked at 111 videotapes of different vaccine discussion techniques used by different providers and their effects on vaccine acceptance and visit experience. They found that a participatory rather than a presumptive approach with the parents was correlated with lower rates of acceptance of the vaccine at the visit end but was also more likely to lead to a better visit experience rating. They also found that a presumptive approach was more likely to lead to vaccine acceptance. When providers were met with initial resistance from parents during the vaccine discussion, the providers that continued their recommendations were able to change the parents’ mind 50% of IMPROVING VACCINATION DISCUSSIONS 13 the time. These findings demonstrate that effective provider communication is critical to improving vaccination rates. Dempsey et al. (2018) also examined presumptive versus participatory approaches to provider recommendation in a randomized control trial and concluded that presumptive approaches incorporated into routine care led to significantly more vaccine uptake. The strength of a recommendation from the provider was also an important indicator of vaccine acceptance, with a four-fold increase in those who received a strong recommendation. Simulation. Effective communication is vital to establishing trust and confidence between the patient and the provider. Teaching current providers vaccination communication strategies after they begin their practice has proven largely ineffective at improving provider comfort when discussing vaccination with a vaccine-hesitant patient (Henrikson et al., 2015). Vaccination communication instruction is not currently a standard for medical education curriculums (Williams & Swan, 2014). Reaching providers during medical training and establishing patterns through simulated experiences in vaccination communication prior to practice may be beneficial in increasing provider vaccination recommendation. Simulation is a method with proven utility in medical training that offers future providers opportunities to practice skills in a safe environment without the threat of patient harm (Loomis, 2016). The National Council of State Boards of Nursing (NCSBN) conducted a study of pre-licensure nursing students, examining cohorts who spent 10%, 25%, and 50% of their clinical education in simulation experiences, and found that there was no statistically significant difference detected in passing licensure exams among the groups. This finding demonstrates that simulation was equally effective as time spent with a preceptor in an actual clinical setting (Loomis, 2016). IMPROVING VACCINATION DISCUSSIONS 14 Simulated experiences in nursing education have exhibited success in increasing students’ confidence and comfort in performing clinical and decision-making skills (Lavoie & Clarke, 2017). Rosenzweig et al. (2008) looked at the effects of a communication simulation program in the acute care nurse practitioner program at the University of Pittsburgh. Live simulated patient actors were used to help the students learn communication strategies related to delivering difficult news, motivational interviewing, and de-escalating angry patients. Students were given pre and posttest self-assessment surveys to identify changes in levels of confidence and self-efficacy. The researchers found that the students’ self-ratings of confidence level and perceived communication skills were statistically significantly higher immediately after the simulation experience. The researchers also found in a follow-up study, that the reported enhanced levels of self-efficacy remained the same four months after the intervention (Rosenzweig et al., 2008). Self-efficacy is an essential element in a provider’s professional development. Kiernan (2018) found that providers’ confidence level was predictive of competence in unfamiliar circumstances. The University of Minnesota medical school implemented a lecture, video, and role-play/simulation into their standard curriculum to increase provider confidence and comfort in discussing and recommending the HPV vaccination. Pre and post surveys were given and demonstrated a statistically significant increase in recognition of the benefits of HPV vaccination, the likelihood of recommending the vaccine in future practice, and comfort level with initiating challenging vaccination discussions with vaccine-hesitant patients (Schnaith et al., 2018). The purpose of simulated communication practice is to provide the student with a toolset through repetition in order to intuitively and consistently respond to patient questions and concerns (Kiernan, 2018). Sarnquist et al. (2013) conducted a national survey of family IMPROVING VACCINATION DISCUSSIONS 15 medicine, pediatric, and internal medicine residents and found that more than 95% of those surveyed felt their education of vaccine safety and communication was inadequate and desired simulation experiences for vaccination discussions. Havelock’s Theory of Change One cannot expect to enhance or improve care processes without altering or augmenting how things are currently done (Finkelman, 2018). Change is an unavoidable life experience. Despite continuous changes in life, change is often uncomfortable for some individuals. The way that people respond to change can have a significant impact on a quality improvement practice change. Change theories are often used to help ensure strategic planning resulting in a more efficient change process (Finkelman, 2018). Havelock's theory builds on Lewin's Force Field Theory of Change, which consists of unfreezing, moving, and refreezing stages. Havelock's theory includes additional steps that account for the complexities of the real world (Finkelman, 2018). The first stage is relationships, where the individual who desires to make a change, partners with an organization and spends time in the environment to assess the need for change. The second stage is diagnosis. This stage is where the subject of change decides if the change is wanted or necessary. The second stage is also the stage where the problem is defined. The third stage is acquiring the resources needed for the change. This stage is where several solutions to the problem are developed, and the resources needed to make the change are pursued. The fourth stage is selecting a pathway. In this phase, a final solution is chosen as the best option and implemented. The fifth stage is establishing and accepting change. In this phase, the individual must monitor to see if the plan is being implemented as a new standard behavior and assess the change's approval to prevent stagnation. The sixth and last stage of Havelock's Theory is maintaining and stabilizing. The sixth stage is IMPROVING VACCINATION DISCUSSIONS 16 the phase where the new change may become integrated into policy and routine. The change is now sustainable, and the change agent may separate from the organization if desired (Tyson, 2010). Havelock's theory was applied to the practice change of incorporating a vaccination discussion simulation into the FNP curriculum at WSU. Stage one involved building relationships with the Annie Taylor Dee School of Nursing and partnering with the professor teaching the appropriate curriculum for project implementation. Stage two was where a needs assessment for the simulation was discussed with the school of nursing, and it was decided that the organization desired the change. Stage three involved looking at what already exists in the literature regarding simulation and vaccination discussions, as well as, researching simulation toolkits. It is essential to look for individuals with experience in creating simulations and seeking expert consult. The fourth stage involved the actual development of the simulation and its implementation. This phase entailed scheduling a time to meet with the FNP students to provide the simulation experience and administer a pre-simulation survey. In the fifth stage the students were given a post-simulation survey to assess any improvements in knowledge or increased confidence and comfort with vaccination discussions. If the simulation proves to be a successful practice change, then the school of nursing will be able to implement it in future semesters, ensuring sustainability, and completing the last step of Havelock's Theory. Practice Change Plan Expected Outcomes and Goals At the completion of this project, the participating DNP FNP students at Weber State University will gain knowledge and have increased levels of confidence and comfort in initiating vaccination discussions. The aims of this project were to educate future FNP providers about the IMPROVING VACCINATION DISCUSSIONS 17 safety and efficacy of vaccination practices and the barrier of vaccination-hesitancy with an added emphasis on addressing the Utah population-specific issues related to the HPV vaccine. The overall goal of this practice project was to increase provider recommendation for vaccination and increase vaccination rates in the state of Utah. Setting Utah is a landlocked mountainous region located in the western United States. The state boasts a highly diversified economy and has recently become a popular place for the establishment of the technology industry. Weber State University is a higher learning institution in Ogden, Utah, founded in 1889. The university offers 225 certificate and degree programs and 16 graduate degrees (Weber State University, 2020). The Annie Taylor Dee School of Nursing offers four nursing degrees: Associate of Science in Nursing (AS), Bachelor of Science in Nursing (BSN), Master of Science in Nursing (MSN), and the Doctor of Nursing Practice (DNP). The school holds lab sessions as a means to teach FNP nursing students clinical skills and practical knowledge. There are five suites dedicated to FNP learning that are designed to mimic a clinic exam room. The exam rooms are set up with cameras for recording and simulation manikins. Lab sessions allow students to practice assessments and procedures. The vaccination discussion simulation took place in a debriefing room of the multidisciplinary lab (Weber State University Dumke College of Health Professions, 2020). Population This project took place in the state of Utah. Utah has a population of approximately 3.2 million people. The majority of Utah residents are Caucasian (United States Census Bureau, 2019). A vast majority of Utahns hold conservative views, and the religiosity of the people must be considered in addressing vaccination issues because evidence shows that individuals in IMPROVING VACCINATION DISCUSSIONS 18 abundantly religious areas are much less likely to vaccinate, especially against HPV (Bodson, Wilson, Warner, & Kepka, 2017). 92% of Weber State University students are Utah residents. The average age of attendance is 26 years old, with 56% of the student body made up of females and 44% males. A significant portion of the students, 79%, work while attending school, and 59% attend part-time (Weber State University, 2020). The 2019 DNP FNP cohort comprises 15 BSN and four MSN students, two males and 17 females, who have varying years of nursing experience. The majority of the FNP students are working as registered nurses while attending school. Eighteen of the DNP-FNP students participated in the simulation. The students’ insight into the unique barriers that prevent individuals from obtaining vaccination in the state of Utah will also help future providers address issues such as limited access, and lack of education, thereby improving vaccine uptake. Project Plan Implementation. Prior to implementation, nursing school faculty approval was obtained. This DNP project was decided to be exempt after consideration and review from the Institutional Review Board at Weber State University (see Appendix A). From the spring semester 2020 through fall semester 2021, the DNP student leader researched vaccine mechanisms, vaccine-preventable diseases, motivational interviewing techniques, simulation practices, and vaccination recommendation strategies. Interviews were also conducted with individuals who categorized themselves as “vaccine-hesitant.” Several meetings were held between the DNP student leader, the DNP faculty lead, Dr. Jessica Bartlett, and the DNP project consultant, Dr. Angela Page, to discuss implementation and project planning strategies. The DNP student leader created an educational PowerPoint as well as a vaccination discussion algorithm (see Appendix B), IMPROVING VACCINATION DISCUSSIONS 19 common reasons for vaccine hesitancy information handout (see Appendix C), and vaccine hesitancy discussion scripts for the simulation (see Appendix D). Implementation took place on May 17, 2021, during a regularly scheduled pediatric course lab session. The students were divided into two groups. Half of the students completed the assigned lab work while the other half participated in the simulation, and then the groups switched. The simulation was conducted in a lab debriefing room equipped with desks, chairs, and a large screen to view the PowerPoint presentation. Eighteen students, other than the DNP student leader, were present and participated in the simulation altogether. Handouts of all simulation resource materials were provided to the students at the beginning of each session, and opportunities were provided to ask questions about the simulation or the provided resources. The students then viewed a recorded PowerPoint lecture presented by the DNP student leader and conferred about the vaccination discussion algorithm and its application to multiple scenarios. Students were paired off in groups of two or three and were provided written scripts that simulated a live patient vaccination discussion. Each partner took turns acting out the role of the provider and the patient using one or two of the written scenarios and then was encouraged to come up with their own scripts inspired by their past experiences. Following the simulation, there was a brief question-and-answer session. Role of the DNP Leader. This change initiative was a collaborative effort. The D NP student acted as a leader in this project by creating team of individuals that were able to adapt to the complex and changing dynamics of situations that arise in quality improvement projects as well as secure stakeholder buy -in. The DNP student leade r exercised creativity in order to utilize the organizational resources effectively. The successful execution of this project require d that the DNP student leader effectively communicate d the potential impact of simulation and IMPROVING VACCINATION DISCUSSIONS 20 coordinate d with the scho ol of nursing to ensure that proper objectives were met and appropriate timelines were established. The transformational leadership style was utilized by the DNP student nurse leader to unify team members, focusing on building relationships and networking with others in order to move the vision of practice change reality. Evaluation and Data Analysis Data Collection The DNP student leader created online pre, and post-intervention surveys to evaluate the effectiveness of the practice change. Likert scales, the number of participating students, and open-ended questions were utilized to elicit both student and faculty input and feedback. One week before the implementation date of the project, the project consultant emailed a survey link for the pre-test to all students in the DNP-FNP 2021 cohort. The pre-test consisted of questions that assessed the students’ knowledge prior to implementation regarding vaccination, vaccine-preventable disease, current practice for vaccination recommendation, and perceptions of confidence and competence initiating challenging vaccination conversations (see Appendix E). The students were instructed to complete the survey before attending lab on the date of implementation, and completion of the pre-test survey was required for lab attendance. The post-test survey was identical to the pre-test survey, with the exception of a hard copy handout containing three additional Likert scale questions concerning the students’ perceptions of confidence and any benefit gained from participating in the simulation. Two additional declarative response questions were included to elicit input from the students and encourage precise responses about what was gained from their participation in the simulation (see Appendix F). The post-test survey link was emailed to the students following the simulation. There was no incentive provided to complete the survey. Subsequent to implementation, the DNP IMPROVING VACCINATION DISCUSSIONS 21 student leader met with the project consultant to request further opinion and advice for qualitative feedback. Analysis Descriptive statistics were used for the analysis of the project. Results from the survey were placed into three different categories, including knowledge about vaccination and vaccine-preventable disease, perceived sense of confidence and self-efficacy, and knowledge about effective recommendation practices. Each survey question was scored independently then the mean average test score was calculated for each of the three categories. Three overall themes emerged and were used for qualitative feedback results consisting of use for future practice, the advantage of simulating patient conversations, and increased knowledge. Results Eighteen students were present and participated in the simulation lab (n=18, 100%). There was a 100% (n=18) response rate for the pre-test survey and an 89% (n=16) response rate for the post-test survey. The student survey responses demonstrated that the DNP-FNP students benefited significantly from the simulation exercise, which led to enhanced perceptions of confidence and expertise in discussing vaccine-preventable diseases and vaccination with patients. For the category of knowledge about vaccination and vaccine-preventable disease, the average scores increased 6.5% from the pre-test to the post-test survey. In the category of perceived sense of confidence and self-efficacy, the average scores increased 23% from pre to post-survey. Knowledge about effective recommendation practices was also shown to substantially increase, with average scores again increasing 23% from pre-test survey to post-test survey. These findings are displayed in Appendix G. IMPROVING VACCINATION DISCUSSIONS 22 Written comments in the post-test survey were brief; however, the open-ended qualitative questions revealed three recurring themes, including use for future practice, the advantage of simulating patient conversations, and increased knowledge. Informal responses from the students after the simulation included the comments, “I loved your project. It really helped me, and I have already had a chance to use what I’ve learned in practice” and “Your project was so relevant and really useful.” Responses regarding what could be done differently in future simulations were also solicited from the simulation participants and the faculty. Most of the respondents indicated they would not change anything in future simulations, but two comments were made about how the educational PowerPoint presentation needed more visuals and should move quicker. The faculty member who oversaw the project implementation suggested that the simulation take place in a larger room with better acoustics and that a debriefing session be added in future simulations. Discussion Limitations and Recommendations for Future Practice Despite the project’s overall success, limitations and barriers should be discussed in order to refine the simulation process and ensure sustainability. Project Issues Resources. A large part of this project's success is due to the organizational support and dedication to the excellence of the nursing profession and its students' personal and professional development. The nursing school donated the lab space and the necessary time and funds related to the maintenance and cleaning of the lab. The school of nursing also donated the faculty members' time to oversee the implementation. Because lab sessions are a mandatory requirement in the FNP program, participation and survey response rates for this project were higher than IMPROVING VACCINATION DISCUSSIONS 23 most DNP projects. The cost of this project was low due to the donated time of the faculty and the DNP student leader. Barriers. A significant barrier to this project was the evaluation of its effectiveness. DNP-FNP students participate in many assigned discussions related to their projects. There is a possibility that student awareness and knowledge of the role of provider recommendation increased prior to the project’s implementation through other educational platforms. The participants in the simulation were all DNP-FNP students who were simultaneously conducting their own practice projects. The students have familiarity with the desire to demonstrate project effectiveness which may have altered their responses and artificially inflated feedback. Coronavirus (COVID-19) complicated the completion of the project by hindering communication about the project with the project consultant and the other faculty members. However, by the time the practice change was implemented, all students and faculty had been vaccinated against COVID-19 and were able to attend the simulation in person. Because the simulation took place simultaneously with the pediatric lab, the exam rooms were unavailable. This resulted in inadequate space and acoustic challenges as all of the students crowded into one debriefing room with the students talking over one another, and the idea of simulating a clinic visit did not come to fruition. While the students were role-playing, it was challenging for them to remain focused and avoid distraction from the other conversations occurring in the room. DNP-FNP students have demanding schedules and heavy workloads. The students’ responses may have been brief due to time constraints or lack of incentive owing to the fact that proof of post-test completion was not a course requirement. The quick turnaround time for the different sections of the lab impaired the ability to communicate instructions about the post-test survey, and multiple students did not realize the post-test handout was an adjunct to the online IMPROVING VACCINATION DISCUSSIONS 24 version, leaving the online portion undone. An additional challenge to the project’s implementation was a miscommunication about how the materials should be posted in the Canvas course. Some of the students were in a different section of the course and did not receive instructions for the simulation or the pre and post-test surveys, which resulted in confusion and took some time to sort out at the beginning of the simulation. The multidisciplinary lab was also under construction, which resulted in a few interruptions and difficulty in communicating with the lab coordinator. Future providers may also present with their own biases related to vaccination. It would be more advantageous for the students in future simulations to be in an environment that more closely resembles an actual clinic exam room. While benefit from participating in the simulation with fellow students was observed, the opportunity to practice vaccination discussion with actual patients or live actors might yield improved outcomes. Significance and Implications DNP providers are leaders in designing, executing, and monitoring programs with calculated outcomes. In this practice change project, the student DNP leader was responsible for obtaining SON approval and support and modeling transformational leadership in systems thinking to improve current practice. Other roles of the student DNP leader included collaboration with faculty, communicating project expected outcomes and objectives, managing and overseeing the implementation of the project, and demonstrating project results (Reavy, 2016). This project has the potential to be incorporated into the standard DNP-FNP curriculum at WSU, and with minor modifications, other FNP curriculums in the state of Utah or other populations. The pre-test to post-test scores revealed that the students felt more prepared to discuss and recommend vaccinations in future practice. Effective vaccination recommendation is IMPROVING VACCINATION DISCUSSIONS 25 critical to improving vaccination rates because provider recommendation is the number one indicator for vaccine acceptance (Dempsey et al., 2018). Advanced practice nurses have the responsibility to transform healthcare through evidence-based practice. With improved provider recommendations for vaccination, nurse practitioners become leaders in disease prevention strategies and are able to build trust with their patients and within their communities. The faculty at WSU Annie Taylor Dee School of Nursing will make the decision if the vaccination discussion simulation should be incorporated into the standard DNP, FNP curriculum at Weber State, proving to be a sustainable practice change. Conclusion Vaccination is proven to lower disease transmission, reduce the risk of certain cancers, and improve herd immunity. Vaccine-hesitancy is increasing exponentially in the state of Utah and poses a substantial threat to public health. Increasing vaccine uptake is a global initiative and a high priority, especially amidst the Covid-19 pandemic. Providing evidence-based solutions to improve vaccination is critical in reducing healthcare costs and minimizing disease burden. 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American Journal of Public Health, 103(1), 164-169. doi: 10.2105/AJPH.2011.300600 IMPROVING VACCINATION DISCUSSIONS 33 Appendix A IRB Exemption Documentation October 30, 2020 Jessica Bartlett Laura Clyde Students, Master of Science in Nursing Re: Quality Improvement Project - Initial - IRB-AY20-21-141 Clyde: Improving Future Provider Confidence in Vaccination Discussions Dear Jessica Bartlett: The Weber State University Institutional Review Board confirms Clyde: Improving Future Provider Confidence in Vaccination Discussions has been reviewed under the Common Rule (see 45 Code of Federal Regulations (C.F.R.) § 46.102(l)) and meets the standard of a Quality Improvement (QI) or Program Evaluation (PE) activity. The project does not need formal IRB reviewal and you may proceed at this time. If you have any question please contact your review committee chair or irb@weber.edu. Sincerely, Matthew Nicholaou, DrPH, MT(ASCP) Chair, DCHP IRB Sub-committee Weber State University Institutional Review Board IMPROVING VACCINATION DISCUSSIONS 34 Appendix B Vaccination Discussion Algorithm IMPROVING VACCINATION DISCUSSIONS 35 Appendix C Common Reasons for Vaccine Hesitancy Information Handout Preview Common Reasons for Vaccine Hesitancy and Information Sharing 1. Vaccine ingredients: • People have concerns over the use of formaldehyde, mercury or aluminum in vaccines. It's true that these chemicals are toxic to the human body in certain levels, but only trace amounts of these chemicals are used in FDA approved vaccines. In fact, according to the FDA and the CDC, formaldehyde is produced at higher rates by our own metabolic systems and there is no scientific evidence that the low levels of this chemical, mercury or aluminum in vaccines can be harmful. • In all cases, vaccines containing adjuvants are tested for safety and effectiveness in clinical trials before they are licensed for use in the United States, and they are continuously monitored by CDC and FDA once they are approved. • Aluminum is found in higher concentrations in food, breast milk, and formula than all childhood vaccines combined. Aluminum is also rapidly excreted – half of any dose of aluminum will be expelled from the body within 24 hours. • Guidelines for aluminum exposure (with a 30-fold safety factor built in) are for aluminum exposure to be less than two milligrams per kilogram of body weight per day. That means someone who weighs 80 kilograms could ingest 100 milligrams of aluminum in a day and remain safe. • All vaccines have less than one milligram of aluminum per dose, and most are below half of that. So exposure to aluminum through vaccines is negligible, and well below the already low risk threshold. • Thimerosal has a different form of mercury (ethylmercury) than the kind that causes mercury poisoning (methylmercury). It’s safe to use ethylmercury in vaccines because it’s processed differently in the body and it’s less likely to build up in the body — and because it’s used in tiny amounts. Even so, most vaccines do not have any thimerosal in them. • Thimerosal is broken down to ethyl-mercury in the body. Ethylmercury is found in much greater concentrations in the earth’s crust, air, soil, and water than vaccines. Methyl-mercury is the type of mercury that can be found in certain kinds of fish and at high levels can be toxic. Mercury from tinned tuna takes longer to expel from the body than any mercury in vaccines. 2. Building natural immunity is more desirable and long lasting/ Diseases like Measles are not that serious: • In some cases, natural immunity — meaning actually catching a disease and getting sick– results in a stronger immunity to the disease than a vaccination. However, the dangers of this approach far outweigh the relative benefits. If you wanted to gain IMPROVING VACCINATION DISCUSSIONS 36 Appendix D Simulation Scripts Preview Vaccination Discussion Simulation Scripts MMR Provider: “Sally is due for her MMR vaccine today. It protects against measles, mumps, and rubella. If you don’t have any questions, we will get that taken care of before you leave today.” Patient: “I don’t think we want the MMR today.” Provider: “Ok what concerns do you have?” Patient: “There is a lot of controversy over that vaccine and I don’t want to be responsible for giving my child autism.” Provider: “Autism is very challenging for families. I understand why you want to make sure that everything that goes into your child’s body is safe.” Patient: “I can’t believe how many chemicals and unnatural substances are used in the name of health.” Provider: “You really care about your child’s safety.” Patient: “Yes, doesn’t every parent?” Provider: “I want to make sure I’m understanding you; it sounds like you are concerned that the MMR vaccine could cause Autism and you feel it is unsafe.” Patient: “Yes it’s one of the scariest vaccines and measles doesn’t make people that sick.” Provider: “This is ultimately your decision, but would be it be ok if I share some of my concerns with you?” Patient: “Sure, I guess.” Provider: “The doctor who conducted the study that claimed he found a link between autism and the MMR vaccine only looked at 12 patients. His study was flawed and all of his papers have been retracted. He no longer has a license to practice medicine in the UK. Since that time there have been 17 large studies conducted that have found there is absolutely no correlation between autism and the MMR vaccine.” IMPROVING VACCINATION DISCUSSIONS 37 Appendix E Pre-test Survey Improving Future Provider Confidence in Vaccination Discussions Pretest 1. The most common side effect of vaccination is a. fever b. allergic reaction c. pain and redness at the injection site d. seizure e. passing out 2. HPV is known to cause the following cancers (Choose all that apply) a. anal b. penile c. vulva d. oropharyngeal e. cervical f. liver g. None of the above 3. Which of the following is the best example of a provider presumptive approach to vaccination recommendation? a. Your child is eligible for 2 vaccines today, meningococcal and HPV. Did you want to take care of those today? b. Are we administering vaccinations today? c. Which vaccinations would you like to complete today? d. Today your child is receiving the meningococcal and HPV vaccines. Unless you have any questions, we will go ahead and take care of those. e. We can do meningococcal and flu vaccines today. Did you also want to do the one for HPV? 4. HPV is only associated with high risk sexual behaviors a. True b. False 5. After a patient/family refuses vaccination the best next step for the provider is to recommend the patient starts visiting a different clinic a. True b. False 6. I trust my ability to effectively communicate vaccination side effects to patients and families a. Strongly agree b. Agree c. Neither agree nor disagree d. Disagree e. Strongly disagree 7. I feel confident in my ability to discuss topics relating to vaccine hesitancy with patients and families a. Strongly agree b. Agree c. Neither agree nor disagree d. Disagree e. Strongly disagree 8. I believe there is a crisis in vaccine confidence today a. Strongly agree b. Agree c. Neither agree nor disagree d. Disagree e. Strongly disagree 9. I feel confident in my knowledge about vaccination and communication techniques to appropriately engage in vaccine hesitancy topics with patients and families a. Strongly agree b. Agree c. Neither agree nor disagree d. Disagree e. Strongly disagree 10. I am intimidated by vaccine hesitancy conversations a. Strongly agree b. Agree c. Neither agree nor disagree IMPROVING VACCINATION DISCUSSIONS 38 Appendix F Post-test Survey All questions from the pre-test survey were completed for the post-test as well as the following additional questions. Improving Future Provider Confidence in Vaccination Discussions Posttest 1. I plan to use the knowledge I gained in this simulation experience in my future practice a. strongly agree b. agree c. neither agree/disagree d. disagree e. strongly disagree 2. After participating in this simulation experience, I feel that I have more tools to help me engage patients in vaccination discussions a. strongly agree b. agree c. neither agree/disagree d. disagree e. disagree 3. After participating in this simulation experience, I am more confident that I will be able to build trust with my patients and show empathy for their vaccination decisions a. strongly agree b. agree c. neither agree/disagree d. disagree e. strongly disagree OPEN ENDED QUESTIONS 4. What have you learned from this process? 5. What would you do differently in this simulation in the future? IMPROVING VACCINATION DISCUSSIONS 39 Appendix G Mean Average Pre-test to Post-test Score Results