Introduction

In Australia, healthcare personnel (HCP) are recognized as a vulnerable group prioritised for seasonal influenza vaccination (SIV) due to their ongoing risk of occupational exposure (Department of Health and Aged Care 2022a). International studies have estimated that up to 23% of HCP contract the flu each season (Ng et al. 2009; Pereira et al. 2017) despite extensive SIV programs, and other encouraged self-protective behaviours. Mindful that SIV significantly reduces the risk, but does not prevent all influenza transmission, the annual cost to the Australian healthcare system of seasonal influenza and its sequalae is predicted to be over $828 million (Zachreson et al. 2018). Curiously, there is little contemporary Australian research that explores the acceptance and uptake of SIV by HCP, particularly during the COVID-19 pandemic.

In the context of a pandemic, it is vital to understand the enablers for SIV encountered by frontline HCP due to the potential combined burden of both diseases as well as the possible learnings derived that may potentially be generalisable to other vaccines. Importantly, this examination must be embedded within a testable explanatory theory or framework about how vaccine behaviours are created in order to appreciate not only associated pathways but the opportunities for intervention.

The purpose of this study was to understand how to optimise SIV of HCP to ensure a protected, available, and sustainable health workforce. This study aimed to provide a contextualised understanding of the intentions and practices of Australian HCP towards SIV by exploring their attitudes and experiences. To understand the enablers that impact behavioural outcomes of vaccination decision-making in the context of Covid-19, a theoretical framework based on Triandis’ Theory of Interpersonal Behaviour (Triandis 1977) was applied. This theory enabled a structured exploration of the determinants of vaccination uptake in various healthcare settings by frontline HCP; to identify the factors that contribute towards vaccine acceptance or hesitancy by this highly exposed, but essential cohort.

Method

Design

Following ethics approval, we conducted remote individual interviews, via MS Teams or by phone, with Australian nurses and midwives, pharmacists and medical practitioners. All HCP were aged between 24 and 65 years, from urban and rural primary or tertiary healthcare settings across five Australian states and territories. This cohort is considered the most trusted source of vaccination information (Dybsand et al. 2019) and more likely to promote vaccination if they are vaccinated themselves (Paterson et al. 2016). They are also recognised as a highly vulnerable and exposed workforce to seasonal viruses, including influenza and influenza-like illnesses (Peytremann et al. 2020; Rule et al. 2018). A constructivist approach was employed with the co-creation of data between participant and researcher to explore their vaccination experiences. This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al. 2007), with the 32-point checklist confirmed among the authors. All interviews complied with Public Health regulations dictating Covid-19 Restrictions.

Ethics

Ethics was sought and approved for this qualitative study. Before recruitment began the primary researcher reflected on personal vaccination beliefs, practices, and role as a Registered Nurse, in critical care or infectious disease (ID) settings, as well as personal experiences of seasonal influenza. Rumination enabled identification of beliefs and biases that could impede authentic communication between the interviewer and participant, including membership to professional organisations regulating vaccination behaviours. Field notes included the interviewer’s perceptions, recall of nonverbal communication and level of engagement experienced throughout the interview. The research team was involved in all discussions to resolve uncertainties and support the exploration of issues raised.

Participant recruitment and context

Participants were recruited via purposive sampling from October 2021 to May 2022, after responding by email to a recruitment poster, or snowball sampling through distribution of study information to potentially interested personnel within healthcare organisations or communities. Participant recruitment was challenging as the impact of Covid-19 on the healthcare workforce compromised potential candidate availability. Therefore, theoretical sufficiency was the goal to understand at depth the nuances of the data (Braun and Clarke 2021). A non-linear, recursive, and iterative process, as proposed by Braun and Clarke (Byrne 2021), allowed analysis of 14 HCP interviews, giving voice to their experiences, attitudes, and vaccination behaviours as transparently as possible while maintaining confidentiality and anonymity. The interviews lasted approximately 30–45 min, were only recorded with permission, and were transcribed verbatim. Data de-identification was performed during transcription of the interviews by the principal investigator prior to data analysis by the research team.

Data collection

The primary author and lead investigator conducted participant recruitment and all interviews to ensure consistency. The question guide (Attachment A) was used to focus vaccination discussion, allowing some flexibility for the organic flow of dialogue, and enabling the expansion and further examination of topics to illuminate insights. Pilot interviews were conducted with two senior Registered Nurses and a Medical Practitioner, with small amendments made to language. Questions initially gathered demographic data, then broadly probed participants experiences and attitudes, vaccination habits, influential social factors, facilitating conditions, and vaccination intention and behavioural outcomes. The iterative process employed informed minor adaptations to the question guide, developed from an integrative review of the literature (Hall et al. 2022) and deliberations of the Theory of Interpersonal Behaviour (Triandis 1977). Verbatim transcriptions were de-identified, reviewed and analysis checked by all authors.

Data analysis

Analysis of the data followed the Braun and Clarke’s ‘Reflexive Thematic Analysis’ methodology (Braun and Clarke 2019), utilising the ‘6-phased process’ that initiated a theoretical, analyst-driven inductive approach, moving from the explicit to the latent level of analysis to incorporate data interpretation and a deeper understanding of vaccination behaviours. A manual process of coding, and theme and sub-theme generation was employed to deliver an organic and authentic interpretation of the data.

Themes and sub-themes were generated, ultimately shaping a thematic map (Fig. 1), with meaningful linkages identified, to understand key constructs impacting HCP vaccination behaviour. All authors were involved in the coding and analysis of the interviews, with further discussions illuminating and critiquing data nuances and insights. All authors reached a coding consensus to ensure study credibility, data authenticity and confirmability.

Fig. 1
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Thematic mapping of qualitative results

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Results

Fourteen interviews were conducted, transcribed and analysed. Demographics were collected as per Table 1. The Australian Capital Territory (ACT) was the most highly represented state/territory (7 participants), with the Registered Nurse cohort (7 participants) delivering the most substantial amount of feedback. Five participants worked in urban hospitals, three HCP in rural/regional hospital settings; while three HCP were employed in Aged Care, and three in community healthcare settings. Eleven out of the 14 HCP received the seasonal influenza vaccine in 2021. Two agreed to phone calls only, while one preferred not to be recorded, but validated the transcription, with no changes required, post interview.

Table 1 Participant demographics
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The interviews revealed vaccination attitudes, knowledge and intentions, culminating in the identification of six distinct themes, with subthemes (Attachment B). The Covid-19 pandemic remained a contextual influence impacting on participants perceptions, behaviours or work environment, and was frequently discussed concurrently with influenza vaccination, with the two vaccines enmeshing into one dialogue on vaccine decision-making and behaviours. The themes identified include habit – past behaviours, convenience and ease of access, risk perception, experience and knowledge, professional responsibility and identity, and protection. Complacency was an overarching participant dynamic. The themes and several subthemes will be discussed further; while their interdependencies and links have been highlighted in the thematic mapping (Fig. 1).

Habit- past behaviours

The frequency of past vaccination behaviours, or habit, fostered further HCP intentions to vaccinate for seasonal influenza. Most participants voiced an unquestioning acceptance of the vaccine, with many relying on the workplace to facilitate an opportunistic approach to vaccination.

Nurse 4: Since I was working, I was getting the vaccine, the flu vaccine every year.

Nurse 5: I can’t even remember when I had my first vaccine. And it just becomes part of the routine… You know, you walk in, you get it, you walk out, and five minutes later you’ve forgotten that you even had it…

Equally, the habit of not vaccinating, irrespective of vaccine confidence, was also raised, reinforcing complacency towards the disease, and SIV.

Nurse 2: …I should get it (SIV) but I have never had one and for no particular reason. It’s just not something I have done. I don’t even have a good rationale.

Nurse 7: I believe if you look after your body, eat well, good nutrition, stay home when you are unwell and look after yourself there is no need for a flu vaccine. I don’t believe in the flu vaccine and have never had one.

The initiation of the habit was often associated with student placement protocols or early career workplace requirements. Many HCP stated that SIV was a necessity of student placement in healthcare settings, mandated by the university or the workplace.

Doctor 3: …my experience as a medical student. That’s when I started having my yearly flu jabs. So, it basically became a requirement.

Sub theme: Trigger

Frequently participants stated vaccine uptake was directly related to a trigger or nudge. The repeated or habitual behaviour of vaccination, with limited cognitive processing appeared to require a trigger to initiate the behaviour, to remind the participant it was ‘time to vaccinate’. Most participants voiced limited pro-active planning in vaccination acquiescence and perceived the process as opportunistic. Social media, traditional media, disease visibility (among patients), workplace communications or the presence of a vaccination trolly/hub often triggered participant vaccination behaviour, if vaccine acceptance (intention) was already present.

Doctor 1: We haven’t seen the flu either in the hospital… if there were lots of cases I would have made a bigger effort.

Pharmacist 1: If the flu vax is there, they ask me ‘do you want one?’ and yes please! And get it done right then and there… It gets to April and I know its flu shot season, and I just wait for someone to remind me of the flu shot.

Convenience and ease of access

HCP ability to access the SIV with ease and little inconvenience, with limited planning, and few barriers, proved a major factor in SIV uptake. HCP expressed the opportunistic nature of SIV in the workplace facilitating uptake. Participants described competing Covid-19 priorities limiting SIV accessibility in tertiary healthcare facilities; that prioritisation of pandemic-related occupational health and safety (OHS) activities had impeded access and convenience to obtain SIV.

Doctor 1: Far less of a campaign to make it easy at work to get the flu vax. The MOHS (medical OHS unit) haven’t gone around (the hospital) this year, it just hasn’t happened.

Pharmacist 1: Its opportunistic, absolutely…then I had to ring to make appointment…Which annoyed me. I don’t want to have to ring up and make an appointment, I want to just walk in, which you can’t now…

Doctor 4:…that may have been the only year I didn’t get the flu vaccine and that was because I was too distracted to go and get it and I wasn’t working at that point. I had the whole year off (not at work).

It was noted by HCP associated with or working in the Aged Care sector, where SIV has been mandated since 2020 following direction from the Australian Health Protection Principal Committee (AHPPC) (Department of Health and Aged Care 2022b) during the emergence of Covid-19, access to SIV had improved, with greater visibility, convenience and at no cost to the employee. Placing the onus back on the employer to ensure workplace/residential care safety had improved SIV access, making it a convenient ‘duty’ of HCP working with this vulnerable population.

Nurse 6: I would say it was ramped up! Yeah, they were straight onto it and honestly, it was like a … not like a ‘war scene’ but… like, lets literally ‘roll our sleeves up and get this done’ attitude.

Nurse 4: I think they want the strategy to protect the elderly. I’m not against it. Yeah, so I quite accept it.

Risk perception

Risk perception shaped by fear or complacency towards the organic disease, impacted by experience and knowledge, influenced SIV. Personal and professional experience of the virus, contributed to risk perception, consolidating participants belief in influenza as a serious disease, and influencing uptake, to a degree. Constraining the effectiveness of high disease risk perception as a predictor of vaccination behaviour was ‘ease of access and convenience’, as even those cognisant of influenza risk, relied on a trigger (email, vaccination hub or vaccine trolley) and easy access to progress to vaccination uptake.

Pharmacist 1: Yeah, I probably have more of a fear of it (influenza) than other people… the (ICU) patients were really, really sick, and we didn’t know how to treat them and they got bad infections, and people died… it was awful! And I still feel more worried about influenza than I do about Covid.

Doctor 4: Well, I think it can have some very serious consequences. So, I’m not willing to risk them. I guess it’s another reason I get the vaccine. I’m not willing to find out what the consequences could be…

Misconceptions and lack of experience, or exposure, either professionally or personally, may be lowering risk perception, compounding complacency around seasonal influenza; not impeding acceptance of the vaccine but interrupting the impetus to progress to vaccination positive behaviour.

Doctor 2: I find it frustrating the terminology that’s used… that people say 'I’ve got the flu/I’ve had the flu’… and they have a heavy cold maybe. I think there’s a misconception about what the flu is.

Nurse 6: I think when people say they have flu, generally speaking, and I could be wrong, but they actually have a bad cold. Because true flu you don’t forget.

Doctor 3: Whereas how I see the flu-vax is like, you’re not hesitant because you’re worried (about the vaccine), it’s like you just don’t think that it’s important enough… Or can’t be bothered at the moment.

Complacency or lower risk perception towards the disease did not appear to negate participants confidence in the seasonal influenza vaccine. Most participants felt it was ‘a good vaccine’, with only one participant believing SIV was unsafe. Lack of confidence in SIV, in this case stemmed from the erroneous beliefs that it caused the flu with work colleagues or contained graphene oxide. The predominant confidence in SIV efficacy and safety, however, and higher risk perception appeared insufficient at times to bridge the gap between acceptance and uptake of the vaccine. Other constructs, or themes, appear more valuable in closing this gap.

Nurse 2: I think it’s a really good vaccine for people who are at high risk. So, the elderly population with significant co-morbidities.

Doctor 3: I will get the flu vaccine because I know it’ll protect me and also that it’ll influence other people.

Nurse 7: I couldn’t see the point of getting the flu vaccine as every time my colleagues had it, they then got the flu!

Experience and knowledge

Experience and knowledge incorporated personal and professional experiences with the influenza virus and the vaccine. Many participants conceded a superficial knowledge of the configuration and preparation of the vaccines. No participants had experienced significant adverse events or side effects from SIV. Surprisingly, only 36% of participants believe they had experienced, either professionally or personally, seasonal influenza and its sequalae. However, those claiming a lived experience of the influenza virus profess a degree of fear of the disease, and its ability to incapacitate.

Doctor 1: …and I have had it myself! Probably over 10 yrs ago and it was shocking! I wouldn’t want to get it again.

Pharmacist 1: I worked in ICU…I’ve seen patients die with influenza.

Doctor 2: I clearly remember, when I was about a 3rd year registrar being absolutely floored by the flu – and after that I’ve always had the flu vaccine.

Doctor 3: Yeah, and the way we talk about flu, as if everyone had it. And no, I don’t know, I haven’t had it. And like terms like ‘man flu’ and stuff. And there’s like ‘cold and flu season’ and it’s like, uh, maybe there’s just a general lack of understanding of what flu is.

Professional responsibility and identity

The most highly represented theme from the interviews saw SIV as a professional responsibility; part of participant’s professional identity and duty. Discussions around vaccination normalised the behaviour as a standard expectation that is ‘part of the job’. Few questioned the need for the vaccine and accepted it without examining purported efficacy or extent of uptake. Some comments suggested an obligation to vaccinate, while others revealed a sense of professional pride and solidarity that engendered a collective professional identity. This sense of identity was associated with vaccine acceptance and uptake, as it appeared to foster camaraderie under a common goal of protection.

Nurse 1: So, as I was working in Oncology, we had to have it. If you want to work there you had to have the flu vax.

Pharmacist 1: It’s a responsibility and an expectation… My patients should not have to worry about catching something from me.

Nurse 3: …it’s our responsibility as a health professional to get it (SIV).

Midwife 1: What’s the point of being in, you know, the healthcare field where it’s about caring for others and putting them sort of first… or ‘person-centred’ in your care…then putting them at risk of something that you’ve brought into the hospital?

Subtheme: Advocate and promoter of SIV

Many but not all HCP considered themselves advocates for SIV. Promotion of the vaccine to their patients, clients or family was considered part of their professional duty, but several felt very strongly about free choice, and stepped back from calling themselves ‘advocates’. In contrast, one participant felt their duty as a healthcare professional and a patient advocate was to warn individuals away from SIV as they felt it was unnecessary and potentially harmful.

Pharmacist 1: Pharmacists in the community now deliver vaccinations, which wasn’t a thing…there’s now more incentive for them to know (SIV), and positively influence the community. And I think that’s a really positive development…

Midwife 2: I’m comfortable with giving them that information. Umm, I’m also comfortable with supporting whatever decision they make… it’s their decision in the end.

Nurse 5: I’m pretty happy to be outspoken about things. Ohh, definitely yeah, I’m more than happy to be an advocate.

Nurse 7: You don’t need vaccines to stay safe… Pregnant women are encouraged to have the flu vaccine and the Covid vaccine to protect their unborn child. Instead, the vaccines are making these children sick from a young age. Sick children with the vaccine from the mothers.

Discussions with other HCP about SIV emerged as an interesting complexity. Although promotion or advocacy for the SIV was supported for clients, patients and family, a degree of discomfort and avoidance was evident when HCP were questioned about vaccination conversations with their colleagues. Very few embraced open, candid conversations with peers about SIV, and most felt it wasn’t their place to do so.

Nurse 6: That’s not a conversation I’ve had with many staff. They are completely under the pump…But it’s not a conversation I would be comfortable having with them.

Doctor 3: I didn’t really get into it too much with her, I guess. It’s not my place to have those conversations.

Subtheme: Choice vs mandate

There was uncertainty around the issue of mandating the seasonal influenza vaccine for HCP. In theory, some participants supported a mandate for clinicians, especially when the professions are already obligated to vaccinate against other diseases. However, participants would also extol the virtues of free choice. The underlying belief that the ‘vaccine refusing’ HCP simply did not have all the information or the correct information to make an informed ‘free’ choice, appeared to bridge the disconnect between support for a mandate and support for free choice.

Nurse 2: I wouldn’t have a problem if they did. If they mandated it for healthcare workers. I’m not opposed to them mandating the flu vax.

Nurse 4: Interviewer: So, do you support the mandating of the flu vaccine in aged care? RN: Yes, yes. But I do respect those other people who disagree with it.

Nurse 5: I think that’s very tricky…ummm. I suppose I’d like to think that people would see the logical scientific sense to it. And yet, at the same time, you know, people do have a right to their opinions.

Protection: others, self, resourcing

Confidence in the seasonal influenza vaccine underpinned the overall theme of protection. Most HCP believed that the vaccine offered a degree of protection for themselves, people in contact with them (others), and subsequently, healthcare facility resourcing through securitisation of workforce capability. Primarily protection of others, especially their patients and vulnerable populations, was the focus of HCP’s decision to vaccinate against seasonal influenza. A sense of guilt, weighted by professional responsibility and the ethos ‘first do no harm’, led many participants to choose vaccination.

Nurse 1: I’m happy to go ahead and have the influenza vaccine to protect myself, but also to protect others.

Pharmacist 1: Yeah, my main argument for all this stuff (vaccination) is I don’t want to put anyone else at risk. I have an important job to protect people. I would just die if I caused anybody’s illness!

Doctor 2: We don’t work in professions which are overly bombarded with staff numbers, and so we do have a duty to do what’s available to try and reduce our time away from work through illness.

Discussion

The themes and subthemes identified through the participants voices revealing their lived experiences of seasonal influenza and the vaccine are highly associated and inter-related. Despite past behaviours (habit), and HCP acceptance of SIV, complacency towards the disease showed signs of interrupting the intention to behaviour impetus creating a potential value-action gap. Importantly, countering complacency, and over-coming the value-action gap may be highly associated with professional responsibility and identity, that promotes vaccination as a professional norm, allied with protection of others, and ease of vaccine access.

Seasonal influenza vaccine complacency, not vaccine hesitancy, was experienced by some participants of this study and identified as a behavioural determinant of non-vaccination among other HCP. Acceptance of the vaccine as an effective and trusted preventative health measure was a recurring theme, even among the unvaccinated. A number of participants expressed complacency as ‘low prioritisation of SIV’ and lack of worry about the disease, and its sequalae. These sentiments echoed Schmid’s (2017) findings where SIV complacency was expressed as low worry, low perceived risk and disease severity. A number of HCP having never experienced ‘the flu’ themselves, felt SIV was valuable for vulnerable, ‘at risk’ populations. Although compliant with professional expectations of vaccination, their vaccination status was dependent on other factors, not related to the belief in their vulnerability and potential high levels of exposure, or the efficacy of the vaccine itself.

Countering vaccination complacency may be achieved through interventions that focus not on an individual’s ‘risk’ or the severity of the disease but through professional identity and the associated responsibilities and professional norms. This study found strong representation of healthcare professional identity and the social normative behaviour of vaccination. Vaccination was repeatedly seen as a duty; a professional responsibility to not injure or infect your patients – ‘it’s just what you do’. This duty or acceptance was spoken with a sense of obligation, or with a sense of professional solidarity, to predominantly keep patients/others, themselves and resourcing safe.

Falomir-Pichastor et al. (2009) studied the impact of group identification (nurses) on health-related behaviours, primarily their willingness to be vaccinated, and found similar results. The study of Swiss nurses purported their willingness to be vaccinated was significantly related to professional identity, more so than vaccine or disease knowledge (Falomir-Pichastor et al. 2009). Furthermore, group identification was related to the patient-protection goal, rather than self-protection. These results resonate with this study. The same attitude was expressed by Australian HCP; a strong sense of guilt or fear at the potential harm that could be done by cross-infection. Professional or moral responsibility to ‘do no harm’ has been represented as a recurring theme in numerous studies (Cowan et al. 2006; Godin et al. 2010; Johansen et al. 2011; Mak et al. 2013). Edge et al. (2017) describes HCP desire to conform to social norms, professionalism, and social responsibility as enablers of vaccination behaviour that protect both patients and other healthcare workers.

Clark et al. (2009) counter this argument suggesting professional identity, in a cohort of American Registered Nurses in itself was not sufficient to singularly facilitate SIV uptake. While Boey et al. (2018) describe participant’s belief in ‘do no harm’ and a duty to ‘not infect patients’ (up to 90%), SIV was not consistently observed as the best way to achieve this potentially demonstrating a lack of confidence in the seasonal influenza vaccine. This study found most HCP interviewed had a positive view of the safety and efficacy of SIV, supporting the concept that attitudes, combined with social norms are valuable constructs in health-decision making, facilitating vaccination.

In contrast to most participants, two HCP questioned the efficacy of SIV. Similar to Boey et al. (2018), some HCP felt SIV was only part of the preventative/health ‘protective’ solution, and other elements (handwashing, staying away when ill) were also important. Complete lack of confidence in the influenza vaccine, and vaccine refusal though uncommon in this study, was associated with an alternative view of ‘do no harm’ and patient advocacy. A less common belief in broader socio-economic maleficence at play by powerful actors offers a differing perspective of HCP’s role as patient advocate and ‘do no harm’ which was outside of the scope of this study.

Creating momentum to convert intention to behaviour, even with HCP’s positive attitude towards SIV required a trigger or stimulus as discussed by a number of participants. Communications or visual cues were often required to overcome complacency felt towards vaccination, or augment vaccine convenience and access. Kyaw (2019) encountered high SIV uptake among hospital staff (82%) with preliminary widespread vaccination publicity (communication) and the presence of mobile teams (visibility). Participants of this study similarly applauded SIV mobile ‘trolleys’ or highly centralised (e.g. hospital foyer) vaccination hubs that accommodated vaccinations for all healthcare workers and students, improving convenience and ease of access to facilitate uptake. The importance of ‘facilitating conditions’ as a construct that supports the impetus required to transform intention to behaviour should not be underestimated particularly with competing priorities during a pandemic.

The Triandis Theory of Interpersonal Behaviours (Triandis 1977) has application in transforming vaccination intention to positive vaccination behaviour. Triandis’ theory (1977) purports that human behaviour can never be fully autonomous (dependent of personal factors) or fully social (upheld by peripheral factors) (Salonen and Helne 2012). Figure 2 demonstrates the adaptation of the Triandis model to incorporate a proposed value-action gap that potentially emerges at the point where vaccine/disease complacency interrupts the impetus to action. Facilitating conditions and triggers may overcome complacency and progress the intention to behaviour. As per Fig. 2, HCP social norms associated with identity and professional responsibility were the most significant constructs in promoting vaccination behaviour. Embedding the findings into Triandis’ theory identifies enablers for SIV and may direct focus of future vaccination strategies that target the vital constructs of uptake.

Fig. 2
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Application of the Triandis’ Theory of Interpersonal Behaviour (1977) to study findings

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The impact of Covid-19 on uptake of SIV had a number of consequences according to participants of this Australian study. Pandemic priorities interrupted traditional SIV distribution methods in a number of tertiary healthcare facilities. While aged care/residential care staff encountered mandatory SIV and facilitation (and enforcement) by management, ensuring rapid and thorough distribution, a degree of disquiet around HCP beliefs of autonomy and self-determination in health decision making was felt. This was evidenced in a lack of willingness to discuss vaccination views among colleagues and a sense of obligation, ‘yet another thing we have to do’ as a professional duty to protect others during a pandemic.

Despite Covid-19 being an enabler of SIV behaviour in aged care facilities, this did not extrapolate to the tertiary setting. The pandemic was perceived as a ‘complicating factor’ to SIV for many HCP employed in tertiary hospital settings. Competing priorities with Covid-19 activities hindered SIV distribution and accessibility for some HCP, compounding the belief that SIV uptake was less important/less accepted and the future flu season (2022) would be a prolonged and significant one (CNN Health 2022). Despite variability in vaccine acquiescence, confidence in the seasonal influenza vaccine appeared, by most, to be bolstered by the rollout of the Covid-19 vaccine. Many participants expressed vaccine hesitance around the Covid-19 vaccines but felt confident with the flu vaccine. Statements around the longevity of the flu vaccine (‘tried and tested’) compared to the rapid introduction of the Covid-19 vaccines appeared to provide comparative vaccine confidence. One participant stated that SIV and the public’s confidence in it, was used as a tool to broach vaccination conversations around delivery of the more controversial Covid-19 vaccine.

The Covid-19 pandemic also focused HCP’s awareness of health resourcing protection as a public health priority. The overwhelming nature of managing healthcare facilities during heightened pandemic activity had HCP striving to maintain ‘wellness’ both physically and mentally and recognising the importance of vaccination. COVID-19 and seasonal influenza vaccination were often discussed collectively as a means of protecting others, self and the staffing of critical areas within hospitals. Again, drawing on professional responsibility, social norms and camaraderie between HCP, SIV was seen as a safeguard; a way of protecting staffing capacity and potentially lessening the burden absenteeism impacted on workforce capability.

Study strengths and limitations

This study has several limitations. Firstly, this study was conducted during a period of the Covid-19 pandemic where ‘lockdown restrictions’ were instigated by public health authorities and healthcare facilities were pushed into overdrive managing the Australian health landscape of a pandemic-weary population. These impacts may have hampered recruitment processes for this study. However, a broad cross-section of the HCP community were engaged achieving thematic sufficiency, and providing a rich, nuanced understanding of vaccination behaviours and attitudes from across Australia.

Another limitation is the retrospective nature of the study with HCP ruminating about their SIV behaviours from the last flu season (2021). Recall bias may be present as individual’s reasoning for vaccination/non-vaccination could be unreliable, particularly in the context of public health recommendations widely discussed as part of pandemic preparedness/safety. It is also worth noting that participant views may be influenced by the researcher’s/interviewer’s exploration of vaccination and identity as a registered nurse. Nurses and Midwives registered through the Australian Health Practitioner Regulation Agency (AHPRA) and answering to the Nursing and Midwifery Board of Australian may be reported for ‘anti-vaccination sentiment’ as per the ‘Position Statement for Nurses, Midwives and vaccination’ (Nursing and Midwifery Board of Australia 2016). Exploration of vaccine hesitancy among HCP, completely removed from ‘anti-vax’ rhetoric, may be susceptible to stigmatisation and fears of reprisal among health professional cohorts influencing participant responses and creating bias within the research.

Though a broad cross-section of HCP were invited to participate, only female HCP followed through with interviews. As almost 75% of the Australian healthcare workforce identify as female (Australian Institute of Health and Welfare 2022), the researchers felt the results remain credible and transferable across the population. Consequently, the strength of the qualitative method effectively answers the research question. Strengths include participants from a variety of healthcare settings, rural and urban locations and variable levels of professional experience and years in the professions.

The impact of Covid-19 has elicited both positive and negative effects on this research. Although reducing HCP availability, the participants once engaged were eager to discuss vaccination experiences. The pandemic has uplifted vaccine conversations to the epicentre of public discourse. Increased infectious disease exposure and a heightened awareness and acceptance of self-protective behaviours has vaccines and vaccine hesitance as a well-versed, yet contentious issue among HCP and the public in general. This new pandemic dynamic provides a new perspective and a unique opportunity to test and operationalise behaviour change theory, such as the Triandis Model, into strategies that promote vaccine uptake by HCP.

Conclusion

Future research according to the findings of this study of Australian HCP, should prospectively test strategies fostering a strong sense of connectedness between health professionals within their craft group and linking this to vaccine uptake.

It is likely, however, that these links to professional identity alone will be insufficient to maximise uptake. HCP expressed confidence in SIV and strong ties to professional identity, but the impetus to progress vaccine acceptance (intention) to uptake (behaviour) was occasionally interrupted by impaired facilitating conditions and compounded by complacency, not vaccine hesitancy. Complacency appeared to create a potential value-action gap that potentially impeded SIV among these professional cohorts. The results of this study particularly support the ongoing utilisation of convenience and ‘nudging’ strategies that leverage professional norms relating to vaccination as a form of public health protection.