1. Deem, Michael J. PhD


APRNs and RNs have a stake in these policies-and an invaluable perspective to contribute.


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Many nurses are familiar with the challenges parental refusal of childhood immunizations pose to clinical care. Refusal can stem from concerns over vaccine safety, cultural and religious beliefs, political views, or previous acquaintance with vaccine injury. Persistent refusal may lead to distrust or frustration between primary care clinicians and families, have an adverse impact on the quality of care provided, and cause concern over the risks to other patients who have not received certain vaccines because of age or medical contraindications. These negative effects lead some clinicians to dismiss vaccine-refusing families from their practices.

Figure. Michael J. D... - Click to enlarge in new window Michael J. Deem, PhD

According to a recent study by Hough-Telford and colleagues (Pediatrics, 2016), the percentage of pediatricians reporting parental vaccine refusal increased from 74.5% to 87% between 2006 and 2013. The study also reports that the proportion of pediatricians who claim to "always" dismiss families who refuse vaccines nearly doubled over this same period, from 6.1% to 11.7%. These data help explain why the American Academy of Pediatrics (AAP) shifted its position from discouraging dismissal to presenting it as an acceptable response (Pediatrics, 2016).


In contrast, there are no published data on the perspectives of nurses on this issue. This is surprising, given that nurses spend considerable time administering vaccines and counseling families about the benefits, risks, and safety of immunizations. RNs often provide the first response to families who express vaccine hesitancy or refusal, and some advanced practice registered nurses (APRNs) have the clinical autonomy to decide their practices' policies on dismissal. The AAP does not suggest a role for RNs in making these decisions, nor does it appear to have been informed by the perspectives of either RNs or APRNs. Yet physicians' dismissal policies within a practice will affect the professional lives and clinical relationships of the nurses with whom they work.


Because of their unique clinical competencies and relationships of trust with families, nurses ought to have powerful voices when practices make decisions about adopting dismissal policies. Nurses may or may not agree with their colleagues regarding the appropriateness of such policies. As I contend elsewhere (Nursing, 2017), dismissal policies are ethically controversial, and some nurses might view them as a morally unacceptable response.


Some nurses might also believe there are alternative ways to move vaccine-refusing families toward vaccine acceptance, such as engaging in compassionate dialogue about vaccine concerns and having frank discussions about the obligation to promote safe clinical environments for all patients. Practices that implement dismissal policies without involving nurses in decision making risk causing nurses moral distress over having to execute a policy they may find ethically problematic, as well as potentially undercutting the trust these families have in them as health care professionals. Whatever their view on dismissal, nurses are professional and moral stakeholders in their practices' policies, and their colleagues should solicit their input whenever possible.


We also need new research on how nurses respond to this issue. To date, no major professional nursing association has issued a position statement on whether dismissal is an appropriate response to vaccine refusal. Such statements would provide guidance not only to RNs but also to those APRNs who are responsible for implementing their practice's policies.


Nurses have a significant stake in their practices' decisions regarding dismissal policies. But the impact of their voices should be felt beyond their practices' walls. Increased cooperation and coordination between the AAP and major nursing associations might result in more professionally inclusive policies. This, in turn, would more clearly reflect the real partnership of pediatricians, pediatric nurses, and APRNs in the promotion of children's health.