While every person has some moral responsibility to do no harm, nurses and other healthcare workers are held to a higher standard. In an environment where the slightest infection can mean the difference between life and death, doing no harm takes on a whole new meaning.

Nurses can't simply try to avoid doing harm, they often are asked to be proactive by protecting themselves so they don't inadvertently transmit some kind of sickness to the vulnerable population they serve. In a way, we ask nurses to be almost superhuman, to be totally healthy so they don't complicate an already complicated situation.

Fortunately, this idea isn't daunting to many nurses.

"We chose this profession understanding that we have to hold ourselves to the highest standard, as part of a special population," says Alexander Tomich, MSN, RN, infection control practitioner at Loyola University Health System, Maywood, IL.

What Protection Looks Like
Induction into that special population starts early - even before a nurse begins her employment she must first show proof of several vaccinations. Documentation of vaccines for measles or mumps and an annual TB skin test are often conditions of employment.

Another vaccine is in the early stages of being added to that mandatory list at some facilities: the flu vaccine. After years of continually reinventing new ways to encourage staff to get the flu shot each season, some hospitals have grown tired of putting up with abysmal 30-40 percent rates of compliance.

And now more than ever, there is a heightened sense of attention on this issue, with this fall's flu season expected to be worse than usual. Approximately 200,000 people are hospitalized with complications from the flu and about 36,000 die annually (including 2,600 in Illinois).

"We are encouraging as many people as possible to get the seasonal flu vaccine and practice healthy hygiene (washing hands thoroughly and covering your cough). We anticipate an active flu season with both the seasonal flu and new H1N1 strains, and are working with all our community partners to prevent the spread of flu in Rock Island County and the Quad Cities," says Wendy Trute, administrator of the Rock Island County Health Department.

Healthcare workers are among the groups highly recommended by federal health officials to receive both seasonal influenza vaccine and the H1N1 vaccine.

The Resistance
As every nurse knows, the single best way for individuals to protect themselves and their loved ones against the flu is to get vaccinated. However, some nurses still don't do it. The question is, why not?

"Some of the reasons are true contraindications to receiving vaccines, an allergy to eggs or a very severe adverse reaction to a vaccine in the past," says Elisa Hill, MPH, RN, CIC, manager of infection prevention and control at St. John's Hospital in Springfield, IL. "However, some nurses just get busy and don't take the time to get it done. The primary reason we hear is that they just don't want it. Some people believe that if it's not broke, don't fix it - since they never get sick with the flu, they feel they don't need it. Or they've had a reaction from a previous influenza vaccine, even just a sore arm . some people just don't want a sore arm."

Oddly enough, there still are many nurses who are afraid to get the vaccine because they believe they'll contract the flu from it. This is an unsubstantiated fallacy many hospitals work hard to counteract.

"Most people understand the need for it; however, the nurses who have concerns about the vaccine are people in areas where they've seen patients who had bad outcomes that might be attributable to the flu vaccine, for instance in the neural ICU," says Coreen Vlodarchyk, RN, vice president of patient care services and chief nursing officer at Barnes-Jewish Hospital in St. Louis. "Those nurses requested more information and we were able to provide them with reassurance and education from our credible infection disease doctors. There are a lot of assumptions and fallacies about what the flu vaccines might do, so addressing those through education and fact sheets resolves a lot of concern."

The Fall Out
Although reasons for nurses and other healthcare workers to avoid getting vaccinated come in many shapes and forms, most are becoming a moot point. Last year, BJC HealthCare, which operates 13 hospitals including Barnes-Jewish, became one of the first organizations to require flu shots for all its 26,000 employees. Out of that large number, fewer than a dozen employees were fired after refusing shots without religious or health reasons, and the policy hasn't spawned much resistance.

"Before the requirement, we were at 68 percent compliance and now we're at 99.9 percent," Vlodarchyk says. "We looked at it like we are one big family, asking every member - nursing, pharmacy, accounting - every department to take part in this."

Employees are still able to opt out with an allergy to eggs or a previous reaction to a flu vaccine, or a religious reason.

This year, Loyola University Health System and its health system joins the ranks of requiring their 7,800 employees (except those with health or religious exemptions) to receive seasonal flu shots by Dec. 1 as a condition of employment.

"And those that are exempt because of the two reasons above are required to wear a mask throughout the day for every day during flu season," Tomich says. "In past years, we've had a good response of more than 70 percent of system employees voluntarily getting flu shots. However, that's no longer enough. What H1N1 has taught infection control programs nationwide is just how fast something like this can spread and how harmful it could potentially be - we've always known, but it was able to fall under the radar until recently."

Part of the reason the flu has fallen under the radar is because of how prevalent it is in our society and how easy it is to contract. There's often no telling who might have infected a person.

"It's important to look at how the flu usually works. As professionals, we're all of the mind-set that if we're sick we won't come in. We do the best to not expose our patients. But with the flu, you could be spreading it for 24-48 hours before the onset of any symptoms, before you're even aware of it," Tomich says. "That's when it's critical. We deal with heart transplant patients, lung transplant patients, patients who are immunosuppressed and immnocompromised. Something that's just the sniffles for us could be very devastating for this patient population."

In New York, the trend to require health care workers to be immunized against both seasonal and H1N1 flu has gone statewide with an order from the state department of health. The Illinois Department of Public Health is considering a similar action, according to spokeswoman Melaney Arnold.

The Imperative
St. John's has yet to mandate the flu shot and is instead concentrating on communicating more with its workforce to encourage vaccinations. This involves posters, flyers, overhead announcements of clinics and clinic wait times, blitz days for mass vaccinations, and incentives like cash gift cards and prizes. Last year, 51 percent of its 3,200 employees got shots.

"Despite all the education, encouragement and accessibility of flu vaccinations, we're still not obtaining the high rates we should be to protect the public," Hill says. "Many of us working in infection prevention and occupational health believe it's a moral and ethical imperative for anyone in healthcare to get preventive vaccines since our first duty is to prevent illness and protect patients."

That responsibility, to prevent illness and protect patients, is what many facilities are using as their rationale to add influenza vaccine to the list of stipulations for healthcare workers. It's a part of the bigger picture: A higher health standard this population may be accustomed to after years of being offered free smoking cessation, blood pressure and cholesterol screenings, and other free vaccines.

"Flu vaccines are just one other opportunity to make the environment better for everyone who's in the hospital: patients and employees," Vlodarchyk explains. "Our mission is to give people exceptional care and protect our patients from being hurt by adverse events. For any patient who is acutely ill, you don't want to compromise them by giving them an additional aspect to fight."

Sarah Lebo is a freelance writer based in Royersford, Pa.