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Commentary on Zhang J, While AE and Norman IJ (2012) development and testing of an instrument to assess nurses' knowledge, risk perception, health beliefs and behaviours related to influenza vaccination. Journal of Clinical Nursing 21, 2636-2646.

The study by Zhang et al. (2012) testing a newly developed instrument to assess nurses’ knowledge, risk perception, health beliefs and behaviours surrounding influenza vaccination is significant. We are reminded of the severity of the influenza virus and subsequent importance of vaccination in healthcare workers. However, also reported are the suboptimal vaccination rates among nurses in particular. The instrument designed in this study is tested for its validity and reliability as it is reported that previous instruments used in relation to this topic lack rigour. The design and undertaking of this study appear reliable, and its rationale to understand nurses’ knowledge, risk perception, beliefs and behaviours concerning influenza vaccination is certainly without question. However, the aspect of the instrument which measures vaccination behaviours addresses not only personal vaccination but also the recommendation of vaccination to patients. In a previous study by Zhang et al. (2011), it was found that nurses were more likely to recommend vaccination to their patients if they had been vaccinated themselves. Having made a connection between personal attitudes and subsequent practice, the relevance of the sample upon which the instrument was tested must be considered. The majority of seasonal influenza vaccinations are given to patients by nurses in the community setting. Indeed, this is also the case for H1N1 vaccination, and yet, of the respondents, 78 5% (n = 408) were hospital based and only 14 5% (n = 75) worked in the community (Zhang et al. 2012). Given that influenza vaccination is primarily community based, further validation of the instrument with community nurses would be useful. In the UK, there is some anecdotal evidence of negativity among community nurses almost to the point of disapproval where both the seasonal and H1N1 vaccinations are concerned. Not only does this suggest that vaccination rates among the nurses concerned are likely to have been low but that the impact of this on promoting vaccination to patients could also have been affected with potentially serious consequences; a process that the health promotion literature refers to as modelling where the behaviour of the health promoter can have an impact on the resulting behaviour of the learner (Green & Tones 2010). Previous studies have concluded that the reasons for this apparent lack of enthusiasm are primarily related to adverse effects (Ehrenstein et al. 2010, Zhang et al. 2011). Although Zhang et al. (2012) acknowledge the convenience sample chosen as a limitation, this choice could be considered central to the study if this instrument is to be used and effectively applied in practice. Understanding nurses’ attitudes towards the influenza vaccination is important and could as Zhang et al. (2012) state, lead to future vaccination campaigns becoming more evidence based. Not only could this have a positive impact on the immunisation rates of nurses, but also indirectly influence the uptake of both the seasonal and H1N1 vaccination rates in the general population.