Hospitals weigh-in on flu shot or wear a mask policies

More than voluntary and less than mandatory:

What some hospitals have learned so far about implementing ‘get a flu shot or wear a mask’ policies

This is the second article in a three-part series examining how hospitals approach internal communications. Hospitals function best when their employees are fully engaged. A well organized building can contribute to efficiency but true effectiveness comes from a well organized culture. And one not only willing to change, but wanting to change. This installment looks at the experiences of several hospitals implementing ‘get a flu shot or wear a mask policies’.

FluVoluntary flu immunization campaigns in hospitals across Ontario have been robust and multifaceted but generally only capable of convincing 51 per cent of health care workers to get the shot.

“Despite our best efforts, vaccination rates among health care workers continue to fall short,” says Dr. Tim Rutledge, CEO of North York General Hospital and chair of TAHSN (Toronto Academic Health Science Network) working group that studied best practices to minimize the risk of hospital transmission of influenza.

“We came to the conclusion that we should adopt a mask or vaccinate policy as part of a comprehensive prevention and control program,” he says, explaining that such a policy must be seen as a component of an overall infection control plan that includes elements such as hand hygiene, discouraging ill visitors, cough etiquette as well as early identification of outbreaks.


As parties continue to debate the effectiveness of both the flu shot and mask wearing as preventative measures, more health care facilities (13 in Ontario last year) are moving to bring into effect vaccination or mask policies. They are policies that unions have objected to on health information privacy and human rights grounds.

Only a few flu seasons have passed with these types of prevention policies in effect. And facilities that have implemented them have undoubtedly raised their immunization rates. But at what cost to their employee relations? What practices have some of these hospitals observed to move this from being a top-down initiative to a more broadly accepted component of patient care and safety? Here are seven.

Ask staff and unions for help designing a solution

In 2007, North Bay Regional Health Centre made a decision to force the immunization issue. Employees were told that when there was significant influenza activity in the community and an increased risk to patient and staff safety, flu shots would be mandatory. Employees without flu shots would be sent home – and they could use vacation days if they didn’t want to lose pay.

By 2011, its staff immunization rate was 90 per cent but the hospital also had 22 grievances related to this single issue. It had them put into abeyance and worked in tandem with its unions to address specific concerns staff had about the flu prevention policy. It was this exercise that helped the hospital rewrite its policy to distinguish between periods of high risk, where it would implement a get-a-flu-shot-or-wear-a-mask-in-clinical-areas solution, and periods of outbreak where staff caring for patients would still be required to be immunized.

“The mask was a concession,” explains Danielle Baker, NBRHC’s director of safety and risk. “Adding the option of the mask took away other risks, like the possibility of not being able to staff a unit because not everyone had gotten the flu shot. Or of having disengaged staff.”

Create a climate for thoughtful dialogue

When Bluewater Health implemented a flu shot or mask policy in 2012-2013 it communicated its intentions to the unions early on. It presented the policy to union executives with the help of the chief of professional staff and the chief of nursing. Not only did this demonstrate that it was a hospital-wide initiative, but it also meant key players were there to ask and answer questions immediately.


“They had the ear of those two individuals to talk about the actual policy,” explains Colleen Cook, Bluewater’s director of HR. Most of the questions, she recalls, were about logistics. So having a surgeon there to discuss the details of a mask option, for example, gave this solution credibility.

Dig for the details that matter to staff

To address the employee dissatisfaction stemming from its initial 2007 mandatory flu shot policy, NBRHC struck a multidisciplinary committee that included representatives from the three unions along with senior team members and the chief of staff. The group drafted a list of all the issues – administrative and ethical – and teams conducted focus group work to stimulate discussions.

This helped identify 10 root causes for dissatisfaction over the policy. With a list of solutions in hand, the team reported back to its focus groups to discuss how it would address their concerns. This process is how they landed on the notion that staff wanted more choice in the matter, says Baker.

Other findings included concerns over when immunization was required as well as improved access to the flu shot (night shifts, for example, lacked access to daytime clinics). NBRHC addressed the access issue by appointing nurse and paramedic champions who were trained to administer the flu shot at any time.

To provide clarity around when staff should be vaccinated, NBRHC designated a specific calendar date by which staff must either get the flu shot or sign a form declining it.

B.C., the first province in Canada to move to a vaccinate or mask policy uses an official coverage date (usually December 1st ), explains the province’s health officer Dr. Perry Kendall, adding that it can change depending on an outbreak and that whatever the date, it is important to start on a working day.

Make it part of the conversation

When Bluewater Health sought to build buy-in for its flu shot or mask policy, it employed a number of tactics, including the use of huddle cards, a technique it borrowed from Mt. Sinai and adapted to meet its flu campaign needs.

“Vaccine hesitancy is complex and can be different for each individual,” says Meaghan Lawrence-Kreeft, a communications coordinator who worked on the project. It was important to generate peer-to-peer discussions on the topic, she explains.

The huddle cards, a series of 16 laminated cards with a flu question on one side and a number of facts supporting the answer on the other, were used daily at morning huddles. Informal leaders were encouraged to pick a card and prompt a short discussion about the question and answer.


Leverage your champions

Don’t underestimate the importance of peer pressure. In B.C., units where someone was championing the program had higher rates of immunization than units where you had opponents. “If you can find local champions, it can make a big difference,” says Dr. Kendall.

And when it comes to more general communication, NBRHC’s staff interviews found that employees would rather hear about the flu policy from infection control than from a VP or CEO.

Know your audience

You should have clarity over your staff’s immunization status. In B.C., each regional health authority keeps its own immunization coverage data. Health care workers immunized off-site are asked to enter their vaccine status online and to keep a hard copy record in case they are asked to confirm their status.

At NBRHC, employees whose immunization status is unknown to OH&S as of November 15th are required to submit a ‘Declaration of Intention’ form. Having this information serves two purposes: it allows the hospital to better plan for an outbreak by knowing exactly how many staff members are immunized, and it creates a database of employees to whom it can communicate more directly.

Make the mask or shot policy truly universal

Any hospital developing a flu prevention policy will work with a multidisciplinary team to get each group’s perspective and buy-in. With the chief of staff on board, and professional organizations and patient advocates supporting the need for flu shots, most of the hospitals’ groups are represented, except for visitors.

“One of the points the unions made was that we were making staff wear masks but then visitors coming in from the community didn’t have to,” says B.C.’s Dr. Perry Kendall. So the province modified the policy to include asking visitors who were not vaccinated to either get the shot, which was made immediately available to them, or wear a mask.