Parental refusal of routine childhood immunizations presents an ongoing challenge for the provision of comprehensive primary care to children. Reasons offered for refusing vaccines include fear about vaccine safety, religious objections to vaccine manufacturing, skepticism regarding government mandates for health care, and distrust of health care professionals (Brown et al., 2010; Navin, Wasserman, Ahmad, & Bies, 2019). Nurses working with these families should be prepared to listen to the concerns that parents express about vaccines and accordingly tailor their response to these families, with the aim of building trust (Deem, 2017).
An increasing trend among pediatric practices in the United States (Hough-Telford et al., 2016), Europe (Grossman et al., 2011), and to a lesser extent, Canada (MacDonald et al., 2019) is the implementation of dismissal policies toward families who refuse one or more recommended childhood vaccines. Dismissal typically is an upfront denial of care or termination of care for families who refuse vaccines. A recent study reported 21% of U.S. pediatricians “always or often” dismiss vaccine-refusing families from their practice (O'Leary et al., 2015). Because they play critical roles in promoting childhood immunization and forming relationships of trust with families to whom they provide care, primary care nurses have an important stake in their practices' decisions about whether to dismiss vaccine-refusing families (Deem, 2018).
A high-fidelity ethics simulation experience was designed for the pediatrics course of a baccalaureate nursing program in the United States to prepare nursing students both for challenging discussions with vaccine-refusing families and for participating in decision making with colleagues regarding whether to dismiss or continue to provide care for these families. This article describes the development and integration of the simulation experience, its aims and outcome measures, and students' evaluations of the experience. The Missouri Western State University Institutional Review Board approved the reporting of the content of student evaluations.
The Simulation Experience
Prelicensure nursing education programs increasingly use clinical simulation experiences to replicate clinical practice contexts and create experiential learning opportunities for students. Recently, some prelicensure nursing programs have developed high-fidelity ethics simulation experiences to complement existing clinical simulation experiences and nursing ethics instruction (Donnelly, Horsley, Adams, Gallagher, & Zibricky, 2017; Krautscheid, 2017; Smith, Witt, Klaassen, Zimmerman, & Cheng, 2012). High-fidelity ethics simulation experiences aim to develop effective communicative and reasoning skills through the structured replication of clinical scenarios in which ethical problems commonly arise. These simulation experiences involve students role-playing as practicing nurses and interacting with instructors, actors, and other students who role-play as patients, family members or surrogate decision makers, and professional colleagues. These simulated interactions provide opportunities for students to analyze complex ethical problems in a fast-paced setting, develop mediation and communicative skills for resolving or mitigating ethical conflict, and gain confidence in expressing moral convictions regarding patient care and advocacy.
This high-fidelity ethics simulation was developed and integrated into a conventional pediatrics course required for completion of the baccalaureate nursing curriculum at the university. The ethics simulation was incorporated into the clinical component of the course, with each student completing the experience prior to commencing rotations at clinical sites. The simulation experience was constructed with the recognition that effectively addressing vaccine refusal with parents and colleagues requires communicative and ethical competencies that typically fall outside those developed in conventional classroom settings for nursing instruction.
The simulation scenario involves an encounter with parental vaccine-refusal during a routine pediatric wellness visit within a hypothetical primary care practice that has adopted a standing policy of dismissal for vaccine-refusing families. Students are expected to listen carefully to and attempt to address parents' specific concerns about routine vaccination for their child. The simulation is constructed to lead to multiple possible conversational pathways involving one or more of the following outcomes: conflict resolution and parental vaccine acceptance, protracted discussion with the patient's parents without vaccine acceptance, or engagement with colleagues regarding whether the practice should enforce its dismissal policy for this particular family. These potential pathways simulate conversational branching that could dynamically occur in actual clinical experiences with vaccine-refusing parents, depending on the reasons the parent offers for refusal and the give-and-take of the discussion between the nurses and parents.
Prior to the simulation experience, students complete a briefing assignment. They are informed that they will be providing care for a 2-month-old patient at an outpatient clinic for a well-child visit. The visit will include administration of all vaccines that the Centers for Disease Control and Prevention (CDC) recommends for 2-month-old children. Students familiarize themselves with the electronic health record of the patient and review specific resources about typical growth and development for that age group. The students then create an assessment and teaching plan for the child and family, and complete a vaccine chart detailing childhood vaccines, route of administration, and ages of administration according to the CDC-recommended immunization schedule (CDC, 2018).
The simulation experience began with the instructor designating student roles for the simulation: primary nurse, secondary nurse, patient's parent, and observer. Students in the roles of primary nurse and secondary nurse were informed that they were RNs working in a pediatric practice and that they would be caring for a 2-month-old patient. During the simulation, the students acting as nurses perform a typical 2-month well-child assessment on the infant, including measuring height, weight, head circumference, assessment of motor skills, cognitive development, and language development. The students assess issues such as feeding, sleep, home safety, and car seat safety. These wellness assessments are essential for simulating the character of an actual 2-month wellness visit.
When the nurses move to vaccine administration, the parent of the infant follows a semi-structured script, refusing to accept vaccines. The script includes the following kinds of responses to the nurses' counsel regarding vaccination:
- “I have done my research, and vaccines contain substances that are harmful, such as thimerosal and mercury.”
- “Why does my child need vaccines if other kids are vaccinated?”
- “My friend told me that her cousin had a vaccine injury as a child.”
The parent is free to furnish other reasons for refusal. Students in the various roles then engage in a dynamic exchange, with the nurses spontaneously responding to the concerns and unfolding of the parent's rationale behind vaccine refusal. The parent exhibits distress if the nurses mention the practice's standing dismissal policy, using the following semistructured script:
- “So, you are saying I don't have a choice in this situation?”
- “Where am I supposed to take my child for care?”
- “You must not care about the health of my child.”
The students in the nurse roles are expected to respond carefully and spontaneously to these concerns without a script. The expectation is that they will draw on their previous nursing education and training in communicative strategies, clinical competencies, and understanding of the benefits of immunization programs, as they would in an actual clinical encounter.
A physician colleague, played by the course instructor, is available to the nurses if they seek an interprofessional consultation. If at any point the nurses wish to consult with the physician regarding this issue, the physician informs the nurses that the practice has adopted a standing policy to dismiss families who do not accept the CDC immunization schedule. The nurses may spontaneously engage in further deliberation with the physician about the policy's ethical justification or return to the parent and enforce the policy, thereby initiating a secondary discussion about dismissal based on the parent's response. The discussion between the nurses and parent continue until there is resolution or impasse, or until the instructor ends the simulation.
After the simulation has ended, the instructor facilitates a detailed conversation among the students who participated in the experience. In conjunction with the instructor, the observer provides critical feedback on the communicative skills and ethical reasoning exhibited by the nurses during the simulation. This feedback focuses on the nurses' communication strategies, body language, accuracy in information provision, and consistency in ethical reasoning and communication. Students then explore and discuss the ethics surrounding dismissal of vaccine-refusing families, with reference to the American Nurses Association (ANA, 2015) Code of Ethics, the American Academy of Pediatricians' (AAP) recent clinical report on responding to vaccine refusal (Edwards, Hackell, Committee on Infectious Diseases, & Committee on Practice and Ambulatory Medicine, 2016), and general ethical principles of health care.
This postsimulation discussion facilitates creative exploration by nursing students of the ethical and interprofessional impact of both parental vaccine refusal and practices' dismissal policies. Students consider and arrive at their own ethical views on the appropriateness of dismissal policies, drawing from their understanding of ethical principles and their experience in the simulated enforcement of a dismissal policy. The debriefing session concludes with discussion about ways to work and build trust with vaccine-hesitant parents, and to build nurses' confidence in expressing their ethical perspectives to colleagues within interprofessional deliberation about vaccine refusal.
After each iteration of the simulation experience, the course instructor solicits written evaluation of the experience from participating students. To date, more than 200 students have completed this simulation experience. Students responded anonymously to the following four questions seeking information about their perception of the structure, content, and value of the simulation:
- What did you learn about the nurse's role when caring for patients whose parents refuse vaccines?
- What did you learn about the nurse's role as part of the interdisciplinary health care team when the provider chooses to dismiss the patient from practice for vaccine refusal?
- Was this experience meaningful for you? Please describe why you answered yes or no.
- Do you feel better prepared to handle a scenario such as this than you did prior to the simulation?
Although data from the evaluations were not acquired through a qualitative research study, the authors used grounded theory (which aims to produce common categorical and conceptual themes from qualitative data through induction) and the constant comparative method to identify themes from all of the student evaluations of the simulation experience (Corbin & Strauss, 2014; Navin, Kozak, & Deem, 2019). Each author independently analyzed the contents of student evaluations and completed coding by hand. The authors then compared potential themes to arrive at a consensus on a final list of themes (Table 1).
Themes From Student Evaluations of Simulation Experience and Representative Responses
Three main themes emerged from the analysis of the student evaluation content:
- Enhanced preparation for addressing vaccine hesitancy with parents.
- Awareness of potential biases toward vaccine-refusing families.
- Acquaintance with potential role in enforcing dismissal policies for vaccine-refusing families.
Students indicated that the simulation experience enhanced their preparation for pediatric clinical rotations and that they gained additional communicative and ethical competencies beyond those developed through conventional didactic approaches and ethics education in their nursing program. In particular, students stated they felt better prepared to handle challenging and potentially confrontational situations with parents in the context of pediatric care.
Other students noted the experience assisted them in remaining conscious to remove their biases and judgments toward parents who refuse vaccines from the discussion, and to engage and educate these families with compassion. Others reported the simulation helped them to develop strategies for maintaining respectful discourse even if parents experience and express anxiety or anger.
Several students indicated that prior to the simulation experience, they were unaware that health care providers sometimes dismiss vaccine-refusing families from their practices, much less that dismissal policies are becoming more common in the United States and Europe. For many of the students, this simulation experience was their first exposure to dismissal policies as a response to vaccine refusal, with some indicating they now felt prepared to discuss the appropriateness of these policies with their physician colleagues and to discuss standing dismissal policies candidly with parents.
Ethical reasoning and confident expression of one's ethical judgments in the “real time” of clinical care often require skills beyond those acquired in conventional clinical and ethical instruction within prelicensure nursing programs. High-fidelity ethics simulation experiences can play a unique role in preparing prelicensure nursing students for communicating effectively and confidently in clinical contexts, particularly those in which ethical challenges commonly arise. The success of the simulation experience described in this article is an example in which high-fidelity ethics simulation assists nursing students in developing communicative skills necessary for effectively addressing ethically controversial issues with patients, families, and other health care professionals. Based on the successful outcomes of this simulation experience, it is recommended that prelicensure nursing programs include high-fidelity ethics simulation experiences to complement classroom instruction and clinical training.
Because the simulation experience was implemented in a U.S. baccalaureate nursing program, it incorporated some elements and policies specific to pediatric care in the United States (e.g., the ANA Code of Ethics and the AAP's clinical reports on addressing vaccine refusal). However, refusal of childhood immunizations and dismissal of families who refuse vaccines is a global health and ethics issue (Diekema, 2015; Deem, Kronk, Staggs, & Lucas, in press; Deem, Navin, & Lantos, 2018; MacDonald et al., 2019). The format of this particular simulation experience is transferable across international contexts, and its content can be adapted to prelicensure nursing education programs in other countries.
- American Nurses Association. (2015). Code of ethics for nurses with interpretative statements. Silver Spring, MD: Nursesbooks.org.
- Brown, K.F., Kroll, J.S., Hudson, M.J., Ramsay, M., Green, J., Long, S.J. & Sevdalis, N. (2010). Factors underlying parental decisions about combination childhood vaccinations including MMR: A systematic review. Vaccine, 28(26), 4235–4248.
- Centers for Disease Control and Prevention. (2018). Recommended vaccines by age. Retrieved from https://www.cdc.gov/vaccines/vpd/vaccines-age.html.
- Corbin, J. & Strauss, A. (2014). Basics of qualitative research: Techniques and procedures for developing grounded theory (4th ed.). Thousand Oaks, CA: Sage.
- Deem, M.J. (2017). Responding to parents who refuse childhood immunizations. Nursing, 47(12), 11–14.
- Deem, M.J. (2018). Nurses' voices matter in decisions about dismissing vaccine-refusing families. American Journal of Nursing, 118(8), 11.
- Deem, M.J., Kronk, R.A., Staggs, V.S. & Lucas, D. (in press). Nurses' perspectives on the dismissal of vaccine-refusing families from pediatric and family care practices. American Journal of Health Promotion. doi:10.1177/0890117120906971 [CrossRef]
- Deem, M.J., Navin, M.C. & Lantos, J.D. (2018). Considering whether the dismissal of vaccine-refusing families is fair to other clinicians. JAMA Pediatrics, 172(6), 515–516.
- Diekema, D.S. (2015). Physician dismissal of families who refuse vaccination: An ethical assessment. The Journal of Law, Medicine, & Ethics, 43(3), 654–660.
- Donelley, M.B., Horsley, T.L., Adams, W.H., Gallagher, P. & Zibricky, C.D. (2017). Effect of simulation on undergraduate nursing students' knowledge of nursing ethics principles. Canadian Journal of Nursing Research, 49(4), 153–159.
- Edwards, K.M. & Hackell, J.M.Committee on Infectious Diseases & Committee on Practice and Ambulatory Medicine. (2016). Countering vaccine hesitancy. Pediatrics, 138(3), e20162146.
- Grossman, Z., van Esso, D., del Torso, S., Hadjipanayis, A., Drabik, A., Gerber, A. & Miron, D. (2011). Primary care pediatricians' perceptions of vaccine refusal in Europe. Pediatrics Infectious Disease Journal, 30(3), 255–256.
- Hough-Telford, C., Kimberlin, D.W., Aban, I., Hitchcock, W., Almquist, J., Kratz, R. & O'Connor, K.G. (2016). Vaccine delays, refusals, and patient dismissals: A survey of pediatricians. Pediatrics, 138(3), e20162127.
- Krautscheid, L.C. (2017). Embedding microethical dilemmas in high-fidelity simulation scenarios: Preparing nursing students for ethical practice. Journal of Nursing Education, 56(1), 55–58.
- MacDonald, N.E., Harmon, S., Dube, E., Taylor, B., Steenbeek, A., Crowcroft, N. & Graham, J. (2019). Is physician dismissal of vaccine refusers an acceptable practice in Canada? A 2018 overview. Paediatrics & Child Health, 24(2), 92–97 doi. doi:10.1093/pch/pxy116 [CrossRef]
- Navin, M.C., Kozak, A.T. & Deem, M.J. (2019). Perspectives of public health nurses on the ethics of mandated vaccine education. Nursing Outlook, 68(1), 62–72. doi:10.1016/j.outlook.2019.06.014 [CrossRef]
- Navin, M.C., Wasserman, J.A., Ahmad, M. & Bies, S. (2019). Vaccine education, reasons for refusal, and vaccination behavior. American Journal of Preventive Medicine, 56(3), 359–367.
- O'Leary, S.T., Allison, M.A., Fisher, A., Crane, L., Beaty, B., Hurley, L. & Kempe, A. (2015). Characteristics of physicians who dismiss families for refusing vaccines. Pediatrics, 136(6), 1103–1111.
- Smith, K.V., Witt, J., Klaassen, J., Zimmerman, C. & Cheng, A.-L. (2012). High-fidelity simulation and legal/ethical concepts: A transformational learning experience. Nursing Ethics, 19(3), 390–398.
Themes From Student Evaluations of Simulation Experience and Representative Responses
|Enhanced preparation for addressing vaccine hesitancy with parents||“[This experience] helped me to figure out a way to properly educate the family on the benefits and how to diffuse an angry parent. It has taught me that you need to know your information about vaccines so you can properly educate and answer questions.”|
|“Today was very meaningful as I learned new skills related to communication. The communication dynamics with parent(s), child, other nurses, and possibly doctor is very different from my past experiences.”|
|“I believe this was a meaningful simulation because it exposed the students to a growing subject, and forced them to maintain patience and composure without getting in a debate or argument and damaging the patient-healthcare [provider] relationship.”|
|“This is a growing trend in the community and it is important that nurses know how to respond.”|
|“This can be a very hard situation to deal with. The parent can get very angry or one-sided, but it's your job to educate and push for vaccination.”|
|Awareness of potential biases toward vaccine-refusing families||“The nurse should educate the parent(s) without being judgmental. This type of education can be difficult and more challenging as the parent usually does research. Assess if the parent is using credible sources.”|
|“It was hard to be the one to enforce the policy and explain it to the parent and also let them know they are not a bad parent in the process.”|
|“I feel much more prepared . . . for removing my own opinions from the situation.”|
|“I learned just how simple it really can be to see the parents' point of view. It doesn't have to be a personal ethical issue.”|
|“The nurse must be able to relay policy and back it with reasoning so that the patient doesn't feel abandoned without reason. The nurse in an interdisciplinary health team has the obligation to protect that patient but also all other patients that visit the clinic.”|
|Acquaintance with potential role in enforcing dismissal policies for vaccine-refusing families||“I didn't know about the obligation of the nurse to tell the parents that they could be refused care if they choose not to vaccinate.”|
|“The nurses' role can be to educate the patient on the [dismissal] policy . . . the nurse should assess if the parent had a willingness to compromise — perhaps 1 week to consider vaccinating.”|
|“I learned that it could very well be my responsibility to tell a parent about this [dismissal] policy.”|
|“I was unaware that some clinics have policy to dismiss [patients] due to failure to vaccinate.”|
|“I need to think about how I would respond if I needed to tell a parent about this [dismissal] policy and they were to get upset.”|