June 1999
SAN FRANCISCO - Communication among health care providers regarding informed consent of immunization is minimal, and parents want to have more information on the risks and benefits of immunization, according to focus group discussions held in four regions of the United States.
---Residents in a focus group
The discussion revealed that little communication exists among health care providers. Physicians apparently believe the nurses were discussing all the risks and benefits, while parents said they received little education from either nurses or physicians. Residents, however, said they were unskilled to communicate the risks and benefits and had not received formal education in this area.
"Our study was done to determine how the risks and benefits of immunization are currently being discussed and understood in the United States. The National Childhood Vaccine Injury Act mandates that informed consent be done. It requires the parents and children who are being immunized be given information concerning the risks and benefits of each of the vaccines included in the Act. Physicians are in a pivotal role to communicate the vaccine risks to parents," said Jacob T. Cross Jr., MD, at the recent meeting of the Pediatric Academic Societies held here.
Cross works in the section on infectious diseases and section on MED/PEDS at the Louisiana State University Medical Center in Shreveport, La.
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Focus groups were held in Rochester, N.Y.; Wichita, Kan.; Shreveport, La.; and Albuquerque, N.M. The focus groups included physicians in pediatrics and family practice, residents in training, nurses and parents of children who received immunizations. These parents were using private practices, health departments, free clinics, shots for tots and university-affiliated programs for their children's immunizations.
Focus groups generally consisted of two to 15 participants and were not stratified by race, age or gender. Instead, groups were separated by classification. For the parent focus groups, mothers and grandmothers ranging in age from adolescence to the mid-50s were interviewed. From the parents' perspective, when their children are immunized, they receive the vaccine information statements from the clerk. The nurse then sees them initially, and then the physician comes into the room.
"In many private practice clinics, the physicians often left and sent a nurse in when it was time for the babies' shots. This is the extent of the communication they received about vaccines from these private physicians' offices. At the health unit, a nurse was the only provider," Cross explained.
Parents said that physicians rarely initiate patient education or informed consent discussions; however, they did perceive physicians as helpful and informative when the parents initiated the discussion and asked specific questions. Parents said that most of the information they received came from the vaccine information statements.
"Most parents said they could not take the time at the visit to read them, but would take them home and read them there. Some admitted that they threw them away without even looking at them," he added.
Parents said they wanted both written and verbal communication. They wanted to know common-sense things, such as what the vaccine prevents and the common and severe side effects; however, they did not want detailed, in-depth information about each risk.
"Parents wanted this information given to them as a matter of respect, and they wanted the information to come from the person in the clinic with the highest degree. They also said that they would like to receive the information, if possible, before the visit, either as a mailing or as a packet given to them at the initial visit or at a prenatal visit," he said.
Residents reported that the parents never asked about severe risks and that residents were more concerned about treating diseases than giving immunizations. They said they did not know how to talk to parents about risks and benefits. Most residents did not feel that immunizations were central to their mission. They said that parents wanted to know what to expect from the immunization and how to treat the common side effects.
"They said that parents were not interested in severe side effects, and they believed that communication about vaccine risks would scare parents and patients away. Residents felt that initiating discussion about risks might influence parents to change their minds about receiving the vaccination. Residents thought parents had the ethical right to know the risks and benefits of these vaccines, but they were not sure that they were the ones to provide patient education and informed consent," he explained.
According to the nurses, they are told to give the vaccines. The nurse administers the vaccine and, in most practices, provides the patient education. Nurses perceived that parents had the ethical right to know the risks and benefits of immunization, but that the physician was the one to discuss the severe risks.
From the practicing physicians' perspective, risk communication was not a high priority. Teaching institutions focused on moving the residents through a high-volume clinic, and time was the biggest barrier.
"We concluded that little communication exists between health care providers. The physicians felt like the nurses were discussing all the risks and benefits. However, parents said they received little education from either nurses or physicians, and residents felt that they were unskilled to communicate the risks and benefits and had not received formal education in this area," he added.
For more information:
- Cross JT, Davis TC, Arnold C, et al. Physicians are from Pluto, nurses are from Jupiter and parents are from Mercury: Focus group interviews on immunization practices. Abstract 427. Presented at the Pediatric Academic Societies Meeting. May 1-4. San Francisco.
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