The PrOTCT plan for nurses: A guide to counseling vaccine hesitant patients & colleagues

As health providers, vaccine hesitancy among co-workers, clients and patients poses a significant challenge and requires informed and effective communication approaches. We are grateful to Stephanie Elliott BSc(hon), Noah Ivers MD and Cora Constantinescu MD, FRCPC for contributing the following article presenting evidence-based communication tools. We are also pleased that Dr. Constantinescu will conduct a webinar for RNAO, open to all health professionals, on vaccine hesitancy (see details below).

As healthcare systems and the heroic workers that keep them going struggle in the face of COVID-19, we look forward to the brighter future that may be achieved through vaccination programs. Unfortunately, COVID-19 vaccine hesitancy poses a significant threat to our promise of return to a ‘normal’ life.

Current levels of vaccine hesitancy pose a challenge to achieving herd immunity to COVID-19, but it is important to note that vaccine acceptance is increasing, indicating that Canadians are both open to evidence and increasingly worried about the ramifications of the ongoing pandemic. Nurses across specialties are uniquely situated to address vaccine hesitancy with their patients and colleagues. Compared to other healthcare workers, they have substantial opportunities to interact and converse with patients at the bedside, and have special skills in making scientific information digestible for a variety of audiences. Not surprisingly, nurses are consistently ranked as highly trustworthy sources of information. With the prevalence of misinformation, and the politicization of vaccines and the COVID-19 pandemic, leveraging this privileged position to speak effectively with patients about their vaccine hesitancy is critical.

Interestingly, it’s not just patients that nurses are well situated to discuss vaccine hesitancy with. Rates of vaccine hesitancy amongst healthcare workers mirror that of hesitancy in the general population. Vaccinating healthcare workers is a vital strategy to keeping our healthcare workforce strong and healthy, to protecting patients and to influencing the public through leading by example. Nurses are in the position to influence other nurses as well as the allied health professionals that support them in the workplace.

Vaccine uptake increases when trusted healthcare professionals recommend vaccines. To empower nurses to have an effective COVID-19 vaccine conversation with their patients and colleagues, we propose the PrOTCT plan, an evidence-based communication tool.

Pr: Proactively engage your patients or colleagues in Presumptive conversations. Research shows that presumptive statements that convey confidence are more persuasive. Additionally, some patients perceive more passive language around vaccines to imply that the provider is in agreement with their concerns and supports their decision to refuse vaccinations.

Example: “This vaccine will prevent you from becoming severely ill with COVID-19” or “I have taken this vaccine and I want to help you get it too: the sooner we all get this vaccine, the sooner we will be able to be with our friends and family again.”

O: Offer to share your knowledge and experiences with getting the vaccine to your patients and colleagues.

Example: “It sounds like you’re feeling really nervous about side effects. Can I share with you what I experienced when I got the vaccine?” “I’ve been doing a lot of reading about mRNA vaccines. Can I share with you what I think is so cool about them?”

T: Tailor the conversations to their specific health concerns and/or their role as a nurse. Research demonstrates that linking health behaviors to one’s identity establishes a sense of responsibility and improves adaptation of proposed behaviors.

Example for patient: “I know you’ve been working really hard on stabilizing your blood sugars, and getting your diabetes under control, but we do know that your diabetes puts you at high risk of getting really sick with COVID-19.” Or “One of the sneaky things that COVID does is that it targets blood vessels. Your high blood pressure could put you at an even higher risk of getting sick or dying from COVID, so let’s get you protected.”

Example for fellow nurses: “As nurses we’ve been putting ourselves at risk to help our patients since the beginning of this pandemic. It’s been really hard. Finally, we can protect ourselves, our families, and our patients by getting this vaccine.”

C: Address specific Concerns. Establish empathy and understanding by repeating back what the concerns are and address them to the best of your ability. Understand that concerns may be rooted in historic or personal trauma, personal experiences, or a reflection of a broader worldview that they inhabit, rather than simple misinformation. Address their concern specifically and explicitly, but do not linger on the concern, pivot towards positive and conclusive information.

Example: “It sounds like you’re really worried that this vaccine was approved too fast and feel that we don’t know that it’s safe. I can definitely see why you would be worried about that. The really interesting thing is that they’ve actually been working on this technology for a while and have used it to develop vaccines for Zika and Rabies. They didn’t cut corners with the clinical trials either. They just ran different stages of the trials at the same time. Actually, these vaccine trials have had many more participants than is typical for vaccine trials. It’s amazing what scientists can do when they all work together on a common problem!”

T: Talk about a plan for getting them the vaccine. Making plans increases self-efficacy and the likelihood that someone will enact a health behavior.

Example for patient: “It looks like you’re in group [regional grouping category] which is expected to start [date], your next appointment with us is [date] and we’ll have the vaccine clinic up and running by then. I’ll put a note in the chart to remind you to go down after you see us to get your first shot!”

Example for colleague: “How about after our shift we walk down to the vaccine clinic and get your shot and I’ll buy you a cup of coffee and a donut after!”

Research consistently shows that people respond better to personal stories and anecdotes than data and it’s better to personalize the information rather than to put too much emphasis on facts and statistics when trying to address misinformation. It’s also best to stay away from political discussions. For example, if a patient explains their hesitancy or refusal with a conspiracy theory, you can respond “I have not come across that before, but in my roles as a nurse I have seen what this illness can do to people and I don’t want that for you or for me, so I’m happy to roll up my sleeve for this vaccine.” Avoid labeling the patient as a conspiracy theorist or accuse them of being ill-informed or brainwashed, rather, try to convey your care for them and your hopes for the future. 

The Canadian Nurses Association Code of Ethics for Registered Nurses places Canadian nurses’ ethical responsibilities both within the immediate sphere of nursing practice, and also within the broader societal context in which patients live. Nurses impact their patients directly, but also the world around them and now can play a pivotal role in shifting hesitancy to vaccine acceptance. Values B (promoting health and wellbeing) and D (honoring dignity) of the code of ethics particularly exemplify the way that nurses can embody ethical practice by using the PrOTCT plan to promote COVID-19 vaccination with patients and colleagues. The emphasis on human connection and identity allow the nurse to honor the dignity of their fellow worker or patient.  Such communication empowers patients to vaccinate by not diminishing their concerns or othering them but seeking to promote health and wellbeing by calling the hesitant individual in, rather than out.

Nurses have answered the call to action throughout this pandemic. Now they directly contribute to community immunity and move towards ending the pandemic with their own vaccination and community influence by becoming vaccine communication champions for their patients and colleagues.