Nursing Newsroom Updated November 18, 2016

Flu Shot Season: Time for Nurses to Remember Patients’ Fears

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Vaccinations and Herd ImmunityA nurse can expect to administer many injections in a career. Giving shots is supposed to become second nature. But it never hurts to think about what the patient is experiencing. There’s a wrinkle in this fall’s flu shot recommendations from the Centers for Disease Control and Prevention that almost compels nurses to do just that.

“For the 2016-2017 season, CDC recommends use of injectable flu vaccines — inactivated influenza vaccine (or IIV) or the recombinant influenza vaccine (RIV). The nasal spray flu vaccine (live attenuated influenza vaccine or LAIV) should not be used during 2016-2017,” the recommendation states.

That means all flu shots should be administered by injection because nasal sprays are ineffective, according to studies cited by the CDC. The recommendation matters because the CDC website also says, “Everyone 6 months and older is recommended for annual flu vaccination with rare exception.”

Everyone includes people who are fearful of injections. According to, that group includes not only a majority of children but also nearly one in four adults. Some who are likely to consider forgoing shots need convincing.

“Fear aroused in the absence of any sense of what to do — of a coping procedure — is more likely to lead to delay and avoidance,” says Howard Leventhal, Ph.D., director of the Center for the Study of Health Beliefs and Behavior at Rutgers University.

Where ANA stands on immunizations

Nurses agree with the need to convince the recalcitrant. “To protect the health of the public,” the American Nurses Association (ANA) says, “all individuals should be immunized against vaccine-preventable diseases according to the best and most current evidence outlined by the (CDC) and the Advisory Committee on Immunization Practices (APIC).”

So it’s an apt time for nurses to focus on reducing the pain and fear some people — a 2006 study placed the national numbers at 15 million adults and 5 million children — feel when they need an injection.

The National Center for Biotechnical Information released a study of the extent of the problem, with this abstract:

“Injections may interfere with receipt of vaccines. The frequency, associations, and precipitators of fear-provoking factors of 400 travelers visiting a travel health clinic were evaluated. The median age of this group was 25, 7 percent were medical staff members, and 2.8 percent were regular injectors (insulin). Eighty-five … of the travelers indicated that they were afraid of injections, and in 8.2 percent, the fear was unreasonably intense.”

Some of the factors cited for that fear:

  • Watching other people being vaccinated
  • Fear of pain
  • Needle size
  • A history of fainting

“Injection phobia and a bad past vaccination experience were significantly associated with fainting. Perceived empathy, on the other hand, was a significant protective factor. Fear of injections was common in this cohort and was highly associated with past fainting after vaccination,” the study found.

The fainting syndrome is called vasovagal syncope and is caused by low blood pressure. The patient’s blood pressure soars during the anxiety of receiving the injection, and then subsides too much in the aftermath. Some studies indicate the syndrome is inherited in about one-third of such cases.

How to help patients who fear injections

Cognitive therapy can help a patient’s ability to cope in as few as two or three sessions, says Dorothea Lack, a psychologist who says she was traumatized by an injection episode as a child.

Some practitioners prescribe sedatives to help patients cope with injections.

Procedures to minimize the fear factor are more often aimed at children but also might help adults accept shots with less distress than they otherwise would exhibit.

“The primary message is that the most proven technique is distraction,” said Lindsey Cohen, a professor of clinical psychology at Georgia State University, in an October 2016 New York Times story written by Perri Klass, M.D. Cohen said reassurance is less effective than distraction, and Missouri pediatrician Mark Connelly concurred.

“A lot of parents spend a lot of time on ‘It won’t hurt too much; it’ll be OK,’ ” Connelly told Klass. “That makes kids worry more.”

For older children, Connelly said, reading a book or blowing bubbles might provide that distraction. “Something that changes what they’re attending to is enough to change what the brain does, so the child doesn’t feel it in the same way.”

Confront the pain factor head-on

Canadian pharmacist Anna Taddio told Klass that the pain factor should be confronted. “Everybody’s anxious when they don’t know what is going to happen to them,” Taddio said. “The idea is to tell kids with words what’s going to be involved in the procedure a pinch, pressure on your arm, then it goes away. … ‘We’re going to try to find a way to help you so it doesn’t bother you.’ ”

Taddio is associated with a Canadian movement called Help Eliminate Pain in Kids, which in 2015 listed clinical practice guidelines to reduce pain during vaccinations. Taddio also was one of the eight collaborators on a Canadian report, titled “Far From ‘Just a Poke’: Common Painful Needle Procedures and the Development of Needle Fear,” which appeared in the Clinical Journal of Pain.

Their abstract said: “Pain management is a human right. Unfortunately, most individuals undergoing vaccination do not receive evidence-based treatments for their pain. In fact, for pediatric populations, rather than prioritize pain management to address children’s strong concerns about pain, adult caregivers and clinicians have typically under-prioritized and undertreated procedural pain. … That translates into continued unnecessary suffering for those undergoing needle procedures.”

They said “the vast majority (90 percent) of 14- to 18-month-old infants and 45 percent of 4- to 6-year-olds demonstrate severe distress during vaccination.”

They also said “a recent study found that 63 percent of children endorsed a fear of needles, whereas several studies have reported adult prevalence rates of some degree of needle fear ranging from 14 percent to 38 percent.”

Techniques to help patients

That’s why, Klass wrote, “There’s a lot of research on what makes immunizations less painful — and what helps children handle them without too much distress.”

Methods include topical anesthetics preceding the injection, and no longer adding duration and tissue trauma to the procedure by striving too hard to avert landing the needle in a blood vessel, Taddio said.

“Immunizations are necessary, but the pain is not always necessary as a side effect,” Connelly concluded. “Getting immunizations doesn’t absolutely have to lead to a lot of distress and pain.”

To which Taddio added, “Do your best not to make it a big event.”

Plenty of nurses empathize. “Lots of people have issues with injections/needles, and it was something that I was really nervous about when I started my training,” a nurse wrote in a forum at  “I still can’t bear watching others give injections, as it makes me feel really sick and like I’m about to pass out. However, when I administer them myself it doesn’t bother me at all.”

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Back to: Nursing Newsroom Updated November 18, 2016