A high level of knowledge and a positive attitude towards immunisation in healthcare workers are important factors in achieving and maintaining a high vaccine uptake. Good basic training and regular updates should be provided to achieve this.
The Health Protection Agency issued national minimum standards for immunisation training in June 2005 due to a lack of nationally agreed standardised training programmes regarding delivery and content of immunisation training. The standards apply to all practitioners across all disciplines who deliver immunisations, including health visitors, physicians, registered nurses and OH practitioners.
Practitioners working in NHS OH departments undertake immunisation clinics on a regular basis and become experienced very quickly. However, there are different levels of competency and different standards between trusts.
A private OH provider delivering services to a range of businesses, including NHS customers and other customers who require immunisations for occupational protection, naturally employs staff with a varying range of skills and experience. With immunisation clinics delivered nationally, practitioners work independently and often in isolation.
Although many practitioners delivering OH services have previous NHS experience, some have very little experience of delivering vaccinations. This can be a daunting prospect given that the context in which vaccinators operate is becoming even more regulated through requirements of clinical governance and accountability, audit, patient group directions, and an increasing emphasis on healthcare workers demonstrating specified competencies.
The aim of national minimum standards for immunisation training is to ensure that all health professionals engaged in vaccination are trained to:
provide accurate and up-to-date information about the diseases and vaccines to their patients
ensure their practice is safe and effective
give a high standard of care
promote and administer vaccinations confidently, competently and effectively
ensure that the Joint Committee of Vaccination and Immunisation (JCVI) and the Department of Health (DoH) recommendations (as detailed in Immunisation against Infectious Disease 3, the ‘Green Book’) and chief medical officer (CMO), chief nursing officer (CNO) and chief pharmaceutical officer (CPO) letters are implemented at local level by all involved in immunisation.
This article looks at how one OH service provider, Atos Healthcare, embraces those standards. To meet the standards, a training programme for all practitioners delivering immunisations was developed and is delivered by the clinical standards manager, whose role includes ensuring that standards of practice are evidence-based wherever possible, and are met through competency assessment and audit.
The competency assessment tools were developed by the lead nurse for the immunisation and wellbeing service, with the audit assessment tools developed jointly in conjunction with the lead OH physician for audit. Whoever delivers immunisation training must be a confident practitioner with current experience of delivering vaccinations, and must have in-depth knowledge of immunisation programmes and their application in an occupational setting.
Practitioners who are new to the organisation and have worked in the NHS within the previous three months, who can demonstrate that they have had responsibility for immunisation policy development and supervising staff delivering immunisations, do not need to attend the initial training course. However, they must be able to demonstrate knowledge of the clinical immunisation protocols and pass the vaccination knowledge assessment. Examples of questions are detailed in table 4. All practitioners who deliver immunisation programmes must attend refresher training.
Delivery of training
Delivery of immunisation training has several elements:
Basic training course
The initial training course includes a half-day of pre-course reading. This is sent out to delegates by e-mail at least one week prior to the training course and covers:
Introduction to vaccines
Strategies to improve immunisation rates.
In addition, each delegate is supplied with a PDF copy of the ‘Green Book’ prior to attending the formal taught part of the course.
The delegates receive one full day of formal teaching, covering:
Vaccinations from the national programme which are relevant to customer requirements, including immunisation regimes
Different types of immunisation and their composition
Observation of Mantoux testing by DVD and formal practical training provided separately
Legal aspects of vaccination
Storage and handling of vaccines
The correct administration of vaccines
Documentation, record keeping and adverse incident reporting
Current issues and controversies regarding immunisation
Communicating with clients about occupational immunisation.
Finally, there is a further half day of training covering:
Anaphylaxis management, including recognition of the condition and how to manage it
The type and duration of competency assessment varies according to experience. Once the practitioner has completed the basic immunisation training, he or she will have up to two days of shadowing and undertaking observed practice with a competent, signed-off practitioner.
When the observed practice has been completed, the practitioner will be visited on-site by an immunisation assessor to have their competency assessed. Currently, there are six practitioners able to assess competency, who also undertake audit.
The assessor will observe the practitioner during an immunisation clinic and determine their competence by assessing whether the standards detailed in table 3 are met.
Following the competency assessment, the assessor will notify the lead nurse for the immunisation and wellbeing service when they are satisfied that the correct level of competency has been achieved.
The individual practitioner should then notify the training manager and update their competency on the central training matrix.
Testing of knowledge
Periodically, the lead nurse for immunisations and wellbeing will issue a questionnaire to test vaccination knowledge. The questions are relevant to the immunisations delivered to our customers. The standard is high, with a pass rate of 89% required. A small sample of the questions asked can be seen in table 4.
If practitioners score less than 89%, they will be given feedback advising which questions were answered incorrectly. They will be given a week to reconsider their answers and resubmit the questionnaire.
If the pass mark is still not achieved, the practitioner will have an individual coaching session, usually by telephone, either with the lead nurse for immunisation and wellbeing or the clinical standards manager to clarify the issues about which they appear to be unsure. The questionnaire will then be reissued one week after the coaching session.
If an individual fails to achieve 89% on this occasion, their line manager will be notified and advised that the practitioner has failed to meet the required competency, and should refrain from undertaking immunisation clinics until they have attended refresher training.
Refresher training has several components:
Annual refresher training Updates and refresher training for CPR, anaphylaxis and immunisations will be provided to groups of practitioners, either via regional team meetings or a national/central training event.
Conference calls Six telephone conference calls, lasting approximately 45 minutes each, are held during the year. They are used to address specific topics and appraise practitioners of any changes to immunisation schedules. The content of the calls is available in the regular two-weekly information cascade for practitioners who are unable to attend. Practitioners must attend at least four of the calls per year.
Individual coaching Practitioners who feel they require additional support should approach their line manager. They will notify the lead nurse or the clinical standards manager, who will arrange for a mentor to provide coaching and support.
Clearly when competency standards have been set, audit is required to monitor and review them. Audit will be used to assess practice by two systems:
Audit of vaccination clinic records This will be undertaken by the lead nurse for the wellbeing service line. Practitioners will be awarded A, B or C grades according to the criteria set out in table 5.
Audit scores Grade A is awarded when the completed product fully conforms to the organisation’s professional standards.Grade B is awarded when the clinician has failed to include two of the above criteria in the records. Grade B is considered adequate. Grade C is awarded when the clinician has failed to include three or more of the above criteria in the records, or has endangered themselves or the patient. Grade C means that the product has failed to meet the required professional standards. The GMC and NMC regard a C grade as a failure of professional standard.
Formal audit of immunisation clinics
This is undertaken by the assessors on an annual basis, with each practitioner being visited in a clinic to assess the suitability of the venue and to assess practice. The clinical standards manager collates the audit results and presents them to the clinical governance board.
It is recognised that errors will be made and practitioners are encouraged to report mistakes.
Practitioner error can be identified via either of the audit processes. When an error occurs, the auditor informs the lead nurse or the clinical standards manager who in turn informs:
Practitioner’s line manager
Admin support for risk register.
Clinical errors are entered onto the risk register and are discussed at clinical governance meetings.
The initial contact will be by telephone followed up with an e-mail detailing the issues which need to be addressed.
The lead nurse for immunisations and wellbeing and the clinical standards manager will determine, in accordance with the risk assessment, whether or not the practitioner needs to be temporarily suspended from administering immunisations until further support has been instigated.
Assuming that the practitioner does not need to be temporarily suspended, the line manager will deal with the issue and will liaise with the lead nurse for the immunisation and wellbeing service to determine the availability of a mentor to provide telephone support to the practitioner.
If the practitioner needs to be temporarily suspended, the line manager finds a suitable replacement to cover any clinics booked for that practitioner.
If a practitioner has been temporarily suspended, a supported clinic will be arranged and a mentor will be in attendance.
Clinical issues will then be discussed and an action plan agreed. For example, the practitioner is to refrain from immunisation clinics until they have achieved the required pass rate for the knowledge/competency questionnaire. This is administered by e-mail by the lead nurse using the process described earlier.
In addition, future immunisation clinics will have 100% audit of records for a minimum of four weeks. Line managers may need to invoke the capability procedure if a practitioner is unable to demonstrate satisfactory levels of competence.
In some cases, depending on the severity of the error, it may be necessary to report the incident to the NMC or the GMC.
While immunisations appear straightforward to many practitioners working in the NHS, it is a complex issue that can pose risks for both patients and the staff administering them. Therefore, it is imperative to provide the required training and competency assessment, evaluated by audit to determine if standards are being met.
Standards are necessarily robust and can be seen as a threat. However, audit must be viewed as a process of improvement by which practitioners can learn to protect themselves and their patients.
A recent pilot audit of premises and the type of paperwork in use led to a significant improvement in standards and the development of the current audit tool.
Carol Hargreaves is the clinical standards manager at Atos Healthcare, and Charlotte Lee is the lead nurse, immunisations and wellbeing, at Atos Healthcare.
Immunisation against Infectious Diseases (Green Book) Department of Health, 2006
Working Group of the Resuscitation Council (UK), January 2008
National Minimum Standards for Immunisation Training. Health Protection Agency, June 2005
Table 1: Minimum standards for training
1 The practitioners: Anyone who immunises or advises on immunisation should be on a relevant professional register such as the Nursing and Midwifery Council, the General Medical Council or equivalent.
2 The requirement to be trained: Anyone who immunises or advises on immunisation should receive specific training in immunisation and should attend regular updates. Those new to immunising should be supervised by an experienced immuniser and attend a formal taught course at the earliest opportunity.
3 The training content: The content of the basic training should include as a minimum all the areas outlined in Table 2. All healthcare professionals involved in immunisations should be able to demonstrate competence, understanding, skills in, and current evidence-based knowledge of, these areas.
4 Duration and frequency of training: The minimum duration of a basic training course should be two days. Annual updates must be provided.
5 Access to national policies: Anyone who immunises or advises on immunisation should have access to the Department of Health ‘Green Book’ and national policy updates – for example, chief medical officer letters.
6 Evaluation: Those responsible for clinical governance should ensure that training is included as part of regular audit.
Table 2: Vaccination training course content – core areas of knowledge
1 The aims of immunisation: national policy and schedules
2 The immune system and how vaccines work
3 Vaccine-preventable diseases
4 The different types of vaccines used and their composition
5 Current issues and controversies regarding immunisations
6 Communication with patients
7 Legal aspects of vaccination
8 Storage and handling of vaccines
9 Correct administration of vaccines
10 Anaphylaxis and other adverse events
11 Documentation, record keeping and reporting
12 Strategies for improving immunisation rates
Table 3: Practitioner competency standards
1 Demonstrates understanding of importance of maintaining cold chain, the system of transporting and storing vaccines within the safe temperature range of 2ºC-8ºC. Can state correct temperature range for vaccine storage. Records vaccine fridge temperature at start of each vaccination session.
2 Checks patient’s records prior to vaccination to ascertain previous immunisation history and which vaccines are required to bring patient up to date with national schedule.
3 Knows whom to contact for advice if unsure about which vaccination to give, vaccine regime schedule, compatibility of multiple vaccines.
4 Gives appropriate advice and information to client.
5 Obtains informed consent has been obtained prior to vaccinating.
6 Correctly reconstitutes vaccines and is aware of which vaccines can be given together.
7 Ensures anaphylaxis equipment is readily available, knows what should be provided and how and when to use it.
8 Checks the correct vaccine and dose has been prepared prior to administration.
9 Provides reassurance to client and correctly positions patient prior to vaccinating.
10 Demonstrates correct injection technique, uses recommended needle size and recommended vaccination site(s).
11 Disposes of sharps, vaccine vials and other vaccine equipment safely.
12 Documents type of vaccine, batch number, expiry date, date given and injection site in personal immunisation record sheet, and provides client with an immunisation record card or updates an existing one.
13 Practitioner signs and dates all relevant paperwork and ensures their name is also printed clearly.
14 Gives advice to patient about potential side effects and management of these.
Table 4: Sample of vaccination knowledge assessment questions
1 Can you administer more than one live vaccine in the same day?
2 If a person has a BCG vaccine, how long is it before they can have another vaccine in that arm?
3 What is the normal vaccination regime for Hepatitis B for healthcare workers?
4 What advice would you give to an employee who has a response of 10-99miu/ml following a primary course of Hepatitis B?
5 If an employee has a history of an interrupted course of Hepatitis B, what action would you take?
a) Start a new course
b) Continue from the point where the course was interrupted
c) Take a blood sample and act according to the outcome.
Table 5: Atos Healthcare audit attributes
1 The immunisation history is included in the file, and has been fully completed.
2 The pre-vaccination questionnaire is in the file, has been completed and checked by the practitioner.
3 A consent form has been completed prior to the immunisation being given and is in the file.
4 In cases where immunisation was declined, a record has been kept of this and the reason why is detailed in the case notes.
5 The name, dose route and site of the vaccine is recorded.
6 The batch number and expiry date is recorded associated with correct vaccine name.
7 The practitioner has recorded their name and signed the records correctly.
8 The details of the immunisations given are correctly recorded on the database spreadsheet.
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