Vaccine Hesitancy Communication Strategies Among Pediatric Nurses: A Mixed-Methods Study

Introduction

Vaccine hesitancy, defined by the World Health Organization’s Strategic Advisory Group of Experts as a delay in acceptance or refusal of vaccination despite availability of vaccination services, remains a persistent challenge in pediatric primary care and is influenced by a complex interplay of confidence, complacency, and convenience factors specific to individual families (MacDonald & SAGE Working Group on Vaccine Hesitancy, 2015). A substantial body of research has examined how clinicians frame the initiation of the vaccine conversation itself, most notably distinguishing a presumptive format, in which the clinician announces that vaccination will occur as a routine part of the visit, from a participatory format, in which the clinician instead asks an open-ended question inviting the parent to decide (Opel et al., 2013). Observational research using this framework has found that presumptive initiation is associated with substantially higher rates of vaccine acceptance and shorter overall visit discussion time, even among parents with baseline hesitancy, relative to participatory initiation (Opel et al., 2015).

Much of this foundational evidence, however, has been generated in the context of physician-parent communication, and comparatively less research has directly examined how pediatric nurses, who are frequently the first clinical staff to raise vaccination during rooming or intake, understand and apply these evidence-based communication strategies in their own practice (Leask et al., 2012). This gap is clinically relevant because nurses’ framing of the vaccine conversation during intake may itself shape the tenor of the subsequent physician discussion, and because nursing-specific training in structured communication approaches, such as motivational interviewing-based frameworks adapted for vaccine hesitancy, has been less systematically studied or disseminated than physician-focused communication training (Gagneur, 2020).

The purpose of this explanatory sequential mixed-methods study was to first quantify pediatric nurses’ self-reported use of specific, evidence-based vaccine communication strategies and to identify their correlates, and then, informed directly by the quantitative results, to use qualitative interviews to explain any notable or unexpected quantitative findings in greater depth. This sequential design was selected specifically because an initial quantitative finding, described below, revealed a pattern, general awareness of presumptive initiation’s evidence base coexisting with its comparatively infrequent use, that quantitative data alone could identify but not explain, and that qualitative follow-up was well suited to illuminate (Ivankova et al., 2006).

Methods

Design. This study used an explanatory sequential mixed-methods design, consisting of an initial quantitative survey phase (Phase 1) followed by a qualitative interview phase (Phase 2), with Phase 2 sampling and interview content directly informed by specific, notable results identified in Phase 1 analysis (Creswell & Plano Clark, 2018; Ivankova et al., 2006), illustrated in Figure 1.

Phase 1: Setting and sample. A cross-sectional survey was distributed to pediatric nurses (registered nurses and nurse practitioners) across 14 primary care and specialty pediatric clinics within a single health system between February and July 2025. Of 224 eligible nurses, 180 completed the survey (80.4% response rate).

Phase 1: Measures. The survey assessed self-reported frequency of use, on a five-point scale from “never” to “always,” of six vaccine communication strategies derived from the vaccine communication literature: presumptive initiation, participatory initiation, the C.A.S.E. method (Corroborate, About me, Science, Explain/advise) (Healy & Pickering, 2011), motivational interviewing-style reflective listening, sharing a brief personal or professional anecdote, and providing written or digital educational materials. Communication self-efficacy was assessed using an adapted 8-item scale (range 0–100). Nurses also reported whether they had received formal training specific to vaccine communication technique and, independent of their own reported practice, were asked to identify which initiation format the research evidence associates with higher acceptance, to assess knowledge independent of behavior.

Phase 1: Analysis. Descriptive statistics summarized strategy use frequency and self-efficacy. Chi-square tests compared strategy use frequency and correct evidence identification between trained and untrained nurses; an independent-samples t-test compared self-efficacy scores by training status.

Phase 2: Sample and data collection. Following Phase 1 analysis, 18 survey respondents were purposively selected for semi-structured interviews to achieve variation across two dimensions identified as analytically important in Phase 1: receipt of formal training (trained/untrained) and predominant self-reported initiation style (presumptive/participatory), yielding four sampling cells. Interviews, lasting a median of 31 minutes, explored participants’ reasoning for their typical communication approach and, specifically, their perspective on the gap between the evidence favoring presumptive initiation and its comparatively infrequent reported use, a finding shared with participants as context for discussion.

Phase 2: Analysis. Interview transcripts were analyzed using reflexive thematic analysis (Braun & Clarke, 2019), with coding organized specifically around explanatory themes addressing the Phase 1 quantitative pattern, consistent with the explanatory purpose of the qualitative phase in this design.

Integration. Quantitative and qualitative findings were integrated narratively and through a joint display (Figure 4) explicitly linking each key quantitative result to the qualitative theme(s) that helped explain it, consistent with recommended integration practice for explanatory sequential mixed-methods designs (Fetters et al., 2013).

Results

Phase 1 (quantitative). Among 180 surveyed nurses, self-reported use of the six vaccine communication strategies varied substantially, as shown in Figure 2. Notably, only 38.3% of nurses reported routinely or always using a presumptive opening, while 71.1% reported routinely or always using a participatory opening, a pattern that stood in apparent tension with nurses’ underlying knowledge: when asked directly and independent of their own reported practice, 82.2% of nurses correctly identified the presumptive format as the approach associated with higher vaccine acceptance in the research literature.

Formal training in vaccine communication technique, reported by 34.4% of the sample, was significantly associated with more frequent presumptive-approach use (58.1% of trained nurses vs. 28.0% of untrained nurses reporting routine/always use, chi-square p < .001) and with significantly higher communication self-efficacy (mean 74.6, SD 12.8, among trained nurses vs. mean 58.9, SD 17.3, among untrained nurses; t-test, p < .001), as shown in Figure 3. Correct identification of the evidence-favored format did not differ significantly by training status (85.5% trained vs. 80.5% untrained, p = .38), reinforcing that the presumptive-participatory gap in this sample reflected a knowledge-practice gap rather than a knowledge deficit specifically.

Phase 2 (qualitative). Interviews with the 18 purposively selected nurses produced four explanatory themes addressing the Phase 1 knowledge-practice gap. Preserving relational rapport captured a widely shared perception, including among some nurses who did use presumptive language, that a direct, assumptive opening carried some risk of feeling coercive or damaging to the family relationship, particularly with a family the nurse did not yet know well, a concern that several participants weighed against their awareness of the format’s evidence base. Time pressure favoring the participatory question reflected a perceived, though participants acknowledged frequently mistaken, sense that a brief yes/no question was quicker than a presumptive statement, even though several participants specifically noted, on reflection during the interview, that participatory openings more often led to a longer, more circular conversation when the answer was hesitant. Absence of a concrete script captured untrained nurses’ description of general awareness that presumptive language existed as a concept without a specific, comfortable phrase they felt ready to use, particularly with a family they anticipated would be hesitant, in contrast to trained nurses, who more often described a specific, rehearsed opening line. Inherited default phrasing reflected several nurses’ description of having adopted their typical opening language early in their career by observing physician or senior nursing colleagues, rather than through deliberate strategy selection, a pattern several participants described only becoming consciously aware of during the interview itself.

Discussion

This explanatory sequential mixed-methods study identified a specific and clinically actionable pattern: pediatric nurses in this sample were largely aware that presumptive vaccine initiation is associated with higher acceptance, yet continued to use participatory initiation more than twice as often in their own reported practice, a knowledge-practice gap that qualitative follow-up helped explain through four interrelated mechanisms rather than through any underlying disagreement with the evidence itself. This finding extends prior physician-focused research establishing the presumptive format’s effectiveness (Opel et al., 2013, 2015) by demonstrating that awareness of this evidence, on its own, was insufficient to translate into consistent nursing practice, and by identifying the specific mechanisms responsible for that gap.

The preserving relational rapport theme suggests that some nurses may be implicitly weighing a perceived trade-off between communication effectiveness and relational warmth that the presumptive-participatory research literature does not itself support, since presumptive initiation has not been associated with reduced parental satisfaction or trust in prior research (Opel et al., 2013). This suggests that training addressing this specific, evidence-inconsistent belief directly, rather than only providing general information about acceptance rates, may be necessary to shift practice among nurses who hold this particular concern.

The time pressure theme’s internal contradiction, several participants recognizing during the interview itself that the participatory question they believed saved time in fact more often preceded a longer, more circular conversation, is a particularly notable finding, as it suggests this belief may not survive direct reflection and could represent a tractable target for training that explicitly walks nurses through this specific, common misperception rather than treating time pressure as a fixed structural constraint alone. This is a further point of contrast with the childhood obesity counseling barriers identified in comparable primary care nursing research, in which time pressure functioned more straightforwardly as an external structural constraint (Rausch et al., 2011); here, participants’ own reflection suggests time pressure functioned partly as a misattributed belief about which approach was actually faster.

The absence of a concrete script theme, and its correspondence with the quantitative finding that trained nurses used presumptive language more than twice as often as untrained nurses despite similar underlying knowledge of the evidence, points toward scripting and rehearsal, rather than conceptual education alone, as the specific mechanism through which formal training appeared to translate into practice change, consistent with prior findings regarding communication skills training more broadly (Gagneur, 2020; Leask et al., 2012).

Several limitations should be considered. This study relied on nurses’ self-reported communication practice rather than direct observation of clinical encounters, and self-reported strategy use may not fully correspond to observed behavior. The study was conducted within a single health system, and the specific mix of explanatory themes identified may reflect this system’s particular training history and clinic culture. The Phase 2 sample, while purposively selected for variation across training and reported strategy use, was not intended to be statistically representative and should be interpreted as illustrative and explanatory rather than as an independent estimate of theme prevalence.

Future research should incorporate direct observation of nurse-family vaccine conversations to examine the correspondence between self-reported and observed communication strategy use, and should evaluate whether structured training that explicitly provides a rehearsed presumptive script and directly addresses the relational-rapport concern identified in this study produces measurable improvement in nurses’ presumptive-format use and, ultimately, in vaccine acceptance rates. Taken together, these findings suggest that closing the gap between nurses’ knowledge of evidence-based vaccine communication and their actual practice may depend less on further disseminating the underlying evidence, which nurses in this study largely already possessed, and more on structured, scripted communication training that directly addresses the relational and time-related beliefs identified as the specific mechanisms underlying the persistence of less effective default communication patterns.

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