Fourteen interviews were conducted, transcribed and analysed. Demographics were collected as per Table 1. The Australian Capital Territory (ACT) was the most highly represented state/territory (7 participants), with the Registered Nurse cohort (7 participants) delivering the most substantial amount of feedback. Five participants worked in urban hospitals, three HCP in rural/regional hospital settings; while three HCP were employed in Aged Care, and three in community healthcare settings. Eleven out of the 14 HCP received the seasonal influenza vaccine in 2021. Two agreed to phone calls only, while one preferred not to be recorded, but validated the transcription, with no changes required, post interview.

Table 1 Participant demographics

The interviews revealed vaccination attitudes, knowledge and intentions, culminating in the identification of six distinct themes, with subthemes (Attachment B). The Covid-19 pandemic remained a contextual influence impacting on participants perceptions, behaviours or work environment, and was frequently discussed concurrently with influenza vaccination, with the two vaccines enmeshing into one dialogue on vaccine decision-making and behaviours. The themes identified include habit – past behaviours, convenience and ease of access, risk perception, experience and knowledge, professional responsibility and identity, and protection. Complacency was an overarching participant dynamic. The themes and several subthemes will be discussed further; while their interdependencies and links have been highlighted in the thematic mapping (Fig. 1).

Habit- past behaviours

The frequency of past vaccination behaviours, or habit, fostered further HCP intentions to vaccinate for seasonal influenza. Most participants voiced an unquestioning acceptance of the vaccine, with many relying on the workplace to facilitate an opportunistic approach to vaccination.

Nurse 4: Since I was working, I was getting the vaccine, the flu vaccine every year.

Nurse 5: I can’t even remember when I had my first vaccine. And it just becomes part of the routine… You know, you walk in, you get it, you walk out, and five minutes later you’ve forgotten that you even had it…

Equally, the habit of not vaccinating, irrespective of vaccine confidence, was also raised, reinforcing complacency towards the disease, and SIV.

Nurse 2: …I should get it (SIV) but I have never had one and for no particular reason. It’s just not something I have done. I don’t even have a good rationale.

Nurse 7: I believe if you look after your body, eat well, good nutrition, stay home when you are unwell and look after yourself there is no need for a flu vaccine. I don’t believe in the flu vaccine and have never had one.

The initiation of the habit was often associated with student placement protocols or early career workplace requirements. Many HCP stated that SIV was a necessity of student placement in healthcare settings, mandated by the university or the workplace.

Doctor 3: …my experience as a medical student. That’s when I started having my yearly flu jabs. So, it basically became a requirement.

Sub theme: Trigger

Frequently participants stated vaccine uptake was directly related to a trigger or nudge. The repeated or habitual behaviour of vaccination, with limited cognitive processing appeared to require a trigger to initiate the behaviour, to remind the participant it was ‘time to vaccinate’. Most participants voiced limited pro-active planning in vaccination acquiescence and perceived the process as opportunistic. Social media, traditional media, disease visibility (among patients), workplace communications or the presence of a vaccination trolly/hub often triggered participant vaccination behaviour, if vaccine acceptance (intention) was already present.

Doctor 1: We haven’t seen the flu either in the hospital… if there were lots of cases I would have made a bigger effort.

Pharmacist 1: If the flu vax is there, they ask me ‘do you want one?’ and yes please! And get it done right then and there… It gets to April and I know its flu shot season, and I just wait for someone to remind me of the flu shot.

Convenience and ease of access

HCP ability to access the SIV with ease and little inconvenience, with limited planning, and few barriers, proved a major factor in SIV uptake. HCP expressed the opportunistic nature of SIV in the workplace facilitating uptake. Participants described competing Covid-19 priorities limiting SIV accessibility in tertiary healthcare facilities; that prioritisation of pandemic-related occupational health and safety (OHS) activities had impeded access and convenience to obtain SIV.

Doctor 1: Far less of a campaign to make it easy at work to get the flu vax. The MOHS (medical OHS unit) haven’t gone around (the hospital) this year, it just hasn’t happened.

Pharmacist 1: Its opportunistic, absolutely…then I had to ring to make appointment…Which annoyed me. I don’t want to have to ring up and make an appointment, I want to just walk in, which you can’t now…

Doctor 4:…that may have been the only year I didn’t get the flu vaccine and that was because I was too distracted to go and get it and I wasn’t working at that point. I had the whole year off (not at work).

It was noted by HCP associated with or working in the Aged Care sector, where SIV has been mandated since 2020 following direction from the Australian Health Protection Principal Committee (AHPPC) (Department of Health and Aged Care 2022b) during the emergence of Covid-19, access to SIV had improved, with greater visibility, convenience and at no cost to the employee. Placing the onus back on the employer to ensure workplace/residential care safety had improved SIV access, making it a convenient ‘duty’ of HCP working with this vulnerable population.

Nurse 6: I would say it was ramped up! Yeah, they were straight onto it and honestly, it was like a … not like a ‘war scene’ but… like, lets literally ‘roll our sleeves up and get this done’ attitude.

Nurse 4: I think they want the strategy to protect the elderly. I’m not against it. Yeah, so I quite accept it.

Risk perception

Risk perception shaped by fear or complacency towards the organic disease, impacted by experience and knowledge, influenced SIV. Personal and professional experience of the virus, contributed to risk perception, consolidating participants belief in influenza as a serious disease, and influencing uptake, to a degree. Constraining the effectiveness of high disease risk perception as a predictor of vaccination behaviour was ‘ease of access and convenience’, as even those cognisant of influenza risk, relied on a trigger (email, vaccination hub or vaccine trolley) and easy access to progress to vaccination uptake.

Pharmacist 1: Yeah, I probably have more of a fear of it (influenza) than other people… the (ICU) patients were really, really sick, and we didn’t know how to treat them and they got bad infections, and people died… it was awful! And I still feel more worried about influenza than I do about Covid.

Doctor 4: Well, I think it can have some very serious consequences. So, I’m not willing to risk them. I guess it’s another reason I get the vaccine. I’m not willing to find out what the consequences could be…

Misconceptions and lack of experience, or exposure, either professionally or personally, may be lowering risk perception, compounding complacency around seasonal influenza; not impeding acceptance of the vaccine but interrupting the impetus to progress to vaccination positive behaviour.

Doctor 2: I find it frustrating the terminology that’s used… that people say 'I’ve got the flu/I’ve had the flu’… and they have a heavy cold maybe. I think there’s a misconception about what the flu is.

Nurse 6: I think when people say they have flu, generally speaking, and I could be wrong, but they actually have a bad cold. Because true flu you don’t forget.

Doctor 3: Whereas how I see the flu-vax is like, you’re not hesitant because you’re worried (about the vaccine), it’s like you just don’t think that it’s important enough… Or can’t be bothered at the moment.

Complacency or lower risk perception towards the disease did not appear to negate participants confidence in the seasonal influenza vaccine. Most participants felt it was ‘a good vaccine’, with only one participant believing SIV was unsafe. Lack of confidence in SIV, in this case stemmed from the erroneous beliefs that it caused the flu with work colleagues or contained graphene oxide. The predominant confidence in SIV efficacy and safety, however, and higher risk perception appeared insufficient at times to bridge the gap between acceptance and uptake of the vaccine. Other constructs, or themes, appear more valuable in closing this gap.

Nurse 2: I think it’s a really good vaccine for people who are at high risk. So, the elderly population with significant co-morbidities.

Doctor 3: I will get the flu vaccine because I know it’ll protect me and also that it’ll influence other people.

Nurse 7: I couldn’t see the point of getting the flu vaccine as every time my colleagues had it, they then got the flu!

Experience and knowledge

Experience and knowledge incorporated personal and professional experiences with the influenza virus and the vaccine. Many participants conceded a superficial knowledge of the configuration and preparation of the vaccines. No participants had experienced significant adverse events or side effects from SIV. Surprisingly, only 36% of participants believe they had experienced, either professionally or personally, seasonal influenza and its sequalae. However, those claiming a lived experience of the influenza virus profess a degree of fear of the disease, and its ability to incapacitate.

Doctor 1: …and I have had it myself! Probably over 10 yrs ago and it was shocking! I wouldn’t want to get it again.

Pharmacist 1: I worked in ICU…I’ve seen patients die with influenza.

Doctor 2: I clearly remember, when I was about a 3rd year registrar being absolutely floored by the flu – and after that I’ve always had the flu vaccine.

Doctor 3: Yeah, and the way we talk about flu, as if everyone had it. And no, I don’t know, I haven’t had it. And like terms like ‘man flu’ and stuff. And there’s like ‘cold and flu season’ and it’s like, uh, maybe there’s just a general lack of understanding of what flu is.

Professional responsibility and identity

The most highly represented theme from the interviews saw SIV as a professional responsibility; part of participant’s professional identity and duty. Discussions around vaccination normalised the behaviour as a standard expectation that is ‘part of the job’. Few questioned the need for the vaccine and accepted it without examining purported efficacy or extent of uptake. Some comments suggested an obligation to vaccinate, while others revealed a sense of professional pride and solidarity that engendered a collective professional identity. This sense of identity was associated with vaccine acceptance and uptake, as it appeared to foster camaraderie under a common goal of protection.

Nurse 1: So, as I was working in Oncology, we had to have it. If you want to work there you had to have the flu vax.

Pharmacist 1: It’s a responsibility and an expectation… My patients should not have to worry about catching something from me.

Nurse 3: …it’s our responsibility as a health professional to get it (SIV).

Midwife 1: What’s the point of being in, you know, the healthcare field where it’s about caring for others and putting them sort of first… or ‘person-centred’ in your care…then putting them at risk of something that you’ve brought into the hospital?

Subtheme: Advocate and promoter of SIV

Many but not all HCP considered themselves advocates for SIV. Promotion of the vaccine to their patients, clients or family was considered part of their professional duty, but several felt very strongly about free choice, and stepped back from calling themselves ‘advocates’. In contrast, one participant felt their duty as a healthcare professional and a patient advocate was to warn individuals away from SIV as they felt it was unnecessary and potentially harmful.

Pharmacist 1: Pharmacists in the community now deliver vaccinations, which wasn’t a thing…there’s now more incentive for them to know (SIV), and positively influence the community. And I think that’s a really positive development…

Midwife 2: I’m comfortable with giving them that information. Umm, I’m also comfortable with supporting whatever decision they make… it’s their decision in the end.

Nurse 5: I’m pretty happy to be outspoken about things. Ohh, definitely yeah, I’m more than happy to be an advocate.

Nurse 7: You don’t need vaccines to stay safe… Pregnant women are encouraged to have the flu vaccine and the Covid vaccine to protect their unborn child. Instead, the vaccines are making these children sick from a young age. Sick children with the vaccine from the mothers.

Discussions with other HCP about SIV emerged as an interesting complexity. Although promotion or advocacy for the SIV was supported for clients, patients and family, a degree of discomfort and avoidance was evident when HCP were questioned about vaccination conversations with their colleagues. Very few embraced open, candid conversations with peers about SIV, and most felt it wasn’t their place to do so.

Nurse 6: That’s not a conversation I’ve had with many staff. They are completely under the pump…But it’s not a conversation I would be comfortable having with them.

Doctor 3: I didn’t really get into it too much with her, I guess. It’s not my place to have those conversations.

Subtheme: Choice vs mandate

There was uncertainty around the issue of mandating the seasonal influenza vaccine for HCP. In theory, some participants supported a mandate for clinicians, especially when the professions are already obligated to vaccinate against other diseases. However, participants would also extol the virtues of free choice. The underlying belief that the ‘vaccine refusing’ HCP simply did not have all the information or the correct information to make an informed ‘free’ choice, appeared to bridge the disconnect between support for a mandate and support for free choice.

Nurse 2: I wouldn’t have a problem if they did. If they mandated it for healthcare workers. I’m not opposed to them mandating the flu vax.

Nurse 4: Interviewer: So, do you support the mandating of the flu vaccine in aged care? RN: Yes, yes. But I do respect those other people who disagree with it.

Nurse 5: I think that’s very tricky…ummm. I suppose I’d like to think that people would see the logical scientific sense to it. And yet, at the same time, you know, people do have a right to their opinions.

Protection: others, self, resourcing

Confidence in the seasonal influenza vaccine underpinned the overall theme of protection. Most HCP believed that the vaccine offered a degree of protection for themselves, people in contact with them (others), and subsequently, healthcare facility resourcing through securitisation of workforce capability. Primarily protection of others, especially their patients and vulnerable populations, was the focus of HCP’s decision to vaccinate against seasonal influenza. A sense of guilt, weighted by professional responsibility and the ethos ‘first do no harm’, led many participants to choose vaccination.

Nurse 1: I’m happy to go ahead and have the influenza vaccine to protect myself, but also to protect others.

Pharmacist 1: Yeah, my main argument for all this stuff (vaccination) is I don’t want to put anyone else at risk. I have an important job to protect people. I would just die if I caused anybody’s illness!

Doctor 2: We don’t work in professions which are overly bombarded with staff numbers, and so we do have a duty to do what’s available to try and reduce our time away from work through illness.