Improving Influenza Vaccination Rates in Assisted Living Residents Through a Nurse-Led Standing Order Protocol

Student name

School of Nursing and Health Sciences, Capella University

NHS FPX 8004: Advanced Doctoral Writing for Nurses

Professor Name

Submission Date

Introduction

The high work shortage of preventive care with low influenza vaccination rates in older persons in ALs is a significant gap in the project site. Even though adult congregate living settings have been shown to have suboptimal influenza vaccination rates, the adult population of these settings is eligible for influenza vaccination, and influenza vaccination rates are highly recommended. Within the project site, internal quality measures show that only 58% of those who are first eligible received the influenza vaccine in the previous influenza season, which is lower than the benchmark recommended by the World Health Organization (WHO) of 75% for adults ≥65 years (Nurse Executive, personal communication, 15 January 2026; World Health Organization, 2025). The purpose of the review is to critically appraise literature on the effectiveness of implementing a nurse-led standing order influenza vaccination protocol in adults aged 65 years and over in relation to influenza vaccination rates compared to provider-directed vaccination orders only in 12 weeks (PICOT). PubMed, multidisciplinary digital publishing institute (MDPI), Oxford Academic, and Cumulative Index for Nursing and Allied Health Literature (CINAHL) databases were used to search using keywords including influenza vaccination uptake, older adults, standing order influenza vaccination, and nurse-led influenza vaccination protocols. Ten scholarly publications were thematically synthesized to locate three main themes: strategies for improving influenza vaccination uptake; factors affecting vaccination behavior and barriers to influenza vaccination uptake; and intervention implementation and effectiveness with high-risk populations.

Thematic Synthesis of Literature

Theme 1: Strategies to Increase Influenza Vaccination Uptake 

Promoting uptake of the influenza vaccine in vulnerable populations, including through standing orders and other approaches to systematic implementation, is one of the new trends. There is limited research evidence directly pertaining to nurse-led standing order strategies in assisted living, but there is evidence on other types of strategies that they are successful in promoting vaccine uptake. A toolkit developed by Adams et al. (2025) to support the implementation of standing order strategies in adult groups found that overall, the strategies were effective in boosting uptake of vaccines; however, evidence of effectiveness in adults aged ≥65 years was inconsistent. The results suggest that standing orders may not work, and we need more support and context adaptation.

In the same fashion, an analysis of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) model of an opportunistic vaccine use strategy by an authorized nurse immunizer in a hospital was able to increase access and coverage among adult populations. This success was achieved through embedding eligibility and patient outreach in the normal process (Davies et al., 2025). The strategy is a good illustration of strategies for provider empowerment (e.g., standing orders) and how they can shift the way vaccines are used, though the evidence of effectiveness within community living is limited. Multitarget, multi‑component interventions proved to be much more effective for improving vaccination coverage among older adults compared to single-strategy interventions, according to Wang et al. (2025). Provider-based strategies, like standing orders, for example, when used in combination with other strategies like reminders, education, and outreach work, have more than doubled their impact on vaccination rates compared to provider-based strategies alone. This fact further supports the concept that nurse-led strategies can be more successful if they are a component of a system redesign.

Theme 2: Determinants of Vaccination Behavior and Uptake Barriers

The second theme in the literature is the interplay between individual, social and system factors which influence influenza vaccine uptake in older adults and health care workers. In one study in China, a cross-sectional study design was implemented, comparing and observing older adults in terms of influenza vaccine uptake and the factors that influenced uptake, and finding that attitudes and physicians’ recommendations, as well as family support and perceiving the vaccine to be effective were key factors. This study found that individuals in older adulthood with higher educational attainment and income levels and positive attitudes towards the vaccinations were more likely to use it (Guo et al., 2025). To find the right solution, it is important to tackle the barriers to ensure the vaccination process is optimized among vulnerable people.

Earlier, Liang et al. (2025) found convenience, cost burden, and access to be factors that may have influenced the uptake of influenza vaccination given in the pre- and post-COVID-19 pandemic. The study reiterates the idea that there are practical and psychological barriers to overcome, such as perceptions of inconvenience and cost, in addition to clinical tactics that affect provider roles to improve. In support of the findings of this study, Fuller et al. (2024) evaluated older adults’ vaccine hesitancy. The study found that practical and personal reasons, like the cost of vaccines, fear of needles, the need for a doctor’s recommendation, transportation, and making appointments, are important factors in older adults’ vaccinations. The study shows that personal factors like fear, cost, and provider engagement may play an important role in the vaccine decision-making process of older adults, and the effects are particularly great for those older adults who reside in rural areas, are less educated, and who live alone.

Theme 3: Implementation Frameworks and Intervention Effectiveness 

The third theme focuses on implementation frameworks and the effectiveness of measures to improve influenza vaccination uptake among healthcare staff and adults ≥65 years. Studies indicate that multi-component intervention strategies are more effective in raising the overall coverage of adults and high-risk adults with vaccines than are single-component strategies. While standing order protocols were found to be effective in increasing pneumococcal vaccination uptake among older adults, their effectiveness in increasing other vaccine uptake (including influenza vaccines) was noted to be associated with stand-alone implementation of standing order protocols, as well as other procedures (Pennisi et al., 2025). Wright et al. (2025) designed an intervention, based on a theory, to improve uptake of influenza vaccinations among care home staff. The intervention was identified to have a positive impact on immunization of care home staff. While the study was implemented to enhance vaccination rates among care home staff and not care home residents, the use of a multi-component intervention to enhance vaccination rates is indicative of the effectiveness of behavioral change techniques over other methods.

The study, designed to create a behaviour change intervention to increase influenza vaccination in care home staff, was found to be feasible and acceptable. This study is against the evidence that there is a lack of passive interventions to address the issue (Patel et al., 2025). Particularly, findings in the systematic review of Thomas et al. (2025) regarding outcomes of influenza in LTC residents cared for by vaccinated health care workers were inconclusive because there was a lack of high-quality studies that examined combined intervention strategies that included resident vaccination. Results once again reinforce the notion that the effectiveness of implementation is not just related to standing order or provider vaccination programs.

Conclusion

To conclude, the low influenza vaccination rates among older residents in ALFs are a public health problem and preventable. The organizational structure and the education, along with multi-component interventions, have been documented as promoting vaccination rates when delivered in a nurse-led standing order protocol, as the available evidence supports its effectiveness for facilitating workflow processes, empowering nursing staff, addressing issues of access, and behavioural barriers. From the synthesis of the literature studied on the subject, it can be seen that there is a need for a combination approach, at the organizational and individual level, to help implement the proposed intervention at the project site.