Case Study, Chapter 11, Overview of Selected Middle-Range Nursing Theories 
Elaine Chang is an infection control nurse  at a community hospital. She has been in her position for over 6 years,  since finishing her master’s degree in community health nursing. 
She has noted that the annual influenza  immunization rate for employees has been decreasing each year after  reaching a high in 2009 of 78%. The rate in 2016 to 2017 dipped under  55% for all employees. In addition, this past year, there was a large  outbreak of influenza with multiple staff and patients affected. 
Ms. Chang has decided she needs to review  the situation using Pender’s Health Promotion Model and develop a plan  to educate staff and increase immunization rates.  
If Ms. Chang wanted to assess the reasons for the decline in immunization rates, what types of things should she ask about?  
Ms. Chang developed a survey that was  distributed by each unit manager. After analyzing her results, she  identified three major reasons that many of the staff declined the flu  vaccine:     

A large number (over 40%) believed that the  vaccine might give them the flu. They believed this because either they  or a family member had become sick with some sort of illness around the  time they took a flu shot.  
About 25% of those surveyed would have taken  the flu vaccine, but it was only available at the hospital Monday to  Friday between 10 AM and 2 PM.  

About 10% of those surveyed believed that all  vaccines are bad for one’s health because they introduce something  unnatural into the body.  

The remainder had a variety of reasons for declining the vaccine, from religious beliefs to inconvenience.  
From Pender’s model, what motivational factors might each of these be?
Using Pender’s model, what actions might Ms. Chang take to improve the immunization rates?
Citations from References that are 
synthesized from the assigned article, course text, evidence-based and 
peer-reviewed research articles, and other credible sources are