Engaging Nursing Assistants to Enhance Receptivity to the Coronavirus Disease 2019 Vaccine

Certified nursing assistants (CNAs) are the backbone of long-term care in the United States, and the restoration of safety in nursing homes during and after the coronavirus disease 2019 (COVID-19) pandemic requires successfully vaccinating them. The nearly 600,000 CNAs employed in nursing homes provide the majority of direct care to residents in these settings and represent the largest proportion of nursing home personnel.¹ However, despite having what has been called, “the most dangerous job in America” during the COVID-19 pandemic,² CNAs experience high levels of vaccine hesitancy. In a study of nursing home and assisted living staff in Indiana,³ 62% of CNAs reported they were unwilling to receive the vaccine as soon as it was available; 44% of the overall sample reported they would consider receiving the vaccine at a future point in time. This is consistent with a national study that broadly sampled health care workers, including CNAs.⁴ In that study, 56% of respondents stated they would wait for a future point in time to be vaccinated. Unfortunately, waiting to vaccinate nursing home staff is a dangerous proposition. In nursing homes, vaccines are essential tools for protecting vulnerable individuals and reducing the spread of the pandemic. To ensure a safe, healthy, and vaccinated workforce and resident population, it is critical that vaccine hesitancy in CNAs is both understood and mitigated.

As the deadly pandemic rages on, CNAs have had to balance their care commitments with the risk of contracting COVID-19. The nature of their work makes them uniquely susceptible to contracting and spreading the virus. Assisting with bathing, feeding, toileting, and infection control along with a number of other tasks important to resident care are activities that put them in close contact with residents.⁵ Their likelihood of exposure to COVID-19 is further compounded by less recognized aspects that make CNAs vulnerable such as the increased likelihood to use public transportation, live in densely populated housing, and work in a number of positions across multiple facilities.⁶ Each day, CNAs weigh the perilous aspects of their occupation, such as the threat of compromising their health and the health of their families, with their duty to ensure vulnerable nursing home residents get their basic needs met.⁷ Thus, the pandemic has made an already physically and emotionally demanding position into a dangerous one.

Vaccine hesitancy in CNAs may seem surprising given their increased risk of exposure and the promising efficacy of newly developed COVID-19 vaccines. However, vaccination efforts among long-term care staff have always been fraught with challenges when compared with acute care settings. For example, in the last flu season (2019–2020), nearly 3 in 10 long-term care staff were not vaccinated for the flu compared with less than 1 in 10 for acute care staff.⁸ When reviewing these numbers by occupation, flu vaccination coverage was lowest among nursing assistants and aides at 72.4% while physicians and nurses were vaccinated at greater than 90%.⁸ These findings suggest that there are factors driving vaccine hesitancy that may be unique to CNAs.

Vaccine hesitancy in CNAs is likely multifactorial. Research conducted prior to the COVID-19 pandemic, has attributed vaccine hesitancy to concerns about contracting the virus from the vaccine, a belief that one is not at risk of acquiring the flu, mistrust of scientific research based on historical abuses of racial and ethnic minorities, and language and cultural barriers.^{9 , 10} There is likely even more at play during the COVID-19 pandemic. Possible reasons for CNAs refusing the vaccine as being the politicization of a new vaccine that uses novel messenger RNA technology, concerns over lack of paid sick leave if they experience side effects, the vaccine being rolled out too quickly, and poor communication from nursing home leadership around the distribution of the vaccine.^{4 , 11}

Solutions to these challenges are equally complex. The World Health Organization highlights the need for an informed, engaged, and empowered community to overcome hesitancy and facilitate vaccine acceptance.¹² Previous efforts to support influenza vaccination campaigns in long-term care settings that have been effective include employer vaccination requirements, being offered free onsite vaccination, and employers publicizing vaccination coverage.^{13 , 14} To be sure, many nursing home administrators and medical directors may provide information and reassurance to CNAs with hopes that they will choose COVID-19 vaccination despite their concerns. However, the COVID-19 epidemic is a new public health event requiring consideration for novel factors. To support vaccine efforts in the CNA community of nursing homes, we propose an actionable 4-point strategy to increase engagement which is informed by the Kanter Theory of Structural Empowerment.¹⁵ Below are definitions of these practices and specific actionable recommendations that nursing homes may enact to overcome barriers, foster engagement, and reduce vaccine hesitancy (Table 1 ).

Table 1.

Actionable and Pragmatic Strategies to Address Vaccine Hesitancy in CNAs through Engagement

Barriers/Causes of Hesitancy	Potential Solutions
Information
Lack of trust in public health infrastructure, scientific research, and/or agency leadership	Provide information from trusted voices/trusted sources. Consider: (a) Working with unions that represent the employees
	(b) Encouraging staff to talk to colleagues who already have received the vaccine
	(c) Partnering with the community (eg, community leaders, churches, other faith-based organizations, recreational groups) to be a trusted source of information about vaccines
	Develop a foundation of trust and apologize for past wrongs
Lack of information or misinformation	Engage in dialogue that is clear, constant, consistent, and comprehensive.
Language and cultural barriers	Develop culturally and linguistically appropriate education campaigns that:
Skepticism in effectiveness of vaccines	(a) detail the need, safety, efficacy, and overall benefits of the vaccine
Concerns vaccine is “too new”	(b) counter inaccurate beliefs
Concerns that vaccine is too political	(c) leverage existing resources from the CDC, AHRQ, OR AHCA/NCAL AMDA
Concerns about side effects
CNAs are not provided a comprehensive picture of the status of vaccine efforts	Use staff vaccination rates as an organizational quality measure:
	(a) Create a community vaccine dashboard
	(b) Showcase % vaccinated, side effects encountered, concerns, and positive experiences along with trends in COVID-19 infections and deaths among residents and staff
Resources
Lost wages that will result if sick time is taken to cope with side effects	Consider paid days off that account for anticipated recovery for vaccine side effects
Concerns about leaving co-workers short-staffed if CNA becomes sick	Use adaptive staffing models predictive of missed work
CNAs opting to delay receiving the vaccine right now	Leverage behavioral nudges such as gift cards, pizza parties, raffles or paid-time off to enhance early COVID-19 vaccine receipt
Support
The role of CNAs is often undervalued	Honor engagement and leadership in vaccine programs with recognition – newsletters, posters
CNAs are not always adequately acknowledged for their contributions	Acknowledge vaccinations with paraphernalia such as stickers placed on employee IDs
Fears related to the unknown, side effects, and COVID-19 survival along with unprocessed grief and trauma	Compassionately consider the concerns of the CNAs:
	(a) Provide counseling to address emotional and spiritual injuries
	(b) Give CNAs a reasonable amount of time to make decisions around vaccinations, avoid placing undue pressure that may spawn resentment
CNAs do not believe that their concerns are regarded	Leaders should connect with CNAs one-one-one and:
	(a) Actively listen
	(b) Respond empathetically
	(c) Relay support
Opportunity
CNAs are not included at the table and do not feel as if their input is valued	Grant CNAs power to shape vaccine policy at the facility and/or participate in vaccine policy development – a seat at the table
CNAs are not in positions to share their voice	Create CNA vaccine leadership and ambassador roles
Teams providing communication about the vaccine lack the representation of the CNA and various cultural and ethnic backgrounds	Ask CNAs and individuals who make up diverse cultural and ethnic backgrounds to be part of the vaccine communication team

CDC, Centers for Disease Control; AHRQ, Agency for Healthcare Research and Quality; AHCA/NCAL, American Healthcare Association/National Center for Assisted Living.

Information refers to the data, knowledge, and expertise required to function effectively in a given role. With vaccine hesitancy, credibility in the delivery of the information is vital. Although many health care settings are considering making vaccines mandatory, it is important to note that mandates can backfire if a population resents being coerced and has not received sufficient education about the safety and efficacy of a vaccine.¹⁶ Engagement in group education requires the formation of heterogenous culturally diverse group members who trust one another.¹⁷ To enhance information exchange, CNAs benefit from education by trusted leaders on the safety and efficacy of the vaccine that uses culturally relevant educational materials. One source of innovative engagement is Project Echo (Extension for Community Healthcare Outcomes), which is a collaboration between Agency for Healthcare Research and Quality (AHRQ) and University of New Mexico School of Medicine, and is actively seeking nursing home partners.¹⁸ They provide free COVID-19-related training and mentorship to nursing homes to protect residents and staff.^{19 , 20}

CNAs also need to be engaged in dialogue with organizational leadership that is rooted in clear, consistent, comprehensive, and constant bidirectional communication.²¹ This means providing CNAs forums to ask questions and voice concerns without facing reprisal. Nursing homes may wish to support information exchange and transparency by posting an online discussion board, which reports vaccination percentages, optional self-report of side-effects/experiences, and a forum to voice concerns and ask questions. In addition, any dialogue between CNAs and administration must be underscored with empathy and understanding of the unique professional and social circumstances of CNAs.

Resources refer to the time, materials, money, supplies and equipment necessary to accomplish organizational goals. If organizations wish to see 100% of their staff members vaccinated, they must provide them with the necessary resources. It is anticipated that side-effects may limit the ability of a CNA to work because of flu-like symptoms, fever, and muscle aches (particularly after the second dose in which pronounced symptoms are more prominent).²² These symptoms are self-limiting but not inconsequential to the livelihood of CNAs who require regular employment. Nursing homes should anticipate the need for additional staffing and consider staggering vaccine administration when possible. In addition, the use of paid-sick time regardless if the time has been accrued or not may ultimately be cost-effective when considering the alternatives of avoidable COVID-19 outbreaks or injury to residents because of insufficient staffing.

Support refers to feedback and guidance from colleagues. CNAs who participate in vaccination efforts should be recognized. Participation in vaccination campaigns, for example, may be reinforced with highlighting employees who are vaccinated on social media or offering a sticker indicating they have received a vaccine to put on their badge. They may even write down their reasons for choosing to get vaccinated for others to see. CNAs participating in vaccination efforts must also be acknowledged, particularly those that contribute to CNA community vaccine organization and conversations. Employers may consider compensation or recognition for CNAs engaging in leadership activities and/or serving as champions of the organization's vaccine campaigns. Employers should also provide emotional support, which may extend as far as mental and spiritual counseling for the trauma that this population has endured during the pandemic, and the complex decision-making involved in getting a vaccine.

Opportunity relates to job conditions that allow an employee to advance in a position and develop knowledge and skills to grow in their career. CNAs benefit from greater opportunities in the workplace, and they should be involved in designing what those opportunities look like. For example, they should not only be given opportunities to participate in town halls with leadership, they should be able to lead town halls and other informational sessions. Consider inviting CNAs to serve as vaccine ambassadors who kick start vaccine conversations, identify staff concerns, and represent the voice of CNAs at the organizational and leadership level. Strategies that focus on providing CNAs with opportunities to shape when and how vaccines are delivered support an assets-based approach to addressing vaccine hesitancy. Such an approach has been shown to be a powerful driver for employee behavior.23, 24, 25

CNAs have jobs that are physically and emotionally demanding. Each day, they weigh the threat of compromising their health and the health of their families and loved ones with their duty to ensure vulnerable nursing home residents get their basic needs met. Providing CNAs with information, resources, support, and opportunity will not only serve to improve vaccine receptivity, but may also have downstream benefits. Engagement strategies will also increase the impact CNAs have on organizations and help them find meaning in their role by virtue of enhanced competence and greater self-determination. These may include increased job satisfaction, less staff turnover, and a higher standard of care for vulnerable residents.

Ultimately providing CNAs with opportunities for growth and development will have benefits for them and their place of employment that outlast the pandemic.