Mandating COVID-19 Vaccine for Nursing Home Staff: An Ethical Obligation

As the SARS-CoV-2 Delta strain spreads across the United States, increasing the rates of COVID-19 vaccination is fundamental to protecting both residents and staff in long-term care (LTC) settings. Since the roll-out of effective COVID-19 vaccines in December 2020, more than 80% of nursing home residents have been vaccinated.¹ Unfortunately, LTC settings are now experiencing COVID-19 outbreaks, despite high vaccination rates among residents, some of whom developed breakthrough infections. Health care workers are the primary vectors that introduce SARS-CoV-2, including the Delta strain, into their workplace. Nationally, the rates of vaccination among LTC staff as of mid-August hovered around 60%.¹ As the prevalence of COVID-19 infections increase in the community, the risk of unvaccinated staff acquiring infection and transmitting COVID-19 to the vulnerable residents for whom they provide care also increases. The negative consequences of even a single COVID-19 infection among LTC residents or staff range from at least 2 weeks of quarantine for 1 or more units to severe illness and death. For these reasons, vaccine mandates are gaining momentum. AMDA–The Society for Post-Acute and Long-Term Care Medicine was part of a Multisociety Statement advocating for COVID-19 vaccination as a condition of employment (COE) across all health care settings, including LTC.² Several large health care systems as well as state and federal agencies are now implementing this important public health measure. Finally, on August 18, 2021, the federal government announced that it will require that nursing home staff be vaccinated against COVID-19 as a condition for those facilities to continue receiving federal Medicare and Medicaid funding.³

Vaccine mandates are not new. In 1984, the Advisory Committee on Immunization Practices recommended influenza vaccinations for health care workers to protect residents as well as to reduce staff illness and absenteeism.⁴ Influenza vaccination rates remained low until health care employers mandated staff vaccination as a COE. During the 2019-2020 influenza season, vaccine uptake among LTC health care workers was around 70%. Nursing homes that mandated influenza vaccine reached a rate greater than 85% among their employees.⁵ Although important for influenza, the need to achieve high vaccination rates for SARS-CoV-2 among health care workers is essential for the health, safety, and quality of life of LTC residents.

In this issue of JAMDA, Ritter et al describe implementing COVID-19 vaccination as a COE in a 180-bed community nursing home, eventually reaching an impressive 100% vaccination rate.⁶ Based on the early uptake of the vaccine among employees, the nursing home decided to proceed with requiring vaccination as a COE. The decision was supported by executive leadership and nursing home staff after interviews with key personnel and consultation with legal counsel to confirm that COVID-19 vaccine can be mandated under an FDA emergency use authorization. The decision and development of policies was made over several weeks with involvement of a diverse team, in addition to the collaboration of the leadership with the National Union of Hospital and Healthcare Employees. The authors began by engaging stakeholders from the executive leadership team, human resources leadership, as well as nursing home staff. Specific interventions included the development and distribution of 8 handouts, holding 2 virtual presentations, and hosting 5 on-site vaccination clinics. The Chief Executive Officer communicated the COE policy to all employees on February 9, 2021, with a go-live date of May 1, 2021. The outreach efforts continued and included one-on-one communication with individual employees who remained vaccine hesitant. Of 246 staff members, 221 (90%) accepted the COVID-19 vaccine, 4 (2%) were on a leave of absence, and 3 (1%) received exemptions for medical or religious reasons. Only 18 employees (7%) chose to resign rather than accept the vaccine. Although unfortunate during a time when LTC settings are often understaffed, the nursing home leadership made sustained and good faith efforts to address their vaccine-related concerns while prioritizing the rights of their residents and other staff to work in a safe environment.

The implementation described by Ritter et al² was multifaceted and included many of the approaches recommended by the Multisociety Statement, including a formal program with leadership support, educational materials, enhanced access, and finally, enforcement including punitive action. Other strategies including advertisements and promotional material, incentives, providing data to staff, and mandatory declination have been historically used. Using a multipronged approach that begins with soft mandates can help achieve high vaccination rates. This may mitigate the need for punitive measures as well as reduce the number of employees that must be considered on a case-by-case basis. Another key feature of the approach taken by Ritter et al was to work with their legal counsel and to involve the National Union of Hospital and Healthcare Employees early in their overall process. Perhaps the greatest strength of the implementation of COVID-19 vaccination as a COE as described by Ritter et al was the allowance of time for staff to make their own decisions, which may have included discussing their concerns with a trusted health care professional such as a primary care provider or even a respected peer at the nursing home.

Addressing vaccine hesitancy among health care workers remains a challenging issue. Reasons for not accepting vaccines are legion, with many rooted in misinformation. These include health concerns (side effects, infertility), pseudo-science (incorporation of new genetic material, use of fetal tissue, microchipping), and deeply held political views (personal autonomy). Although the instinct for most clinicians is to respond with hard facts, this approach may not be effective for staff members who are subject to misinformation promulgated through social media as well as by peer groups, including family and friends. Rather, communication of positive stories of the benefits of vaccination and reframing the concerns, often coupled with education, are potential strategies to help overcome vaccine hesitancy for some individuals. The Agency for Healthcare Quality and Research (AHRQ) has developed a guidebook specific to certified nursing assistants in LTC settings⁷; the recommendations within have broad appeal and application. For some, access to the COVID-19 vaccine may also pose a barrier, though this is more common outside of health care settings. On-site vaccination clinics for employees or paid time off to acquire the vaccine from a nearby setting, including retail pharmacies, may help facilitate vaccination for reticent staff.

Regardless of the respectful engagement and communication from nursing home leadership, some staff members may refuse to accept vaccination and thus choose to terminate their employment. A potential mitigation strategy is to coordinate COVID-19 vaccines as COE with other area nursing homes or health care organizations, with an emphasis on promoting the health and safety of all patients, residents, health care workers, and the community at large. Other motivating factors for some vaccine-hesitant staff may be avoidance of loss of work due to quarantine following a positive test and prevention of potential long-term disability following COVID-19 infection. Although less likely to motivate most individual workers, from an organizational perspective, a nursing home that experiences outbreaks may experience a decrease in admissions as a direct effect due to quarantine and as an indirect effect due to families preferring a location with a highly vaccinated workforce.

The potential benefits of COVID-19 vaccination as a COE for nursing homes include avoiding shutdowns, avoiding quarantine, minimizing ill effects of residents' social isolation, advertising high vaccination rates, and of course, saving human life. Another potential benefit is reducing illness and absenteeism in staff in a health care sector that is chronically short-staffed and experiences high rates of employee turnover. Although the focus on residents’ quality of life, hospitalization, and death is critical, prioritizing the health of nursing home front-line staff is crucial as the Delta variant is affecting younger unvaccinated populations. It is our ethical duty to ensure the highest level of safety for our residents and staff. This cannot be achieved without reaching high vaccination rates in our nursing homes.