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Many Americans are eager to get vaccinated against COVID-19. They call hotline numbers. They search online for vaccination clinics. They wait in line for hours. However, others with easy access to the vaccine have declined in large numbers. Staff in long-term care facilities have been given priority to receive the vaccine, but many choose not to be vaccinated. Why?
No one knows the impact of COVID-19 better than the staff of nursing homes and assisted living facilities who have been Ground Zero for the pandemic. Large numbers of residents and staff have contracted the virus. Almost 40% of COVID deaths in the United States have occurred among residents of these facilities. More than 1,500 nursing home staff have also died from COVID, leaving the caregiver America’s most dangerous job.
Nonetheless, many long-term care staff continue to refuse the COVID-19 vaccine. In one recent CDC report, nursing homes had a median vaccination rate of 37.5% for staff during the first month of the federal vaccination effort; by comparison, a median of 77.8% of nursing home residents received the vaccine. This surprised some decision makers. Recently, the Acting Secretary of Health of Maryland tells state lawmakers that about a third to half of the staff who were offered the vaccine chose to receive it – far from an expectation of 80% to 90%. In some positive news earlier this month, a large national chain of nursing homes reported that 61% of staff and 84% of residents had been vaccinated by early February, still a long way from meeting the expectations of many decision makers.
An information problem or a trust problem?
Many experts attribute the low staff vaccination rates to an information problem. Indeed, a recent poll of nursing home caregivers report that many staff are concerned about vaccine safety and side effects. Yet large information campaigns including well-designed toolkits and fact sheets have not been sufficient. The problem is not only a lack of information, but also who provides that information. Direct caregivers in long-term care may lack information about the vaccine, but they also lack confidence in the management of the facility.
We have always undervalued the work of caregivers in long-term care facilities. They do hard work for pay at or near the minimum wage, with few benefits like health insurance or paid sick leave. They often work in multiple establishments to earn a living. Many facilities are understaffed with a high turnover rate. The vast majority of caregivers are women, and many are people of color and recent immigrants. They can be treated badly when asked to work long hours for low pay.
Since the start of the pandemic, this workforce has been further exploited. They often had to work in facilities that very few staff, without adequate personal protective equipment or rapid COVID test. Many staff members did not receive risk or hero bonuses while working in the most dangerous conditions. Unsurprisingly, many staff members do not trust the management of the establishments where they work.
The role of trust, immunization mandates and cash incentives
Given the lack of confidence among caregivers, staff not only need more information about the safety of the vaccine; they need to hear this message from a trusted source. Some facilities with better employer-employee relationships may have had these discussions, such as a recent New Yorker item Notes.
This trust between the management of the establishment and the staff cannot be built overnight. Facilities lacking this culture will need to look to a source of trust in or around the facility. In some cases, these may be respected clinicians and staff who work in the facility. In other cases, it can be a professional organization.
Does policy have a role to play in increasing staff immunization rates? Perhaps. One idea is to force staff to be vaccinated. The federal government has been reluctant to do so, mainly because the vaccine has been approved by emergency use authorization. Although a few assisted living chains have made the vaccine mandatory, most companies have not chosen this route. Everyone recognizes that the mandates will have the intended effect of increasing staff immunization rates. However, warrants may also have the unintended effect of causing some staff to leave their posts instead of getting vaccinated. It all comes down to trust. With severe staff shortages and the challenge of recruiting new workers for these jobs, establishments can hardly afford to lose more workers.
Another approach is to pay staff to be vaccinated. Some facilities offer free breakfast or gift cards. These rewards are nice but fairly nominal and are unlikely to move the needle much. Larger sums of money, such as $ 500 for the first shot and $ 1,000 for the second shot, would likely encourage more staff to get vaccinated. However, there is ethical considerations staff compensation, and the financing of these payments would require government support.
Ultimately, regardless of the approach, trust and relationships will play a central role in resolving this situation. When it comes to immunizing staff in long-term care facilities, the messages we share matter, as does the messenger who conveys that information.
Follow me on twitter @DavidCGrabowski
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