Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein: The coronavirus has devastated nursing homes and other long-term care facilities.

News clip: The death toll in nursing homes across New Jersey continues to rise.
News clip: In the first week of November new cases tied to nursing homes surpassed 24,000…

DG: 136,000 people — people who either lived or worked in long-term care facilities — are now dead.

That’s 36% of all US COVID-19 deaths.

This is why nursing homes residents and staff have been pushed to the front of the vaccine line, hoping that these shots will save lives.

But many workers — so far — are taking a pass. 

Today, why workers are hesitant to get vaccinated and what research suggests could get these people to change their minds.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

Tracey Couliboly thought this was it. 

Tracey Couliboly: I didn’t think I was going to make it through the night.

DG: Tracey struggled to breathe lying in her hospital bed that Sunday night in early April.

Just a few days before, the 50-year-old was at work videotaping virtual singalongs and trivia games for the residents at the Jewish Home at Rockleigh, a 180-bed New Jersey nursing home, just a football field from the New York border. 

Carol Silver Elitott: I always refer to April as the 5-year-long month of April. We didn’t have testing. We didn’t have sufficient PPE. We didn’t have anybody giving us the answers. So we had to figure it out.

DG: CEO Carol Silver Elliott’s facility was already in lockdown.

She directed residents to stay in their rooms. She tapped specialists to devise care plans for the sick. 

CSE: I don’t know that any of us got any sleep for the entire month. I will tell you, I didn’t. And all night long, all you think is what else can I do? What else can I do? What else can I do? 

DGL 21 residents died in those first weeks.

More than 50 staff members got sick. 

That included Tracey, the nursing home’s director of recreation.

Now, diagnosed with COVID-19, Tracey found herself curled up in the fetal position in a hospital bed hooked up to 8 liters of oxygen.

She reached for her phone and called her oldest daughter.

TC: I told her she gave my life purpose, and I told her to make sure that my youngest daughter goes to whatever college she wants to. She was like, “Ma, don’t speak like this.” And I asked her to keep quiet, because I was that winded, my breath was very labored. I heard her tears. I felt her pain, but I needed her to just listen.

DG: She called her twin sons next.

Then she went to call her youngest, 16-year-old Bria, but she couldn’t. 

TC: Something made me pause. She wants to be a doctor. I wanted to be here to see her in her white lab coat, to see Dr. Coulibaly on a nameplate.

I had taken some photos of her with her cap and gown and with her in her uniform. And I took pictures of her with stethoscopes on. And so I just kept scrolling through my phone looking at her. And I wanted that to be the last thing that I saw.

DG: As Tracey lay in bed, she thought of her mom, her rock.

TC: I was looking up to my mom, who’s no longer with me, and I remember saying, “Mom, I’m not ready. My kids are not ready.”

DG: Tracey made it through the night and found a nurse standing over her the next morning. 

TC: She said, “Wake your ass up.” And it reminded me of my mom. I kind of felt my mother spoke through the woman. Through the nurse.

DG: Prayers answered. 

Doctors discharged Tracey three weeks later.

When she could finally return to work in late June, Tracey immediately saw that “5-year-long April” had ended.

The Jewish Home had closed all but one of its COVID units.

Still, the virus had left its mark.

TC: I went up to the units, and I just circled the unit. And I immediately recognized who was no longer with us.

DG: Tracey made her rounds, gathering up ghosts. 

TC: Ruth Weisman. Every day she’d see me, she’d be in her wheelchair. She would give me a kiss and say, “Good morning. Good afternoon, sweetie. I love you.”

DG: Tracey carried Ruth and all the others she’d lost back downstair to reclaim what COVID had robbed from her — a chance to say goodbye. 

TC: I came back to my office and pulled out my box of tissues. And I cried for about five minutes and pulled myself together and then restarted my day.

DG: When we come back, nursing home vaccine mandates, Waffle House gift cards and Tracey’s reluctance to get a shot. 


DG: Welcome back.

Long-term care facilities have now — by mid-January — received more than 4 million doses of the COVID vaccine according to the CDC. 

The high infection and death rates in these facilities pushed residents and staffers to the front of the line. 

But here’s one of the biggest problems: Lots of nursing home workers are declining the shot.

Sure, some facilities say they’ve vaccinated at least 80% of their workers.

And it’s hard to be definitive when there’s no coordinated data collection on this yet, but anecdotal evidence and reports from state officials offer a bleaker picture.

News clip: New at 11 Dr. Mandy Cohen says most nursing home workers in North Carolina don’t want to get the COVID-19 vaccine.
News clip: 60% of those working in Ohio’s working homes have opted not to get the COVID-19 vaccine.

DG: Some facilities say just 20-30% of workers are rolling up their sleeves.

Surveys and first-person accounts suggest people are worried about a few things: unknown side-effects, overall medical safety and a general sense the vaccines were rushed for political gain.

Jasmine Travers: If we don’t see substantial rates when it comes to vaccinations we will see continued threats to the safety of our residents, the safety of our staff, and then the safety of our communities.

DG: So what can be done?

Jasmine Travers is an assistant professor at NYU’s Rory Meyers College of Nursing who has studied vaccination rates in long-term care facilities.

She says there are a few options — none of them perfect.  

First up: mandates, a policy some facilities have in place for the annual flu vaccine.

JT: When we see vaccinations being mandated, we see upwards of 90% and plus of vaccination uptake.

DG: Juniper Communities, which runs 22 long-term care facilities in three states, is one of the few nursing homes to publicly institute a COVID mandate. 

The upside: Their CEO reports a 95% uptake so far. 

The downside: The 5% unvaccinated includes 15 people who quit over the order.

JT: There’s that sense of violation of individual rights, thinking about cultural norms, loss of control, especially when thinking about not really coming into this with the understanding that if I work here, I’m going to be required to be vaccinated for this new vaccine that just came out.

DG: Jasmine, one step removed from mandates are incentives, right, like we talked to an administrator in Ohio who’s promising a $50 gift card to Target or Wal-Mart. There’s a Georgia company that’s offering free breakfast at Waffle Houses to anyone who gets vaccinated. What are the upsides and downsides of effectively paying people to get the shot?

JT: Of course, we see improved vaccination rates. In a study published in the American Journal of Infection Control, looking at employee vaccination rates and nursing homes specific to influenza, there was a 12 percentage point increase among nursing homes that used incentives compared to nursing homes that did not use incentives.

DG: And what about the downside? Is there any downside to these sorts of nudges?

JT: So folks may indeed perceive these incentives as being coercive. And then their perspective on that could be, if this vaccine is so safe and effective, why do you need to pay me to get the vaccine, which we’ve seen some nursing home facilities doing.

DG: Jasmine knows some nursing homes don’t have the resources to throw around gift cards or the bandwidth to launch time-consuming COVID education campaigns.

She’s particularly concerned about places with high shares of Black residents and people on Medicaid, which often have fewer resources and lower staff flu vaccine uptake rates.

But Jasmine says something important is getting lost in this mad dash to vaccinate staff — the longstanding issues that have often made frontline workers in nursing homes feel unvalued and invisible.

JT: We hear a lot about the low payment that nursing assistants receive. But I’ve heard a lot of nursing assistants say, “Pay is one thing, but it’s the respect.” They want to be respected. 

DG: Jasmine has conducted interviews with nursing home staff since 2014.

She’s focused primarily on nursing assistants, who are responsible for much of direct resident care.

About half are people of color nationwide, and they’re some of the most reluctant to get COVID shots.

Jasmine’s research documents the significant mistreatment some of these workers have faced.

When you say significant mistreatment of nursing assistants, what are you referring to?

JT: It’s verbal abuse, it’s physical abuse, abuse from residents. It’s been characterized as being on a plantation. I’ve seen these things. I’ve seen where nursing assistants are called very hurtful things, things that, you know, people of color were called very often years ago, but are still called that in the nursing homes.

DG: Jasmine says given this history of mistreatment, it’s especially important for nursing homes looking to solve vaccine hesitancy to engage workers directly.

Is there any research that shows when you do include nursing assistants at the table, that has an impact?

JT: Yes. They perform their duties better. They have higher morale and job satisfaction, and they’re less likely to leave their jobs. So we have nursing assistants who are more invested in their work and the work that is coming out of the institution. 

DG: This idea hasn’t been tested on vaccine uptake specifically.

In your mind, as an academic, is the evidence solid enough that you would go out and you would personally encourage other nursing homes to take this step to bring the nursing assistants and other staff to the table?

JT: Most definitely, This is a piece that is missing, that nursing homes need to include nursing assistants. They’re the largest proportion of staff within a nursing home. They provide the majority of the care. So it only makes sense that these people would and need to be at the table. We’re not trying to convince, right? We’re trying to understand the reluctance. The slogan, the messaging is really, “We need you.”

DG: Jasmine, I really appreciate you taking the time to talk with us on Tradeoffs. Thank you very, very much.

JT: Sure. No problem. Thank you so much for having me, Dan. It’s been a pleasure.

DG: Tracey Coulibaly has seen this reluctance in her own eight-person team at the Jewish Home in New Jersey.

TC: All of us were reluctant.

DG: Everybody had their reasons. 

One woman worried the shot could set off her allergies. Another had respiratory problems.

And Tracey? Why, after her close call with COVID, would she hesitate?

TC: I don’t live in fear and I don’t work in fear. But when I caught COVID, I was definitely operating out of fear.

DG: Tracey was afraid of how the vaccine would affect her after having had the virus.

Tracey and her staff talked about their fears again and again in daily meetings the home calls “learning circles.”

TC: Whatever is a concern, we address it in a learning circle. It’s not structured. So it’s a free meeting for the staff to communicate, ask questions and just learn.

DG: Management had introduced the concept a few years back as a way to empower frontline staff. Their version of the “at the table” approach Jasmine talked about.

Literally getting everybody into a circle, all on the same level.

Tracey said it was a perfect way to air out all the fears. 

TC: What we did is, that person who may have an allergy to something I was able to communicate in the learning circle that, you know, “Carol just mentioned in Morning Huddle, they have epipens, they have additional nurses on standby. If you need support, we will have staff there to support you specifically. So that gave a level of comfort.

DG: It’s Monday, Dec. 28: vaccine day at the Jewish Home.

Balloons with big stars hang from the ceiling, greeting staff at the door. 

Music booms through the hallways. Staff and administrators dance, dressed in matching turquoise T-shirts. 

After researching the vaccine, Tracey has decided the risk of getting COVID again isn’t one she wants to take. 

She’s nervous as she sits down.

TC: There was some anxiety because I was chosen to be first.

DG: Co-workers watch as the pharmacist rolls up Tracey’s sleeve, wipes down her arm, and injects the vaccine.

AMBI: Cheers

TC: I remember, you know, my eyes welling up with tears as the needle was going in and as I walked towards the exit to go to the recovery station, they actually dropped. They dropped. You kind of feel like. It’s over like covid can’t touch me like you got a forcefield on.

DG: Every member of Tracey’s team got vaccinated that day.

In all, 56% of the Jewish Home staff got a shot.

That’s about in line with the anecdotal average nationwide.

CSE: I’d like 100 percent, but I thought 56 percent was a good first step for us.

DG: Jewish Home’s CEO Carol Silver Elliott says the home’s second vaccine day, the last chance for the remaining 44% to get their first shot, is next week.

So Carol’s channeling politicians right before election day — working the halls, hearing people out and coaxing them to sign up. 

She tells them to think back to what the building felt like during the 5-year-long April.

CSE: You remember standing at the bedside of people that we loved and treasured and knew for years and watching them struggle for breath. You remember wondering, “Am I going to be the next?” And, you know, I think invoking those memories and recognizing that if we’re going to keep ourselves and our families and our colleagues and our elders safe, this is what we need to do. 

DG: The vast majority of residents at the Jewish Home — and nursing homes across the country — are getting the vaccine, which is good.

But experts say low staff uptake will leave workers at risk, residents not fully protected, and herd immunity harder to achieve.

Carol wants to get there. She’s committed to getting there. 

But she’s not going to force anyone with a mandate or dangle out some gift card. 

She’s going to talk to people, give them facts, her respect, and hope that that’s enough. 

I’m Dan Gorenstein, and this is Tradeoffs.