We Need You

January 14, 2021

Photo courtesy of Jewish Home Family

Nursing homes have been one of the epicenters of the COVID-19 pandemic. So why are so many nursing home workers hesitant to get vaccinated, and what can be done to turn those numbers around?

Listen to the full episode below, read the transcript, or scroll down for more information.

4 Things You Should Know About Vaccine Hesitancy in Nursing Homes

Since the beginning of the pandemic, nursing homes and other long-term care facilities have been among the hardest hit by COVID-19. More than 130,000 people who lived or worked in these facilities have died, representing more than one-third of all COVID-19 deaths in the United States.

This disproportionate impact is why long-term care facility residents and staff were pushed to the front of the line to receive COVID-19 vaccines.

But one month into the vaccine rollout, state health officials and nursing home leaders are sounding the alarm over the large number of workers who are choosing not to get vaccinated. Experts say even if most long-term care residents get vaccinated, as anecdotal evidence suggests has been the case, low uptake among staff will leave workers at risk, residents not fully protected, and herd immunity harder to achieve.

Here’s what else we know:

1. Hard Data Is Hard to Come By

While the CDC is collecting and publishing data on how many vaccine doses have been distributed and administered in long-term care facilities, there is no central repository for information about how many of those doses have gone to staff and how many staff have declined.

The information we have is based on self-reporting from nursing home companies and state health officials:

Genesis Healthcare, which runs more than 325 long-term care facilities across 24 states, said its staff uptake ranges from 80% at the high end to below 50% in some buildings.
Other facilities say as few as 20-30% of staff have taken the shot so far.
Only 55% of nursing home staff in West Virginia took the first round of shots, and fewer than half rolled up their sleeves in Ohio and North Carolina, according to state officials.

The CDC does have data on annual flu shots, which only around 70% of nursing home workers get on average, compared to more than 90% of hospital workers, suggesting that low COVID-19 vaccine uptake should not be entirely surprising.

2. There Are Several Factors Contributing to Low Uptake

Surveys and first-person accounts suggest the following are some of the biggest concerns driving nursing home staff’s vaccine hesitation:

Side Effects

One of the most common issues staff are raising is possible side effects from a vaccine. Seventy percent of workers in Indiana nursing homes cited side effects as their primary concern. Facilities report that side effects for staff who have taken the shot so far have been minimal, which they hope will encourage more workers to get vaccinated.

Too Many Unknowns

Was the vaccine rushed out the door for political gain? Could it cause allergic reactions, fertility complications or other negative medical interactions with pre-existing conditions? These unknowns are driving many nursing home workers to, at the very least, not be first in line for the vaccine. "The biggest [fear] you hear is, 'It's so new. What are the long-term effects?" says Carol Silver Elliot, CEO of the Jewish Home at Rockleigh in New Jersey.

Misinformation

Several nursing home administrators say they're having to debunk wild rumors about the vaccine that have been floating around on social media. "People think they're being injected with microchips to track where they go," says Greg Miller, executive vice president of the Healthcare Management Group, which operates seven facilities in southwest Ohio and northern Kentucky.

3. This Goes Deeper Than COVID-19 and Vaccines

Jasmine Travers, an assistant professor at NYU’s Rory Meyers College of Nursing who has studied nursing home staff and vaccinations in long-term care facilities, says in addition to COVID-specific drivers of hesitancy, many nursing home staff have long felt unvalued and invisible.

Much of her research has focused on interviewing nursing assistants who are responsible for the majority of direct resident care and are some of the most reluctant to get vaccinated. Jasmine says these workers — about half of whom are people of color nationwide — have long received low wages and faced a sometimes hostile, even abusive workplace. “It’s verbal abuse, it’s physical abuse, abuse from residents,” Jasmine says. “It’s been characterized as being on a plantation.”

Jasmine says this history of mistreatment has bred in some nursing assistants a mistrust of management, which must be considered when addressing vaccine hesitancy.

4. There Are Research-Backed Solutions ... With Tradeoffs

In addition to education campaigns, nursing homes looking to increase vaccine uptake among their staff are looking to several different strategies, none of which are perfect.

Mandates

Some nursing homes require their staff receive annual flu vaccines. This has been shown to increase vaccine uptake to 90% or higher. But few facilities are embracing mandates for the COVID vaccine as of yet over fears that staff would quit rather than comply. Juniper Communities, which runs 22 facilities in three states and is mandating staff receive a COVID shot, says it's seen 95% uptake so far, along with 15 people quitting.

Incentives

Many facilities are trying to entice their staff into getting vaccinated by offering gift cards, free meals or cold hard cash. Incentives have also been found to increase flu vaccine uptake in nursing homes, but they can also send the wrong message. "[A worker's] perspective may be, 'If this vaccine is so safe and effective, why do you need to pay me to get the vaccine?'" says Jasmine Travers.

Staff Engagement

For facilities trying to address more systemic mistrust with their staff, Jasmine Travers points to research that shows more engaged and empowered staff perform better, have higher job satisfaction, stay in their jobs longer, and provide better resident care. This approach has not been studied for vaccine uptake, but she says it's key to making sure staff know their importance in this moment. "The messaging [to staff has to be], 'We need you,'" Jasmine says. "The success of the vaccination, the health of our older adults, this all really depends on you."

Nursing homes with fewer resources may struggle to find the time for intensive staff education and engagement, the money for incentives, or the additional staff needed to weather a mandate. Facilities with higher populations of Black residents and residents covered by Medicaid tend to have fewer resources and lower resident flu vaccine uptake, disparities that could emerge for COVID vaccines as well.

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Episode Resources

Select Research and Reporting on Vaccine Hesitancy:

COVID-19 vaccination in nursing homes is a tale of bumpy logistics, fear and uncertainty about the future (Stacey Burling, Philadelphia Inquirer, 1/10/2021)

Vaccine rollout hits snag as health workers balk at shots (Bernard Condon, Matt Sedensky and Carla K. Johnson; Associated Press; 1/8/2021)

Willingness of Long‐Term Care Staff to Receive a COVID‐19 Vaccine: A Single State Survey (Kathleen T. Unroe, Russell Evans, Lindsay Weaver, Dan Rusyniak and Justin Blackburn; Journal of American Geriatrics Society, 12/28/2020)

Vaccine Push At Nursing Homes Meets Resistance (Barron’s, Eleanor Leslie, 12/17/2020)

Factors Associated with Resident Influenza Vaccination in a National Sample of Nursing Homes (Jasmine L. Travers, Patricia W. Stone, Ragnhildur I. Bjarnadottir, Monika Pogorzelska-Maziarz, Nicholas G. Castle and Carolyn T.A. Herzig; American Journal of Infection Control; 9/1/2016)

Influenza vaccination rates and beliefs about vaccination among nursing home employees (Jill D. Daugherty, Sarah C. Blake, Jessica M. Grosholz, Saad B. Omer, LuMarie Polivka-West and David H. Howard; American Journal of Infection Control; 2/1/2015)

Episode Credits

Guests:

Tracey Couliboly, Director of Recreation, Jewish Home at Rockleigh

Carol Silver Elliott, CEO, Jewish Home at Rockleigh

Jasmine Travers, AGPCNP-BC CCRN, PhD, RN, Assistant Professor of Nursing, NYU Rory Meyers College of Nursing

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions.

This episode was reported and produced by Ryan Levi. It was mixed by Ryan Levi and Andrew Parrella.

Additional thanks to:

Ezra HaLevi, Bria Couliboly, Esmeralda Tovar-Mora, Rich Feifer, Melissa Fijalkowski, Bacheni Antoine, Lynne Katzmann, Heather Klusaritz, David Grabowski, Greg Miller, Rebecca Turner, Lori Taylor, Lisa Sanders, Tamara Konetzka, Vincent Mor, Whitney Robinson, Marty Wright, Paul Katz, Larissa Lucas, the Tradeoffs Advisory Board and our stellar staff!