COMMENTARY

How Can We Get Healthcare Workers to Trust the Vaccine?

Arthur L. Caplan, PhD; David C. Grabowski, PhD; Judy A. Stone, MD

Disclosures

August 10, 2021

This transcript has been edited for clarity.

Arthur L. Caplan, PhD: Hi. I'm Art Caplan, and welcome to another edition of Both Sides Now. I'm your host as well as director of the Division of Medical Ethics at New York University Grossman School of Medicine. I'm excited to be here for what I think you'll find a very interesting and enlightening discussion. It's about a much-debated topic that has been in the news quite a bit lately and has all sorts of nuances, twists, and turns: vaccine mandates.

Recently, Houston Methodist Hospital became the de facto epicenter of this battle after they decided to require vaccination of all their staff under the penalty of firing. A group of over 100 healthcare workers there, mainly nurses, organized and went to court to fight this requirement. A federal judge dismissed their lawsuit, basically saying that the hospital was within its rights to try to promulgate health and safety to protect patients. Yet many employees still said they weren't going to do it, and over 150 were either fired or quit. Houston Methodist Hospital has not backed down, and the mandate is still set to go.

Similar mandates are starting to be seen in other institutions around the United States, including Barnes Hospital in St. Louis, Columbia University in New York, and the Inova Health System.

Judy Stone is an infectious disease physician and contributing author to numerous publications, including Medscape. David Grabowski is a professor in the Department of Health Care Policy at Harvard Medical School, as well as a member of the Medicare Payment Advisory Commission. Thanks for joining me on Both Sides Now.

David, up where you are at Harvard, have you encountered people who say no?

David Grabowski, PhD: Most of my colleagues are vaccinated, like all of us here. Through my work in the long-term care setting, however, I have encountered quite a bit of hesitancy, even here in Massachusetts. Among nursing home staff, there's a range of different positions, from physicians to therapists, registered nurses to licensed practical nurses.

Unfortunately, vaccination rates have been lowest among those with the most direct contact with the residents, specifically among those nurse aides. That's where the hesitancy is most concerning and strongest. To me, the greatest policy challenge has been how to move the needle with that group. I think among physician colleagues, I've encountered very little hesitancy, but quite a bit in other parts of the healthcare workforce.

Caplan: Although I know the surveys that have been done in this area do not include extensive numbers, they do seem to show more resistance among nurses and nurse aides than among doctors.

One thing I'm interested in, David, is what those in the long-term care setting who are resistant to vaccination are saying. What kinds of worries do they express, or do they just say, "I'm not doing it and buzz off"?

Grabowski: I think it's really an issue of trust. They don't trust the vaccine. Speaking specifically about the nurse aides, they're making close to minimum wage. Oftentimes they don't trust management or leadership at these facilities. They're very resistant, as Judy just said, to authority and being told what to do, because there's not a strong relationship between labor and management in this setting. This is not the same as you'd see among physicians and leadership at somewhere like Massachusetts General Hospital. This applies to the workforce in a for-profit nursing home that hasn't been treated very well historically.

And by the way, they also weren't treated very well during this pandemic. Direct caregivers in nursing homes had among the highest death rate of any profession in the United States during the pandemic, more so than commercial fishermen, logging workers. You usually don't group nurse aides in with those professions. But this was a really challenging time. This workforce was incredibly stressed. Now you're telling them, "Guess what, this will really benefit you and potentially save your life," and there's just not that strong relationship or trust there.

I've also heard concerns about side effects, although hopefully some of that has since receded.

Caplan: I'm assuming they mean long-term side effects?

Grabowski: It's short- and long-term side effects. When it comes to the short-term side effects, hopefully that's declined as they've seen their colleagues getting vaccinated. We saw very few of the staff in the long-term care settings calling out of work after receiving the vaccine. There were only a few side effects, which was really encouraging. But you're right — there's a lot of concern about these longer-term side effects and just the overall safety associated with the vaccine.

Caplan: Judy, I'm curious: Do you think the hesitant healthcare workers you encounter, in the public or among your own friends, are persuaded by these incentive ideas? Do you think if we paid more, gave them free meals, or offered them some kind of a reward, would that move those people? Or are their hesitancies and concerns deeper?

Judy Stone, MD: I don't think that it would move them. Particularly among nursing home workers, there is a level of suspicion around coercion. If you're offering them a $20 gift card, they may think, "Well, why do you have to give me a gift card to take this?"

Caplan: Do you think that sows suspicion?

Stone: I do. I think that one of the problems here, at least at the hospital I worked in for 25 years, carries over from penalizing people for taking sick time. They call them "occasions." If you had a certain number of occasions, then you were disciplined or fired. So, I think that makes it more difficult to offer a vaccine that may make people feel unwell for a couple of days.

Caplan: We made a strong point at NYU about trying to give staff extra days off for the same reason; they're very worried about biting into their sick time.

Stone: Following up on what David said about the lack of trust between management and the staff, one of the interesting things that I came across was that mandates could lead some people to feel that they were accepting a riskier choice. This comes back to the fact that offering healthcare workers adequate personal protective equipment (PPE) was not a priority during the pandemic. They worry that if they're vaccinated, they'll be forced to work in a higher-risk setting.

Caplan: Interesting. That's the old worry about risk reduction, and that if you adjust one variable, you're going to increase the risk in another way.

Stone: That's right. Certainly, I was torn between feeling an obligation to take care of patients and feeling like it would be suicidal, at my age and with underlying health conditions, to go work in a place where there's not adequate PPE.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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