‘If There’s No Trust, There’ll Be More Hesitancy’: Nursing Homes Must Overcome Staff Skepticism of COVID Vaccine

Dec 2, 2020

The Centers for Disease Control and Prevention (CDC) was emphatic in a Tuesday meeting that it has the systems and processes in place to keep track of any adverse events from a COVID-19 vaccine, whenever one is approved.

Whether that is enough to quell the concerns of the health care workers and long-term care facility residents — whom the CDC’s Advisory Committee on Immunization Practices (ACIP) this week recommended should be first in line for immunization — is still an open question.

“There is hesitancy, of course,” Lori Porter, the CEO and co-founder of the National Association of Health Care Assistants (NAHCA), told Skilled Nursing News on December 2. “Until we know if it’s mandated or not, we’re not really going to know exactly what’s going to happen. From what we can tell, the CDC won’t make it mandatory. It’ll be up to the states, and the states might pass it off to the facilities as more of an employer policy. So until we know what the outcome is, there is a great deal of hesitancy among CNAs [certified nursing assistants].”

The CDC voted on Tuesday by a 13-1 margin in favor of a recommendation that health care personnel and long-term care facility residents be offered a COVID-19 vaccine in the first phase of the COVID-19 vaccination program — classified as 1a — whenever such a vaccine is authorized by the Food and Drug Administration and recommended by the ACIP.

Dr. Helen Talbot of Vanderbilt University, who cast the lone dissenting ballot, said that while it was a difficult vote to cast, that she has “no reservations whatsoever” about health care workers taking a vaccine when one is approved and available.

“I really hope this highlights that our skilled nursing facilities are a population that needs lots of vaccines, not just COVID,” Talbot said, discussing her vote after the recommendation was finalized. “And we really need to start finding ways of developing and testing these vaccines to prolong quality of life for our long-term care facility residents. I think that’s key.”

But it’s workers who may be particularly hesitant — a serious challenge since they are the ones most directly exposed to COVID-19 in the community at large.

Rick Matros, the CEO of the skilled nursing and senior housing landlord Sabra Health Care REIT (Nasdaq: SBRA), said at an investor event last month that residents and employees are likely to be skeptical even amid promising early results from Pfizer and Moderna on their COVID-19 vaccine trials.

His assessment was similar to Porter’s on how well a mandate for a vaccine would be taken.

“To the extent that it’s mandated … I just don’t see how that works,” he said on November 17. “I think there’ll be a certain percentage of people that just aren’t going to take it, and I don’t think there’s anything that anybody can do about that. If half your employees decide not to take it, you still need them to come to work because you need people to take care of patients.”

‘CNAs do not trust their leaders’

The Department of Health and Human Services (HHS) in October signed a deal with retail pharmacies Walgreens Boots Alliance (Nasdaq: WBA) and CVS Health (NYSE: CVS) to distribute COVID-19 vaccines to nursing home residents. Under the Pharmacy Partnership for Long-Term Care Program, residents of nursing homes and assisted living facilities can receive a COVID-19 vaccine on-site when one is approved.

“The overwhelming response” by SNFs to this program demonstrates acceptance of COVID-19 vaccination by long-term care facilities, Dr. Kathleen Dooling of the CDC said during a presentation on vaccine allocation during ACIP’s Tuesday meeting.

“To date, 99% of SNFs nationwide have enrolled in this program,” she said.

But that figure only tells part of the story, particularly when it comes to how the frontline staff of those facilities — the ones who do the most intimate work of changing, turning, and bathing residents, within the closest quarters — feel about getting vaccinated.

Porter maintains a private website that culls opinions from 7,000 CNAs across the U.S., and some informal polls there indicated “a lot of anxiety among CNAs” surrounding COVID-19 vaccination she said.

“They don’t believe there was time to develop a proper vaccine,” she said. “They don’t want to be guinea pigs. Even one said: I’ll take it if they’ll [the facility] buy life insurance on me, but I’m not going to take it and die poor.”

Another significant disconnect is the lack of trust between CNAs and the leadership at their facilities.

“My concern is not necessarily the vaccine, if it’s proven safe,” Porter told SNN. “My fear is that if we don’t educate them, if we allow the facilities to provide the education on the vaccine, there is a trust issue. CNAs do not trust their leaders.”

And because of the politicization around responses to the virus, which would pit the outgoing administration of President Donald Trump against the CDC on multiple occasions, even the CDC has lost its credibility among many frontline workers, Porter explained.

Trusting long-term care physicians

But there is trust still for long-term care doctors, so as NAHCA plans education for its members on the vaccine, it’s working closely with AMDA, the Society for Post-Acute and Long-Term Care Medicine, which focuses on medical specialities in post-acute and long-term care, to provide webinars where CNAs can ask questions of physicians directly.

The CDC may also end up participating in some of those efforts; the agency has agreed to appear on a TV channel dedicated to CNAs, which NAHCA plans to use as a showcase for educational materials, in addition to making use of social media and other channels. Overall, Porter estimates the reach of NAHCA at about 90,000 workers in the U.S.

Th exact thrust of that content will not be determined until there is a vaccine, however. When one or more are authorized, Porter said, it’s imperative that there be transparency around its efficacy, the process and the side effects.

But it also means taking into account the information landscape that frontline workers are navigating.

“So much misinformation is the problem,” Porter said. “They no longer trust the institutions.”

Any education on vaccination for the health care workforce thus needs to be tailored to the trust concerns for CNAs. This could include focusing on education on the vaccine itself, but also education on the administration of it and the possible side effects, which as Porter observed, “don’t sound too fun.”

Even if CNAs are not put off by the side effects, their severity might necessitate at least a couple days off, which will entail working out a scheduling process for immunization that can accommodate potential absences.

This will be challenging amid an ongoing shortage of CNAs, but a botched rollout could mean an even greater workforce crunch, since many CNAs have indicated that they would leave the sector if forced to take a vaccine, Porter said.

But for now, she is simply asking CNAs across the country to be patient, since there are so many unknowns still.

“We just ask them to keep calm for now,” she said. “Don’t buy into the hype. Don’t look at 50 different opinions, and we will provide what we need — once we know what we need to know.”

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