The vaccine mandate staffing crisis that wasn't

Rancorous opposition to vaccine mandates from a fraction of the hospital workforce has drowned out the voices of the administrators and staff who desperately want to feel safer at work during a pandemic that has killed thousands of healthcare personnel.

Before President Joe Biden declared that all healthcare providers that participate in Medicare and Medicaid must vaccinate their 17 million employees against COVID-19, dozens of hospitals and health systems around the U.S. took the step on their own. The CEOs of three pioneer hospitals—Houston Methodist, the Medical University of South Carolina and Inova Health System—say their successes demonstrate the wisdom of requiring vaccines.

Healthcare worker shortages are real and hospitals shouldn't take lightly the possible loss of staff to vaccine mandates, said Dr. Stephen Jones, president and CEO of Inova Health System in Falls Church, Virginia. But the small numbers of employees who are giving up their jobs over vaccine mandates suggest the worry may be overblown.

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"It'll be disappointing losing a single person," Jones said. "We'll regret that they're not here. But we have a responsibility to prioritize the safety not only of our patients, but our own team members."

Hospital leaders face an admittedly sticky situation.

The COVID-19 vaccines are heavily politicized and resistance to immunization is higher in regions that voted for President Donald Trump over Biden in the 2020 presidential election. That influences healthcare workers as much as anyone else. Vaccine hesitancy also is higher among healthcare personnel with lower levels of education and professional training, as illustrated by a recent JAMA Internal Medicine study showing less than half of the lowest-trained nursing home employees were vaccinated. Healthcare professionals also are subjected to the same misinformation about the vaccines as the general public. And people of color have historical reasons to mistrust the medical establishment.

Healthcare workers are exhausted after more than a year of working through a pandemic that has claimed an estimated 675,000 American lives. Nurses, in particular, have cried out for help in the form of bigger staff, more personal protective equipment and greater respect from their managers—perennial complaints made more acute by the pandemic.

This is a workforce that's become skeptical of bosses—the very same people now pushing them to get vaccinated. The lackluster rollout of the federal vaccine mandate for nursing home employees illustrates the challenge.

The biggest fear is that mandating vaccinations will drive workers to take jobs at healthcare facilities without mandates, and hospitals can ill afford to lose employees at a time when shortages are already rampant and COVID-19 cases are rising. If the experience of those hospitals that were early to require inoculations is any guide, those concerns may well turn out to have been exaggerated.

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Ultimately, hospital leaders must prioritize the rights and privileges of all parties involved: unvaccinated employees, vaccinated employees, patients and anyone else who enters a hospital. To do so, administrators reemphasized the fundamental notion that a hospital's first priority is its patients.

First in the nation

At Houston Methodist in Texas, the choice was clear, said Dr. Marc Boom, the seven-hospital not-for-profit system's president and CEO.

"We have a sacred obligation to care for patients and keep them safe. And frankly, we have an ethical responsibility as an employer to keep our employees safe," Boom said. "It was absolutely, unequivocally the right thing to do. I'm very proud of our almost 26,000 men and women for everything they've done for this pandemic, for stepping forward and doing the right thing."

Houston Methodist was the first U.S. hospital to announce a vaccine mandate when it notified employees of the coming policy in April, with a June 7 deadline. The results: a vaccinated workforce and only about 150 resignations, or 0.06% of its staff.

The health system weighed conflicting ethical obligations when making the decision to require employees to be vaccinated: bodily autonomy, informed consent, beneficence (do good) and non-maleficence (don't do bad), Boom said. In the end, the duty to patients and vaccinated workers trumped the rights of those who refused inoculations, he said.

A "small, vocal minority" protested the policy and they've garnered most of the attention, but Boom rejects their argument that bodily autonomy is the most important consideration.

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"My autonomy to throw my fist ends when it hits your face," Boom said. "My autonomy as an individual is essentially overwritten by those other ethical principles if my autonomous decision to not get vaccinated as a healthcare worker results in the irreversible harm to somebody I'm caring for," he said.

"The majority of our team were thrilled to do this. They were already vaccinated. If they were vaccinated, they wanted everybody else vaccinated. They wanted to keep our patients safe," Boom said. "They were very proud of the fact that we were leaders in the country. Our tagline is 'Leading Medicine' and they were like, 'Yeah, we're living that,'" he said. Patients and community members have also expressed gratitude, he said.

A group of 178 Houston Methodist employees tried to sue to block the mandate after being suspended for not following it, but a federal judge dismissed the case in June.

What worries Boom now is the thought that those workers who left Houston Methodist rather than get vaccinated are spreading the coronavirus to patients elsewhere. "It chills me to know that some people leave and then just find other jobs—a home health agency, for instance. One of our individuals who left did that. I'm like, 'OK, great. They're walking into someone's home unprotected, and not protecting that—by definition—vulnerable person," he said.

Employee engagement

The Medical University of South Carolina's 11-hospital system also told staff in April that a vaccine mandate was coming, and set a June 15 deadline. Although nearly 70% of MUSC employees were immunized by the end of February, the not-for-profit's vaccination rate had plateaued. A mandate was the obvious solution once leaders were satisfied it passed legal muster, said Dr. Patrick Cawley, the academic medical center's CEO.

"At the leadership level, a lot of worry—a lot of worry—about, if we mandate, it is going to lead to staff turnover," Cawley said. "I myself never fully believed that would be a problem, for two reasons. Number one, we would language the concept of safety. And I just had a hard time believing that somebody would leave our organization because we were doing something that was more safe. So that was the first thing. The second reason is, we have pretty good employee engagement scores."

By the deadline, 97% of MUSC employees were in compliance and 178 of its 17,000 workers weren't, Cawley said. In the end, the health system lost just four employees—0.0002% of the staff—all of whom were also in violation of other company policies, he said. About 3,000 workers qualified for exemptions from the requirement, mostly because they'd contracted COVID-19 and possessed some level of natural immunity.

The Medical University of South Carolina eased its way toward a mandate in an effort to win over skeptical employees and get them to volunteer for shots first, similar to the approaches taken at Houston Methodist and Inova Health System. The vaccination mandate rolled out in four phases: new hires, then managers, then almost all other employees, followed by contractors and other miscellaneous workers.

More than that, the health system's leaders embarked on a multifaceted outreach and educational campaign to assuage doubts about the vaccines, Cawley said. The overarching message was that MUSC and its professionals have a responsibility to promote safety, he said.

"We made it very personal. So we got to the point that I was sending emails that were coming straight from me to employees to get vaccinated. So we communicated very hard internally with the safety message," Cawley said.

At Inova Health System, a six-hospital not-for-profit chain, the employee vaccination program is still underway, with an Oct. 1 deadline. As of late August, 96% of its 19,000 workers were in compliance, Jones said. Inova expects to lose only a few dozen employees over the mandate, he said.

"You have to go back to math," Jones said. "The clear majority of people in healthcare had already been vaccinated. They kind of were sending a signal they wanted to work in a place where the people around them were vaccinated."

Inova succeeded because it focused on persuasion and on messaging safety, Jones said. The health system held numerous town halls and produced informational videos in multiple languages, reflecting the racial and ethnic diversity of its northern Virginia home.

Jones and other prominent employees, including cardiologist and former country music recording artist Dr. Cleve Francis, made rounds through the hospitals to take questions from workers. Jones got his own vaccination alongside Francis, who is Black, to model behavior for the workforce and build trust among Black employees, he said.

Flipping the script

Hospitals with vaccine mandates are subject to the same staffing pressures as their counterparts. But Inova's vaccine mandate could help with hiring and recruitment, Jones said. "We're worried about it being a staffing challenge, maybe, in the short term. I think that it's actually going to be an advantage for us, that people will want to work around others who are vaccinated."

The vast majority of nurses who leave employers aren't doing so because of vaccines, said Jennifer Gil, who serves on the American Nurses Association board and is a registered nurse at Thomas Jefferson University Hospitals in Philadelphia. Gil was not speaking on behalf of her employer, which announced a vaccine mandate for its 34,000 workers last month with an Oct. 29 deadline.

"My conversations are never about vaccine mandates, or that being the root of the problem. I never hear like, 'So and so's leaving because they're being required to get vaccinated,'" Gil said. Instead, nurses lament being responsible for too many patients because of short-staffing, not getting breaks to rest, eat or even use the bathroom, and having inadequate resources, she said.

"The root of the problem is: It's an unsafe practice. Because we are seeing an increased number of COVID-19 patients and our staff are not vaccinated, then it's just going to continue that unsafe environment—nurses leaving because they feel unsafe and unhappy," Gil said. The American Nurses Association laid out its concerns and possible solutions in a letter to Health and Human Services Secretary Xavier Becerra this month.

Moreover, those hospitals that carried out vaccine mandates are experiencing a major staffing benefit: fewer employees catching COVID-19 and missing work, which worsens staff shortages, dampens morale and threatens hospital operations.

"You know what's very, very different than a year ago?" Boom said. "We have far, far less absenteeism. So another thing we've done is preserve the capability of these brave men and women to be frontline responders during the time of a crisis."

'Ethical no-brainer'

All medical professionals take oaths to protect patients, and getting vaccinated is necessary to fulfill those pledges, said Arthur Caplan, director of New York University's division of medical ethics.

"Ethical no-brainer. Patients come first. That's what it says in every code of ethics of administrators, doctors, nurses, pharmacists, occupational therapists," Caplan said. "They don't say doctors' choices come first or nurses' worries come first," he said.

"If you can't accept the science of vaccination, you shouldn't be an employee. I have no sympathy for that view," Caplan said. "Listening to the rights of the unvaccinated doesn't make any sense because you're just prolonging everybody's misery."

Mari Devereaux contributed to this report.

Correction: The original version of this article misspelled Houston Methodist CEO Marc Boom's surname.