Vaccine hesitancy and noncompliance in healthcare

March 30, 2021

Emily Gridley

Introduction to vaccinations and healthcare 

Doubt in vaccination is a worldwide issue we have faced for decades. The delay of receiving vaccination, or outright refusal despite availability, is known as vaccine hesitancy (Kwok et al., 2020). Healthcare workers, who are often held to a higher standard than others by healthcare officials and society, face additional scrutiny. It seems that they are looked at under the fine lens of a microscope surrounding the matter.  The Centers for Disease Control and Prevention (CDC) has stressed that those working directly with patients or handling infectious material are most likely to spread infection. Because of this, it is important to follow the appropriate vaccination schedule to reduce the spread of vaccine preventable disease (CDC, 2016).  

Health officials believe this can be accomplished by “herd immunity,” a term most are at least familiar with. This is the idea that increased rates of immunization lower the risk of disease in those who are not vaccinated (Malone & Hinman). This is proven ineffective when employees do not comply, leading to potential outbreak, and making immunity maintenance in healthcare facilities imperative (CDC, 2016).  

At the frontline, we are surrounded by the most vulnerable and at risk population on a daily basis. It is important to protect the community and our coworkers, but at what cost? The majority of healthcare workers follow the recommended vaccination guidelines. But the healthcare industry, like universities, represent a microcosm of society as a whole, and a considerable percentage of workers refuse particular or all available vaccines. Because of this, drastic measures have been put into place by healthcare facilities to increase vaccination outcomes. Some methods may prove to be more ethical than others.  

This article will take a closer look into the uncertainty behind vaccination in the healthcare field, non-compliance of healthcare workers and the processes put into place for higher acceptance rates. We will take into consideration what this means for healthcare workers today in the midst of the COVID-19 pandemic. 

Why the hesitancy? 

The product of an age-old science that remains a very controversial topic of interest, vaccines have been under development for many years. There are many things to consider prior to vaccination, but it seems the main drivers behind hesitancy maybe fear and lack of information.  

Fear 

After speaking with coworkers from multiple facilities, it seemed that most of this fear stemmed from the possible side effects that could accompany a particular vaccine. This is understandable considering the never-ending list of potential health hazards that seem to be associated with many medications and treatments. It is simply impossible to guarantee overall vaccine safety (Field, 2009). Others had low confidence in the effectiveness of certain vaccines. If there is not enough evidence behind its efficacy, why take the chance? This may be the reason some choose to opt out: the belief there is no personal adverse risk in avoiding vaccination (Malone & Hinman).  

Inadequate information 

Low confidence can also be related to a lack of knowledge about particular vaccines. Some healthcare workers do not feel well prepared to answer questions surrounding vaccination. Consequently, they are less likely to recommend these vaccines. We do need to remember, not all providers are experts when it comes to this matter. At times, pertinent information is not made readily available to healthcare workers. We would like to have trust in our providers and confidence to turn to them for advice surrounding these issues. However, inadequate training and a lack of information supporting vaccination benefit versus risk remains a major barrier when it comes to hesitation (Kwok et al., 2020). 

Despite these adverse feelings, healthcare facilities continue to stress the importance of vaccination. So, what happens when employees do not comply with their recommendations? Although we are entitled to our own opinion, this may not be the deciding factor on whether or not to vaccinate healthcare workers. 

Mandating workers for better outcomes  

Although some facilities have decided to strongly advocate following the suggested vaccination schedule, others have chosen to mandate. In my experience, I have worked for a facility that mandated workers to get the seasonal flu vaccine following the H1N1 pandemic. Prior to this, we had the option of opting out and wearing a mask during peak season. As most of us would prefer not to wear a mask for 8 to 12 hours a day, many chose to vaccinate. This was short lived as vaccination numbers were not as high as desired.  

Today, if you do not receive your vaccination by a specified date, you are deemed non-compliant and terminated at this facility. There are exceptions made only for those who have an approved medical condition or religious conflict. I have heard of this approach being used at many other hospitals as well. It does seem to be a very forceful tactic, but it has been one of the most effective in reaching the goal of hospital-wide immunization (Field, 2009). Although aggressive, the reasoning behind it is defendable: 

  • As healthcare workers, it is crucial for us to keep our patients healthy and safe. Vaccination is successful in inhibiting the potential spread of vaccine preventable disease to our patients, which is necessary for good patient care.  
  • It is also essential that we stay healthy ourselves. During peak season, healthcare facilities cannot afford to have their employees calling in sick. Providing protection to healthcare workers means healthy employees who report to work. Everyone in the facility plays a key role in patient care, some very specialized. We cannot take care of our patients if we are not there to do so.  
  • Another reason some facilities choose to mandate is to make sure their employees are modeling this behavior for the community. Healthcare workers who vaccinate are more likely to share this information with their patients and others. This can lead to higher vaccination rates in the general population (Youngdahl, 2013). 

Although proven to be successful, it is often questioned if mandating vaccination is an ethical move toward immunity. There are several active lawsuits dealing with this issue (Field, 2009). Most have chosen to comply to protect their job. Many may not truly know the implications or benefits, but elect to vaccinate because they are required to. While we are healthcare workers and patient safety is the ultimate goal, aren’t we entitled to our own decisions? Is it truly justified to use vaccination as a term of employment for healthcare workers? 

A more ethical approach is needed 

Unfortunately, though it is a significant problem in healthcare, there has not been a lot of focus on different methods of mediation for those hesitant to vaccinate. There has also not been enough data collected on the impact of different intervention strategies. Movements should be put into place to address this problem in a more virtuous manner. We need to be able to restore faith in vaccines while reassuring individuals, centered on their own motives rather than using force. 

How is this possible? 

Make training available and educate our healthcare providers

To this day, healthcare providers are known to be the most trusted and effective sponsors of vaccination. However, like we said before, not all healthcare workers are vaccine experts or feel comfortable speaking about the topic. Studies have shown that if valid information was provided on a vaccine, their efficacy and safety, provider confidence increased and their likeliness to recommend vaccination to others did as well (Jarrett et al., 2015).  

Healthcare workers were also more likely to vaccinate if they had the support of their colleagues (Paterson et al., 2016). Because of this, major efforts should be made to ensure our providers have the ability to access pertinent information and receive specialized training. Unfortunately, mass education of a specific group can be difficult to implement. These tools can be pricey and it is never guaranteed that everyone will utilize them. To some degree, this can be combatted by –

Incentives

Let’s face it, if there is some type of reward involved, aren’t you more likely to follow up?

Reminders

This seems simple. However, everyone can be forgetful at times. Especially when working in such a fast-paced environment. If prompted, it seems we are more likely to follow through.

Ensuring access and ease of use

Healthcare can be busy and stressful without tasks being added to your plate. Sometimes these things seem to be more of a hindrance when already working under time constraints. Educational training needs to offer pertinent information that is interesting enough to keep employees captivated. A positive impact on feelings and awareness toward vaccination was seen when education on the topic was instilled in everyday routine procedures (Kwok et al., 2020).

It is possible this may also be achieved by allowing providers to contribute and have more hands-on involvement in vaccine recommendations.  In order to achieve this, a relationship must be developed between providers, healthcare authorities and policy makers (Kwok et al., 2020). This could be difficult to accomplish based on interest, regulations and education.  

This issue proves to be very complex and it seems not many attempts have been made to find a more ethical approach than mandating. It is evident that the use of only one strategy is not going to be able to resolve this. 

How does this effect healthcare workers today? 

COVID-19 upturned many of our lives last year. Today, we are starting to see a glimpse of hope as we come closer to a solution. There are 2 vaccines available in the U.S., although not FDA approved. They have been made accessible through the use of an Emergency Use Authorization (EUA). The FDA uses an EUA as a mechanism to validate the emergency release of drugs and biological products throughout the pandemic. Particular standards must be met in order for an EUA to be justified: 

  1. There are no other existing, suitable or approved alternatives. 
  1. It must be based entirely on scientific evidence indicating its success in the prevention of COVID-19 during the pandemic. 
  1. The known and possible advantages outweigh any potential risk. 

This documentation is given to everyone prior to vaccination along with any other important information you should be aware of (BioNTech, 2020). However, the material provided does not have everyone in healthcare on board with immediate vaccination. The given timeline and emergency release of the vaccine has made many hesitant. Some believe that there has not been enough data collected as they are still in the clinical trial phase. This leads to doubt regarding the extent of protection the vaccine offers against COVID-19 because at this time, it remains unknown (BioNTech, 2020).  

Others are eager to vaccinate. Studies have related current clinical work stress to the increased likelihood of getting vaccinated (Kwok et al., 2020). This stress can be contributed by: 

Insufficient supply of personal protective equipment (PPE) 

During our first wave of COVID-19, we did not have the necessary or even a consistent supply of gloves, masks, face shields, bleach, alcohol, or essential testing materials. We were asked to re-use masks for up to a week at a time. Some facilities did not even provide the essential PPE, such as masks, to their employees. Instead, they were asked to purchase or make their own. Often, we were asked to not use as many supplies although it was indicated due to increased workload and for proper decontamination. This has improved greatly as many businesses have stepped up to make supplies they may have previously not provided. However, the vaccine seems to bring hope to those who were affected by these provisions for so long.  

Close patient interaction 

Those who have to go into isolation rooms and work directly with COVID patients are more likely to vaccinate (Kwok et al., 2020). It takes time to gown up and un-gown when going from room to room. Just the thought of having to go into an isolation room in general is anxiety inducing for many. The idea of having an extra barrier of protection offers some relief when working under these conditions for the past year. Alternately, studies have shown that healthcare workers not caring for COVID-19 patients are less likely to vaccinate (Dror et al., 2020). 

Attitudes toward recent control policies (Kwok et al., 2020) 

Once COVID-19 became a threat in the U.S., control policies were immediately implemented in our facilities; some changing by day as more information about the virus rolled out. Daily screenings seemed unorganized and quickly became a nuisance. The facility I currently work for was very late to implement temperature screenings as a requirement of entry. If an employee presented to work with one of the numerous possible symptoms, screening staff were unsure how to proceed. Each day, there were never-ending lines of workers waiting outside in poor conditions for assessment prior to clocking in. This process has recently improved as we are now having temperatures taken regularly and have the option of doing our daily health screening online prior to starting work.   

Some healthcare facilities do not have the space for people to properly socially distance when on break or lunch. While limiting capacity in the cafeteria and break rooms, we have been asked to find alternatives such as eating in our vehicles during the cold months. Then, there is the mask policy that we have all become familiar with. Having to wear a mask constantly is restricting and simply bothersome. I think it is safe to say, many of us are ready to have at least some sense of normalcy again. 

While a high percentage of healthcare workers remain skeptical, the vaccine may offer hope and could potentially relieve employees of some work-related stress. Hospital-wide compliance is not an achievable goal at this time with the available COVID-19 vaccines. Although it could be a possibility in our future, healthcare workers are currently not mandated to get the COVID-19 vaccine in the U.S. It is clear that immunization is important in the healthcare field. Nonetheless, greater efforts must be made toward providing relevant information and educating employees for better results.

BioNTech. (2020). Fact Sheet for Recipients and Caregivers: Emergency Use Authorization of the Pfizer-BioNTech COVID-19 vaccine to prevent COVID-19 in individuals 16 years of age and older [Brochure]. Mainz, Germany: Author. 

Centers for Disease Control and Prevention. Vaccine Information for Adults- Healthcare Workers. (2016). Retrieved January 20, 2021, from www.cdc.gov  

Dror, A. A., Eisenbach, N., Taiber, S., Morozov, N. G., Mizrachi, M., Zigron, A., Sela, E. (2020). Vaccine hesitancy: The next challenge in the fight against COVID19. European Journal of Epidemiology, 35, 775-779. doi:https://doi.org/10.1007/s10654-020-00671-y 

Field, R. I. (2009). Mandatory Vaccination of Healthcare Workers. Pharmacy and Therapeutics, 34(11), 615-616,618. PMID: 20140133. Retrieved January 20, 2021, from ncbi.nlm.nih.gov  

Jarrett, C., Wilson, R., O’Leary, M., Eckersberger, E., Larson, H.J., & the SAGE Working Group on Vaccine Hesitancy (2015). Strategies for addressing vaccine hesitancy – A systemic review. Vaccine, 33, 4180-4190.  http://dx.doi.org/10.1016/j.vaccine.2015.04.040  

Kwok, K. O., Li, K., WEI, W. I., Tang, A., Shan Wong, S. Y., & Lee, S. S. (2021). Influenza vaccine uptake, COVID-19 vaccination intention hesitancy among nurses: A survey. International Journal of Nursing Studies,114, 1-9. https://doi.org/10.1016/j.ijnurstu.2020.103854 

Malone, K., & Hinman, A. R. (n.d.). Vaccination Mandates: The Public Health Imperative and Individual Rights [Editorial]. Centers for Disease Control and Prevention. Retrieved January 20, 2021, from https://www.cdc.gov/vaccines/imz-managers/guides-pubs/downloads/vacc_mandates_chptr13.pdf 

Paterson, P., Meurice, F., Stanberry, L. R., Glismann, S., Rosenthal, S. L., & Larson, H. J. (2016). Vaccine hesitancy and healthcare providers. Vaccine, 34, 6700-6706. http://dx.doi.org/10.1016/j.vaccine.2016.10.042 

Youngdahl, K. (2013, October 1). Healthcare Worker Influenza Immunization: Mandates, Benefits, Consequences. Retrieved January 20, 2021, from www.historyorfvaccines.org 

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