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The Exit of the CNA: Mandate or Me—What Now?

With the introduction of the vaccine mandate for nursing home employees, many organizational leaders fear staff, especially certified nursing assistants (CNAs), will quit rather than get the vaccine. This week, several industry experts have voiced concerns about the potential for a mass exit of CNAs, questioning how facilities can continue to provide care without frontline staff. In some areas, nursing home staff are lining the streets with signs reading “my body, my choice” or similar statements. Nurse leaders have two options: they can approach the circumstances with a doom-and-gloom mentality that dwells on what-ifs, or they can spend their time and energy creating plans to address the situation. To achieve the best outcomes for the facility and its residents, leaders should formulate one plan to mitigate departures and a second to address a potential staffing crisis.

Start with strategies to reduce turnover. In addition to being valued team members who deserve recognition for their contributions, every staff member retained is one fewer vacancy. In a supportive, person-centered environment, nurse leaders may be able to prevent the feared staffing crisis from developing—or at least reduce its impact.

Vaccines are safe; COVID is not

Many staff who are upset about the vaccine mandate express concerns about what the vaccine will do to them. They report that they are reluctant because they don’t know what’s in the vaccines or don’t know the long-term effects. Listen to each person’s specific concerns and have resources available to provide information that responds to their fears. This article, How to Talk to Someone Who is Misinformed about Coronavirus provides tips on how to approach the conversation. Be prepared to address misinformation with facts. The Centers for Disease Control and Prevention (CDC) has shared extensive resources to address concerns, including a video that discusses vaccine safety. The CDC also has a COVID-19 Vaccination Communication Toolkit that can be used to promote vaccine confidence in staff. Don’t belittle staff concerns; instead, focus on fact-based education and allow for questions. Address the fact that the vaccine isn’t intended to completely eliminate all risk of contracting COVID-19, but it does reduce the risk of severe illness, hospitalizations, and death. Be empathetic and non-judgmental while being supportive.

Recap how vaccines helped

Provide reluctant staff with information on what the vaccine has done. Use specifics from your facility when possible. For example:

  • After vaccinations of staff and residents, we saw a sharp decline in the number of COVID-positive cases in the facility.
  • In April 2020, we had 28 residents test positive for COVID. Six residents became seriously ill and were transferred to the ICU. Two died after being on a ventilator. Contact tracing revealed that COVID entered the facility through a staff member. Cases of COVID continued to rise in staff and residents through November 2020.
  • In late December, staff and residents were vaccinated. By April 2021, there were no cases of COVID in the facility.
  • In July 2021, with the emergence of the Delta variant, an unvaccinated staff member tested positive for COVID, and by August, three residents had tested positive, but no one was hospitalized or died.

Find champions

Each facility has individuals who have received the vaccination and feel a sense of relief. Encourage these staff members to share why they got the vaccine and allow them to describe their experience to reluctant staff. If possible, help these staff to film a short video on their phone that can humanize the prospect of being vaccinated. Use social media to share stories from staff and residents about why they got vaccinated and what their vaccine status has meant to them. Particularly in areas where vaccination rates are low, introducing a person who has been vaccinated can help to normalize the vaccine.

Focus on we, not me

Many staff who are hesitant to receive the vaccine report that they are troubled that they are being mandated to put something in their bodies that they don’t want in there. It is easy to share stories about other life choices that put things in our body we don’t want, but that doesn’t necessarily address the core issue. Instead, shift the focus on how the vaccine will improve the safety of the working and living environment for all in the facility. Higher levels of staff vaccination are linked to fewer outbreaks in facilities. For staff members, this reduces the risks of bringing COVID-19 home to their families or bringing it back to the facility. This is particularly important for the residents of nursing homes, who tend to be at higher risk of infection, hospitalization, or death. Working with the elderly is a privilege, and it is our duty to do what is necessary to keep them and co-workers safe. Share stories about how the residents feel about a fully vaccinated workforce. For example, one resident shared that having a fully vaccinated staff means less fear of contracting COVID and getting sick.

The pros of a fully vaccinated workforce

Spend time talking about the benefits of having a fully vaccinated workforce. Where previously, the vaccination status of co-workers was unknown, in a fully vaccinated environment, staff can have confidence that they are unlikely to contract a severe case of COVID-19. The mandate also has the potential to make the facility a more appealing workplace to those who are reluctant to work in an unvaccinated environment. Think about what changes could be made within the facility if all staff were vaccinated, and allow staff to share what that might mean to them. Measures like no-visitor policies and extensive personal protective equipment were difficult for staff and residents alike in 2020; among the positives of being a fully vaccinated workplace is avoiding the necessity of their reintroduction.

Worst case, prepare for crisis staffing

Positive COVID cases left many facilities with staffing challenges that required a crisis plan. Use that plan to prepare for staff who decide, despite all outreach efforts, to leave. Have a resource pool of as-needed staff ready to pick up shifts, and contact staffing agencies for support as a contingency plan.

Several organizations who instituted their own vaccine mandates prior to the Biden administration’s announcement report minimal vaccine-related turnover after they educated staff and provided individual and group support sessions. They reported that, when they were transparent in sharing the justification for the vaccine mandate, people responded positively.

Remember, staff will be looking at the reaction of facility leaders. Despite the introduction of a vaccine mandate, taking the time to persuade vaccine-hesitant staff and address their concerns will help to demonstrate that the facility values the employees’ perspectives. Provide clear communication about the mandate and keep staff updated as more information about the mandate emerges. Celebrate and support those staff who have made the decision to get vaccinated. By focusing on the benefits of a fully vaccinated workforce and reinforcing the behavior desired, leaders can help create a nursing home environment that is safer for both staff and residents.

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