Pioneer Network’s Council of Elders set out to explore two dilemmas that currently are affecting long-term care communities: vaccine hesitancy among staff members and indoor visitation. This article is an excerpt from the full paper, which shows how ethical principles can be used as a guide for discussion of complex dilemmas.

The focus of this excerpt is on motivating vaccination among staff members who are reluctant or fearful. The recent mandate by President Biden to make vaccinations or testing a requirement for all recipients of Medicare and Medicaid funding, as well as employers of 100 or more people, does not eliminate the ethical dilemmas and consequences around these decisions but magnifies the importance of proceeding with care and compassion.

Reasons for vaccine hesitancy among staff members are numerous and varied. Some long have been uncertain about vaccines and have not always vaccinated their children or themselves. Others verbalize fear of vaccination, fear of the unknown, religious concerns, childbearing considerations, worry about having to miss days at work and loss of income due to a vaccine reaction. Before the vaccine received full approval, some staff expressed questions about its emergency use authorization status. Still others express a lack of trust in government and their organization’s leaders, worry that the science has been hurried, concern about abuse by medical professionals of Blacks in the past, and anxiety about unanswered questions such as long-term side effects.

Many approaches to reducing hesitancy have surfaced across the country: educating, using peer pressure, listening to staff members and answering their questions, harnessing relationships in the community, offering monetary bonuses or special status for the vaccinated, and using other staff members or trusted elders as key influencers. The following two stories were chosen as examples of multi-layered responses offered by seasoned leaders.

A report in the New York Times described how Tina Sandri, CEO of Forest Hills of DC, which offers assisted living, memory care, skilled nursing and rehabilitation, faced a daunting dilemma when only half of her staff members agreed to receive the vaccine. The majority of her staff members were Black.

Ms. Sandri eschewed the authoritarian temptation of making vaccination mandatory for employees (with the alternative of employment termination) and equally resisted the enticing tactic of offering cash bonuses and other benefits as patronizing and not respectful of deep-rooted fears and beliefs. She decided to meet with each staff person, intending to “meet them where they were,” without judgment but with empathy.

For example, to the analytically inclined she showed the science, the empirical data. For those concerned with past medical abuses that afflicted Black communities, she played testimonials of prominent Black leaders and brought in members of the Black Coalition Against COVID-19. Relationship-oriented staff members were sensitively reminded of the vision of a return to family reunions for them personally as well as for their residents starving for human contact.

Over a several-week period, the vaccine percentage for staff rose to 79%, exceeding the long-term care industry’s #GetVaccinated campaign goal of 75% at that time.

An ethical tenet that is salient in this example is autonomy that is, that individuals have a right to self-determination, to make decisions about their lives without interference from others. An authoritarian style would have repressed individual choice. Although some would have gotten the vaccine in response to the threat of losing their jobs, there likely would have been turnover as others resigned, exacerbating the workforce shortage. 

During the first wave of the pandemic, an experienced director of nursing shared her concern with vaccine hesitancy among direct caregivers. She knew there had to be a way to get the COVID-19 vaccine rates close to 90%. The Eden Alternative-registered home where she worked had been reorganized into six neighborhoods where learning circles were held with staff members and elders who worked and lived in these neighborhoods.

Before the pandemic, those neighborhood learning circles had been where communication flowed and decisions happened. Resuming this practice — to give voice to everyone — seemed like the best approach to explore how vaccination was being perceived.

They talked about vaccines and all the fears and the successes. Staff members trusted the information they gleaned from the elders because relationships had developed in many cases over the years. Hearing the elders’ positive experiences with vaccination gave them reassurance that taking the vaccine would be OK.

The staff slowly started taking the vaccine over the next month, and the overall staff vaccination rate improved exponentially, with an additional 30% getting vaccinated. Returning to person-directed practices with wise leadership resulted in significant improvement in vaccination rates.

Preserving choice while holding to the ethical standard of non-abandonment allowed the leadership team to show how committed the organization was to staff. In the learning circles, the elders were able to share their own experiences and reactions to taking the vaccine. They were able to express how important it was to them that staff members would be able to protect their own health and safety by accepting vaccination. It also was clear that the elders were relying on the staff’s beneficence to avoid the potential harm of receiving direct care from someone not vaccinated, and also to avoid illness that could come from working alongside others who were not vaccinated.

A call to action

Our call to action is for senior living and nursing home providers, partners and stakeholders to employ ethical principles in decision-making, especially during the challenges involved in responding to the vaccine mandate. Those approaches reduce friction while providing for respectful disagreement and thoughtful deliberation. Using ethics as a foundation produces powerful outcomes for elders, staff members and providers.

The voice of the elder matters, as does input from those who provide direct care along with those who manage the provision of care. With juxtaposed points of view, no matter how polarized, ethical principles help us find our bearings. Ethics committees in long-term care settings have been shown to be productive and safe places to air differences and work through dilemmas in fresh ways. Those settings have many complex issues that can benefit from ethics committees, beyond the pandemic.

The full version of this paper offers a list of ethical principles, links to relevant sources, additional stories, as well as a detailed discussion of ethical issues related to indoor visitation. Click here to read it.