Beyond Mandates

Meet Maria, an experienced nurse and union leader. Her journey through the COVID-19 pandemic has given her a firsthand account of its toll on healthcare workers. As healthcare administrators across her state, including at Maria’s own hospital, began to talk of issuing mandates for employees to get vaccinated or face job loss in 2021, Maria found herself at the forefront of opposition. Her stance was not against vaccination. She believes vaccination is the most effective protection against COVID-19 and that everyone who can safely do so should be vaccinated. For this reason, she and her fellow union leaders have actively encouraged their members to get vaccinated. But she knew a hospital mandate that would strip healthcare workers of their voice and autonomy was not the answer.

Criticism of Maria emerged in social media and the press, suggesting that she was on the wrong side of the vaccine issue. However, those critics failed to understand the nuances of her stance. As a representative of all of her union members, including some who were hesitant about vaccination, Maria’s opposition to vaccine mandates was also a strategic move to protect against a sudden loss of valuable staff during an ongoing shortage crisis. She called for negotiation because she knew that the best pathway to effective safety measures was by fostering trust and consensus among workers, ensuring that any vaccine policies implemented at the hospital resonated with the needs and concerns of all her members.

Maria’s goal was to find and implement policies that would encourage maximum voluntary vaccine uptake to keep her members—and their patients and communities—safe. And in Maria’s world, that journey was about balancing the urgent need for protection against COVID-19 with the delicacy of workplace dynamics and individual choices.

Exploring Vaccination Mandates: Ethics, Legality, and Effectiveness

In July 2021, Dr. Zeke Emanuel, a physician and vice provost for global initiatives at the University of Pennsylvania, and Dr. David Skorton, president of the Association of American Medical Colleges, organized a statement signed by over 80 medical societies and organizations.¹ The statement called for mandatory vaccination for all healthcare workers, citing multiple reasons healthcare employers should mandate vaccination. Here, we share and expand on their rationales before turning to the more complex question of how to increase vaccination acceptance.

First, vaccination mandates are ethical. Healthcare professionals have a duty to protect others, especially when vaccination, a low-risk method to do so, is available. Beyond this general duty, they also have a unique ethical and professional responsibility to promote the health of patients and communities. Vaccination aligns with this duty and protects vulnerable individuals they encounter daily. Also, the COVID-19 vaccination requirement builds on established practices, as many healthcare facilities already mandate vaccinations against diseases such as hepatitis B.

Second, vaccination mandates are legal. The US Supreme Court has upheld the states’ authority to enforce vaccine mandates twice: in 1905 for adult smallpox vaccinations and in 1922 for school-based vaccinations. Additionally, a 1944 US Supreme Court ruling emphasized that parents don’t have the right to expose their children to contagious diseases.² And, according to the US Equal Employment Opportunity Commission, employers are legally authorized to mandate vaccines.³

Third, mandates are effective in increasing vaccination rates. The influenza vaccination coverage is consistently at its highest (94 percent) among health workers where vaccination is mandatory (with limited exceptions, such as an allergy, medications, or medical conditions that make vaccination risky).⁴ Similarly, studies show the effectiveness of COVID-19 vaccine mandates. One study across 13 states found that mandates for K–12 schools, congregate settings, and long-term care facility workers resulted in more than 634,000 first-dose vaccinations over two months, totaling 11.5 percent of first-dose vaccinations.⁵ Another study in 38 states showed that COVID-19 vaccine mandates in nursing homes increased staff vaccination rates by an average of 6.9 percentage points, with a 14.3 percent increase in Republican-leaning counties.⁶

As the pandemic’s acute phase subsides, the future of vaccination requirements remains uncertain despite the ongoing evolution of the COVID-19 virus. In May 2023, the US government officially lifted federal COVID-19 vaccination requirements. Soon after, the Biden administration ended the COVID-19 public health emergency declaration.⁷ However, these decisions were influenced more by social and political considerations than scientific reasoning. With the gradual rescinding of vaccine mandates at the federal and state levels, healthcare institutions face an important policy question: Is there still an ethical and scientific rationale for maintaining some form of COVID-19 vaccination requirements, or should they be abandoned entirely?

The Case for Continued COVID-19 Vaccination Requirements

As we move from the debate about whether vaccination mandates should be implemented to the more nuanced discussion of how they should be implemented, it is essential to note the significance of such measures. Encouraging both healthcare workers and the public to receive, and continue receiving, the latest COVID-19 vaccine is crucial for several reasons. Despite the official announcement of the pandemic’s end in May 2023, there has been a significant increase in severe cases and hospitalizations. Between July 1 and December 30, 2023, hospitalization rates surged by 8.5 percent nationwide, along with a rise in COVID-related deaths from 542 to 2,189 per week.⁸ Holiday gatherings fueled this surge, with wastewater data (an admittedly rough estimate) indicating that the United States was in its second-largest wave of COVID infections in early January 2024.⁹ Amid nurse shortages, hospital administrators worry about healthcare workers contracting COVID-19. This concern arises from the fact that the majority of patients age 65 and older recently hospitalized for COVID-19 received the primary vaccine series but not the bivalent booster.¹⁰ In addition, according to data from the Centers for Disease Control and Prevention (CDC), while almost all healthcare workers received the primary vaccine series, only 17 percent of those working in acute care hospitals were up-to-date with the COVID-19 booster vaccine in June 2023.¹¹

Study after study shows the benefits of COVID vaccination. Research suggests that during the first two years of their rollout, COVID-19 vaccines in the United States saved more than 3 million lives and prevented over 18 million hospitalizations. On the other hand, vaccine hesitancy led to the loss of about 234,000 lives between June 2021 (when vaccines became widely available) and March 2022.¹² The vaccine has been shown to be highly effective and safe, with nearly 700 million doses administered to over 80 percent of the population.¹³ It significantly reduces the risk of long COVID and helps with recovery from its symptoms. One study indicated that the vaccine’s effectiveness against long COVID increases from 21 percent after one dose to 73 percent after three or more doses.¹⁴ Additionally, COVID-19 vaccination effectively lowers the risk of heart attacks and strokes that are associated with COVID-19 infection,¹⁵ providing a compelling case for widespread immunization.

Although vaccination is undoubtedly beneficial, polls indicate that only half of US adults planned to receive the latest COVID-19 vaccine (recommended by the CDC in September 2023).¹⁶ Recent polls show that political affiliation significantly influences people’s willingness to vaccinate. The majority of Democratic voters, 79 percent, said they were likely or certain to get immunized with the new vaccine. In contrast, only 39 percent of Republican voters planned to receive the vaccine,¹⁷ which aligns with the anti–public health measures stance of some high-profile Republicans. For example, Governor Ron DeSantis’s administration publicly discourages Florida residents from receiving the latest booster.¹⁸

The Role of Vaccine Hesitancy in the Mandate Discourse

Division over the benefits of repeated vaccination extends to healthcare workers—and their vaccine hesitancy can impact patients’ willingness to get immunized. To understand the factors influencing vaccine hesitancy among healthcare workers, we worked with a team of researchers to conduct several large studies of healthcare workers in Southern California.¹⁹ Our goal was to uncover the varied reasons for vaccine hesitancy, paving the way for targeted interventions and impactful education campaigns. It is essential to address vaccine hesitancy among healthcare workers, given the high level of trust²⁰ the public has in them to provide accurate information about vaccination benefits and risks.

One of our main findings was that placing healthcare workers into dichotomous groups such as anti-vaccine vs. pro-vaccine is inadequate in accurately tailoring vaccine uptake interventions.²¹ Healthcare workers choose not to get vaccinated for various reasons, such as personal beliefs, cultural influences, misconceptions about vaccine safety, and variations in perceived personal risk. Therefore, the decision-making process involved in vaccine uptake is much more nuanced than a simple binary view suggests. This finding aligns with broader research on vaccine hesitancy. Numerous studies²² have attempted to define the concept of vaccine hesitancy, but existing definitions often hint at different ideas. Some describe vaccine hesitancy as a cognitive state, emotion, attitude, or belief. Others focus on vaccination behavior, involving acceptance, refusal, or delay of immunizations. Additionally, certain definitions describe vaccine hesitancy as a decision-making process. The range of available definitions reflects diverse attitudes among healthcare workers. This diversity highlights the importance of conducting research to understand factors driving vaccine hesitancy within an organization before implementing interventions to enhance vaccine uptake.

Our studies of vaccine hesitancy highlight its dynamic nature, which is influenced by context and evolves over time. Factors like emerging virus variants, political polarization, and local outbreaks shape hesitancy, with public perceptions changing as situations unfold. For example, during the early stages of our research,²³ we found that some nurses hesitated to get vaccinated due to concerns about the COVID-19 vaccine’s potential impact on fertility and pregnancy. Some nursing groups on social media (which were initially created to support burned out staff) unintentionally spread misinformation and amplified vaccine hesitancy among nurses.²⁴ However, with increasing evidence of vaccine safety and the implementation of interventions that target group-level resistance, nurses’ attitudes toward vaccines have improved significantly, resulting in higher vaccination rates. Similarly, vaccine hesitancy among healthcare workers of color, which seemed like it could be related to a lack of trust in vaccines, was often, in fact, due to access issues to vaccines or reliable information.²⁵ For instance, finding reliable information about vaccines in Spanish was challenging at the pandemic’s beginning. Additionally, Latinx healthcare workers, who disproportionately work in lower-paying roles with fewer protections, such as paid sick leave,²⁶ faced difficulties in taking time off work for vaccination or dealing with any side effects. Moreover, the process of signing up for vaccines, which relied on emails, unique identifiers, and web access, presented obstacles for nonclinical frontline staff.

Beyond Mandates: Tailoring Vaccination Campaigns for Vaccine-Hesitant Groups

With the prospect of a vaccine mandate looming at Maria’s hospital, she reviewed the research on effective ways to increase voluntary vaccine uptake among healthcare workers. There were promising employer interventions to make voluntary vaccination easier—including offering paid time off and childcare support and providing convenient vaccination stations. But Maria was also intrigued by the research on communication campaigns, which can increase awareness of the importance of vaccination while addressing misinformation for those who are hesitant or undecided about vaccination. Maria learned that successful vaccination campaigns rely on tailored messages. However, instead of tailoring messages by demographic characteristics (e.g., age), campaigns need to address specific beliefs prevailing in various groups of hesitant healthcare workers.

In our research, we identified four groups with varying levels of uncertainty regarding the COVID-19 vaccine.²⁷ The smallest and most hesitant group, which we labeled misinformed, staunchly opposed vaccination. This group was slightly older, leaned Republican, and was influenced by vaccine-related myths, questioning the reality of the COVID-19 pandemic and doubting vaccine effectiveness. They significantly underestimated the risks of the virus and mortality, influenced by politically biased news media. Establishing trust in this group may require approaches using direct peer communication. For instance, the “Nurses Who Vaccinate” campaign effectively used healthcare workers as “vaccine ambassadors” to dispel misinformation.*²⁸

Group 2, which we labeled uninformed, had lower levels of education and a higher proportion of Latinx members who worked in allied health roles. Unlike the misinformed, they were less influenced by misinformation but faced difficulty accessing reliable vaccine information. They were twice as likely to use messaging apps like WhatsApp and Telegram, often relying on them as a source of COVID-19 information.²⁹ The Latinx community was disproportionately affected by COVID-19 due to their overrepresentation in frontline jobs. Effective communication strategies are needed to take this reality into account. The involvement of trained community healthcare workers, called promotores, may significantly improve vaccine attitudes within this group. In one study, promotores successfully used social media to spread culturally relevant, accurate vaccine information.³⁰ Effective messaging for this group aligns with their cultural values, such as emphasizing the limits of natural immunity, connecting vaccination to family responsibility, and presenting vaccination as a tool to push through difficult times.³¹

Group 3, which we labeled undecided, was the closest on the hesitancy scale to accepting the COVID-19 vaccine. The group was primarily composed of white nurses and respiratory therapists working in ICUs. They recognized the personal risk of virus exposure and the severity of COVID-19. It’s worth noting that members of this group were mostly Republicans, which implies that their reluctance to vaccinate could be linked to their political identity. Several communication strategies can be implemented to encourage vaccination in this group. For example, highlighting the nonpartisan nature of vaccination decisions and emphasizing endorsements of the COVID-19 vaccine by political figures can have a positive impact.³² Additionally, wearable tokens like badge stickers and pins can be employed to increase the visibility of vaccination status.³³ Highlighting shared values and framing vaccination as a means to protect families or fight poverty by enabling people to return to work can also be effective.³⁴

Finally, Group 4, which we labeled unconcerned, comprised healthcare workers who were willing to recommend vaccination to others but hadn’t themselves been vaccinated yet. Members of this group were younger, educated, racially diverse, and primarily Democrats. While they had accurate knowledge about the vaccine’s effectiveness, they tended to underestimate the personal risks associated with COVID-19, causing them to postpone vaccination. Nudging techniques can encourage members of this group to get vaccinated. Techniques such as asking them to write down the date and time of their scheduled vaccination or emailing a pre-booked vaccination appointment that can be modified if needed are effective.³⁵ Email or text reminders that give them a sense of ownership over the vaccination decision, such as “claim your dose,” are also effective.³⁶ Furthermore, providing incentives, like bonuses, pay raises, tuition reimbursements, student loan forgiveness, or lottery prizes, may be particularly effective in motivating this group to get vaccinated.³⁷

The fact that at this point in the pandemic, many healthcare workers haven’t kept up with subsequent COVID-19 shots following the first series suggests that they are not influenced by hesitancy; instead, a sense of exhaustion may influence their decision about getting further immunizations.³⁸ This vaccination fatigue is marked by burnout, decreased motivation and enthusiasm for ongoing vaccination efforts, and a sense of futility about vaccination campaigns.

Several factors may contribute to vaccination fatigue. Witnessing the steady toll of the pandemic on patients can lead to emotional fatigue and doubts about the effectiveness of vaccination efforts. Increased workloads and dealing with COVID-19 cases alongside routine responsibilities can also decrease enthusiasm for vaccination efforts. The continuous influx of information and evolving guidelines about COVID-19 may overwhelm healthcare workers, further contributing to fatigue. To address vaccination fatigue, healthcare institutions need to reduce administrative burdens and logistical challenges associated with vaccination. This can be achieved by offering time off after receiving boosters, for example. Additionally, strategies designed to address staff burnout—such as meditation, mindfulness-based programs, and improved communication and teamwork³⁹—may also prove effective in combating vaccine fatigue.⁴⁰

Harnessing Behavioral Economics Strategies

In addition to tailoring vaccine messages for different groups of hesitant healthcare workers, health administrators—and union leaders—can explore strategies based on behavioral economics principles known as nudges. Nudges offer alternatives to mandatory vaccinations by subtly influencing people’s behavior without restricting options or significantly changing incentives. Nudges change behavior using choice architecture—that is, by organizing the context in which people make decisions. The idea behind choice architecture is that people often make less-than-ideal decisions not because they lack information but because they are affected by predictable irrational biases and cognitive errors. Examining how these biases affect people’s decisions about vaccination can help us develop nudges to enhance vaccine acceptance among healthcare professionals.⁴¹

• Omission bias: People may prefer doing nothing (omission), even if it poses a greater risk than taking a potentially less harmful action. In various studies, when weighing the benefits and risks of vaccination, people tended to accept a higher risk of catching a disease rather than experiencing vaccine side effects.⁴² Interestingly, they were more willing to endure prolonged symptoms if caused by an infection than if they occurred due to a reaction to a vaccine.⁴³
• Ambiguity aversion: Individuals may prefer a known risk (avoiding treatment) over an unknown risk (a confusing treatment). This bias influences vaccination decisions when safety information appears unclear or constantly changes.⁴⁴
• Present bias: People may prioritize immediate benefits and ignore future ones. For instance, someone might hit the snooze button instead of going for a morning jog or indulge in a dessert instead of working toward their long-term goal of losing weight. Similarly, healthcare workers may avoid getting vaccinated due to the inconvenience of scheduling or fear of side effects despite its long-term protection from COVID-19.⁴⁵
• Availability heuristic: Factors that are easier to recall or imagine may play a disproportionate role in decision-making. For example, vaccine side effects may appear more likely or frequent than they actually are if they are more memorable. Anti-vaccination activists and media coverage of rare adverse reactions can create vivid messages that stay with people during the vaccination decision-making process, influencing their choices.⁴⁶
• Optimism bias: People may believe that health risks are higher for others than for themselves. Studies have shown that regardless of their knowledge of risk factors, people estimated their susceptibility to various diseases as much lower than that of other people of the same race, gender, or age. This bias may lead individuals to underestimate their susceptibility to infections like COVID-19, driving their decision against vaccination.⁴⁷
• Naturalness bias: Individuals may prefer natural products or substances, even when they are identical to or worse than synthetic alternatives. This bias can explain why some people prefer natural immunity over vaccine-induced immunity.⁴⁸
• Confirmation bias: People may favor information that aligns with their existing beliefs and avoid information that contradicts them. Vaccine-hesitant healthcare workers may seek out information supporting their concerns from anti-vaccine websites or social media groups while avoiding evidence in favor of vaccination from mainstream media or scientific reports.⁴⁹

Research on healthcare workers’ vaccination decisions not only uncovers various cognitive biases but also suggests practical strategies to influence behavior. One successful method is to schedule all hospital staff for the COVID-19 vaccine by default. Healthcare workers can opt out, but they have to fill out a form explaining why they won’t get vaccinated. This nudges higher vaccine uptake by making it the default choice, with a small burden for those opting out. A similar approach has also worked in schools, where requiring detailed processes for exemptions has led to significantly higher vaccination rates.⁵⁰ Healthcare institutions often use this type of nudge by requiring nonvaccinated employees to wear masks indoors and undergo regular testing. Many would prefer returning to normal by getting the vaccine and not standing out among their peers.

To improve the vaccination rates in healthcare settings, it is essential to include nudges in communication strategies. One effective way to do this is to have trusted figures within the organization deliver the vaccination messages (in some hospitals, that may be the union president, and in others it may be a widely respected nurse or doctor). Studies have also shown that anticipated regret can strongly motivate healthy behavior. Vaccination rates can be improved by reminding employees that vaccination can prevent specific regrets, such as the fear of a loved one getting sick.⁵¹ Another study indicates that sending two text messages three days apart may be effective if they instill a sense of ownership (e.g., there’s a vaccine “waiting for you”).⁵²

States, local governments, and large companies have rolled out various incentives to increase COVID-19 vaccination rates. For example, New York and Ohio established lotteries with millions of dollars in prizes for vaccinated individuals.⁵³ Hospitals and companies like Instacart and Kroger provided cash rewards to vaccinated employees ranging from $25 to $500.⁵⁴ In addition, many employers offered paid time off for vaccination and recovery, with support from the federal government. Some even subsidized transportation through ride-sharing or car services to facilitate access to vaccination clinics. While incentives are typically effective in promoting healthy behaviors, their effectiveness in increasing COVID-19 vaccination rates remains uncertain.⁵⁵ Despite concerns that financial incentives might reduce trust in vaccine safety or altruism in vaccination decisions, studies have not supported these assumptions.⁵⁶ And many incentive programs to promote COVID-19 vaccination have seen limited success.⁵⁷ There could be several reasons why such incentives are less effective in increasing COVID-19 vaccination rates. Incentives usually work better for one-time behaviors, such as cancer screening, and are more effective for the first vaccine dose than the second.⁵⁸ Targeting incentives toward late adopters of vaccination may also be perceived as unfair to those already vaccinated.⁵⁹ Additionally, given the political divisions in vaccine uptake, incentives offered by local governments may encounter resistance in certain groups.⁶⁰

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Armed with the research and behavioral insights above, Maria collaborated with other union leaders on a vaccine campaign tailored to the unique needs and motivations of their members. Rather than relying on generic assumptions about vaccine hesitancy, they first created a survey to better understand why those who were under- or unvaccinated had not gotten the recommended vaccines. Survey responses uncovered vaccine myths and misinformation circulating the hospital, along with information gaps and barriers that Maria and her colleagues had not considered before.

The responses also helped the team pinpoint specific groups that shared similar beliefs about vaccination. They decided to focus first on groups that expressed hesitancy rather than those firmly opposed to vaccination. With these groups in mind, they dedicated time at shift meetings, hosted educational sessions, and engaged in direct peer-to-peer conversations to share information about the vaccine and address concerns, highlighting the numerous benefits and the importance of protecting others. They leveraged the voices of trusted individuals from vaccine-hesitant groups to appeal to shared values with messages reflecting unity and collaboration—and used collective terms urging “us” to act for the common good to reinforce each group’s collective identity. Recognizing that vaccine misinformation often relies on single cases that evoke strong emotions, they included positive cases alongside statistics about vaccine benefits and shared stories of employees reconnecting with older relatives or families going on vacations after being vaccinated. And they negotiated with hospital management specific interventions to make vaccination more convenient and accessible for everyone, including signing everyone up for vaccination during their work hours (with a moderately cumbersome form for declining the appointment) and paid time off as needed for side effects. 

Maria’s vaccination campaign also addressed cognitive biases that prevent people from getting vaccinated by incorporating several nudges. She and her team wore and distributed colorful “I Got Vaccinated!” badge stickers to normalize vaccination and alleviate fears among those concerned about potential side effects. They sent text reminders that “A vaccine is waiting for you!” to instill a sense of ownership and responsibility.

These strategies enhanced the effectiveness of Maria’s vaccination campaign, helping improve the health and safety of members and their families, and of the patients and communities they serve together.

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Alex (Oleksandr) Dubov, PhD, MDiv, is an associate professor of behavioral health and bioethics at Loma Linda University. He has worked at Emory University Hospital as a palliative care counselor and at Florida Hospital Celebration Health (now AdventHealth Celebration) as a certified healthcare ethics consultant. Lisa R. Roberts, DrPH, MSN, RN, FNP-BC, CHES, FAANP, FAAN, is a professor and director of research at Loma Linda University’s School of Nursing. Her research focuses on nursing interventions and public health programs to address the needs of vulnerable populations.

*For a model of direct peer conversations that can help dispel vaccine misinformation, see “Become a Vaccine Champion” in the Spring 2022 issue of AFT Health Care. (return to article)

Endnotes

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[Illustrations by Kotryna Zukauskaite]