Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes

Are COVID-19 vaccination mandates for healthcare workers effective? A systematic review of the impact of mandates on increasing vaccination, alleviating staff shortages and decreasing staff illness

INTRODUCTION

The rapid development of COVID-19 vaccines is a cornerstone in the global effort to combat the pandemic. Healthcare workers (HCWs), being at the forefront of the pandemic response, have been the focus of vaccine mandate policies. This review aims to evaluate the impacts of COVID-19 vaccine mandates among HCWs, a critical step in understanding the broader implications of such policies in healthcare settings.

OBJECTIVE

The review seeks to synthesize available literature to contribute to greater understanding of the outcomes associated with COVID-19 vaccine mandates for HCWs including vaccine uptake, infection rates, and staffing.

METHODS

A systematic search of relevant literature published from March 2020 to September 2023 was conducted. The Newcastle-Ottawa scale was employed for quality assessment of the included articles. A total of 4,779 publications were identified, with 15 studies meeting the inclusion criteria for the review. A narrative synthesis approach was used to analyze these studies.

RESULTS

COVID-19 vaccine mandates for HCWs were broadly successful in increasing vaccine uptake in most settings. Although the penalties imposed on unvaccinated HCWs did not lead to major disruption of health services, less well-resourced areas may have been more impacted. Furthermore, there is insufficient literature on the impact of the vaccine mandate on reducing SARS-CoV-2 infection among HCWs.

CONCLUSION

COVID-19 vaccine mandates for HCWs have significant implications for public health policy and healthcare management. The findings underscore the need for tailored approaches in mandate policies, considering the specific contexts of healthcare settings and the diverse populations of HCWs. While mandates have shown potential in increasing vaccine uptake with minimal impacts to staffing, more work is needed to investigate the impacts of mandates across various contexts. In addition to these impacts, future research should focus on long-term effects and implications on broader public health strategies.

Staying silent during a crisis: How workplace factors influence safety decisions in U.S. nurses

RATIONALE

It is critical for healthcare organizations to promote upward communication of safety information to ensure safety issues experienced on the work floor are promptly identified and addressed, especially during crisis events.

OBJECTIVE

This study investigates mechanisms through which workplace factors affect nurses' motivation to speak up about safety issues, and ultimately their safety behaviors, in a pandemic work environment.

METHOD

The work experiences of 152 frontline U.S. nurses were captured across three time-points during the height of a global pandemic.

RESULTS

Findings indicate that nurses who experienced a greater frequency of pandemic-related demands and/or perceived a greater social risk associated with voicing concerns were more likely to remain silent about safety issues due to job-related constraints or a fear of negatively impacting their reputation, respectively. As a consequence, nurses were more likely to bypass safety protocols while completing work tasks, especially those who had a lower risk propensity.

CONCLUSION

These findings advance the literature on workplace safety by investigating factors that affect employee communication and ultimately safety workarounds in nurses within the context of a global pandemic.

COVID-19 Vaccination Among Skilled Nursing Facility Staff: Challenges and Strategies Identified by Administrators

COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding which strategies are successful for promoting staff vaccination, and examining the relationship between vaccination policies and staff retention/turnover is key for identifying best practices. We conducted repeated interviews with SNF administrators at 3-month intervals between July 2020 and December 2021 (n = 156 interviews). We found that COVID-19 vaccines were initially met with both enthusiasm and skepticism by SNF staff. Administrators reported strategies to increase staff vaccine acceptance, including incentives, one-on-one education, and less stringent personal protective equipment requirements. Federal and state vaccination mandates further promoted vaccine uptake. This combination of mandates with prioritization of the vaccine by SNFs and their leadership was successful at increasing staff vaccination acceptance, which may be critical to increase staff booster uptake from its current suboptimal levels.

Assessing the impact of COVID-19 passes and mandates on disease transmission, vaccination intention, and uptake: a scoping review

PURPOSE

Policymakers have struggled to maintain SARS-CoV-2 transmission at levels that are manageable to contain the COVID-19 disease burden while enabling a maximum of societal and economic activities. One of the tools that have been used to facilitate this is the so-called "COVID-19 pass". We aimed to document current evidence on the effectiveness of COVID-19 passes, distinguishing their indirect effects by improving vaccination intention and uptake from their direct effects on COVID-19 transmission measured by the incidence of cases, hospitalizations, and deaths.

METHODS

We performed a scoping review on the scientific literature of the proposed topic covering the period January 2021 to September 2022, in accordance with the PRISMA-ScR guidelines for scoping reviews.

RESULTS

Out of a yield of 4,693 publications, 45 studies from multiple countries were retained for full-text review. The results suggest that implementing COVID-19 passes tends to reduce the incidence of cases, hospitalizations, and deaths due to COVID-19. The use of COVID-19 passes was also shown to improve overall vaccination uptake and intention, but not in people who hold strong anti-COVID-19 vaccine beliefs.

CONCLUSION

The evidence from the literature we reviewed tends to indicate positive direct and indirect effects from the use of COVID-19 passes. A major limitation to establishing this firmly is the entanglement of individual effects of multiple measures being implemented simultaneously.

Coronavirus disease 2019 (COVID-19) vaccination rates and staffing shortages among healthcare personnel in nursing homes before, during, and after implementation of mandates for COVID-19 vaccination among 15 US jurisdictions, National Healthcare Safety Network, June 2021-January 2022

OBJECTIVE

To examine temporal changes in coverage with a complete primary series of coronavirus disease 2019 (COVID-19) vaccination and staffing shortages among healthcare personnel (HCP) working in nursing homes in the United States before, during, and after the implementation of jurisdiction-based COVID-19 vaccination mandates for HCP.

SAMPLE AND SETTING

HCP in nursing homes from 15 US jurisdictions.

DESIGN

We analyzed weekly COVID-19 vaccination data reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network from June 7, 2021, through January 2, 2022. We assessed 3 periods (preintervention, intervention, and postintervention) based on the announcement of vaccination mandates for HCP in 15 jurisdictions. We used interrupted time-series models to estimate the weekly percentage change in vaccination with complete primary series and the odds of reporting a staffing shortage for each period.

RESULTS

Complete primary series vaccination among HCP increased from 66.7% at baseline to 94.3% at the end of the study period and increased at the fastest rate during the intervention period for 12 of 15 jurisdictions. The odds of reporting a staffing shortage were lowest after the intervention.

CONCLUSIONS

These findings demonstrate that COVID-19 vaccination mandates may be an effective strategy for improving HCP vaccination coverage in nursing homes without exacerbating staffing shortages. These data suggest that mandates can be considered to improve COVID-19 coverage among HCP in nursing homes to protect both HCP and vulnerable nursing home residents.

Longitudinal Associations of Staff Shortages and Staff Levels with Health Outcomes in Nursing Homes

OBJECTIVES

To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

A total of 8466 NHs with staffing and outcome data.

METHODS

This study used NH COVID-19 Public File (2020), Nursing Home Compare (2019-2020), and Payroll-Based Journal data (2019-2020). Outcome measures included the percentage of long-stay residents in a facility with declines in activities in daily living (ADLs), decreases in mobility, weight loss, and pressure ulcers in 2020 Q2, 2020 Q3, and 2020 Q4. Independent variables were whether NHs reported any shortage of aides or licensed nurses and total staff hours per resident day (HPRD). Separate 2-level (NH, state) Hierarchical Generalized Linear Mixed models examined the association of facility-reported shortages and staff hours with key NH resident outcomes, controlling for NH characteristics and COVID-19 infections.

RESULTS

The weekly percentage of NHs reporting any staff shortage averaged 20%. Total staff HPRD increased slightly from 3.7 in 2019 to 3.8 in 2020. Health outcomes were stable during 2019 and 2020 Q1 but worsened substantially starting in 2020 Q2. For example, the percentage of residents with mobility loss increased from 16.2% in 2020 Q1 to 27.9% in 2020 Q4. Facility-reported staff shortages were associated with an increase in the proportion of residents with an ADL decline (0.54 percentage points), mobility loss (0.80 percentage points), weight loss (0.22 percentage points), and pressure ulcers (0.22 percentage points) (all P < .01). Total staff HPRD was not associated with changes in any outcomes (all P > .05).

CONCLUSIONS AND IMPLICATIONS

NHs reported worsened health outcomes among long-stay residents in 2020, with worse outcomes found among facilities that reported staff shortages but not among those with lower total staff levels. Facility-reported shortages provide important quality information during the COVID-19 pandemic.

Vaccination Mandates-An Old Public Health Tool Faces New Challenges

This Viewpoint discusses how federal vaccine requirements have helped thwart vaccine-preventable diseases as well as how growing public resistance to vaccines and judicial and legislative limits to vaccination mandates may change that.

The balance of prescriptive and dynamic regulatory policies in nursing homes: Lessons learned from the COVID-19 pandemic

See related Brief report by Festa et al. in this issue.

Effects Of An Employee COVID-19 Vaccination Mandate At A Long-Term Care Network

We assessed COVID-19 vaccination and employment status among employees of a long-term care network that announced an employee vaccination mandate on July 29, 2021. The day before the announcement, 1,208 employees were unvaccinated; of these workers, 56.2 percent subsequently were vaccinated, whereas 20.9 percent (3.7 percent of active employees) were terminated because of noncompliance with the mandate.

Healthcare professionals' attitudes to mandatory COVID-19 vaccination: Cross-sectional survey data from four European countries

Mandatory vaccinations are widely debated since they restrict individuals' autonomy in their health decisions. As healthcare professionals (HCPs) are a common target group of vaccine mandates, and also form a link between vaccination policies and the public, understanding their attitudes toward vaccine mandates is important. The present study investigated physicians' attitudes to COVID-19 vaccine mandates in four European countries: Finland, France, Germany, and Portugal. An electronic survey assessing attitudes to COVID-19 vaccine mandates and general vaccination attitudes (e.g. perceived vaccine safety, trust in health authorities, and openness to patients) was sent to physicians in the spring of 2022. A total of 2796 physicians responded. Across all countries, 78% of the physicians were in favor of COVID-19 vaccine mandates for HCPs, 49% favored COVID-19 vaccine mandates for the public, and 67% endorsed COVID-19 health passes. Notable differences were observed between countries, with attitudes to mandates found to be more positive in countries where the mandate, or similar mandates, were in effect. The associations between attitudes to mandates and general vaccination attitudes were mostly small to neglectable and differed between countries. Nevertheless, physicians with more positive mandate attitudes perceived vaccines as more beneficial (in Finland and France) and had greater trust in medical authorities (in France and Germany). The present study contributes to the body of research within social and behavioral sciences that support evidence-based vaccination policymaking.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making

INTRODUCTION

Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making.

METHODS

We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach.

RESULTS

Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate.

CONCLUSIONS

Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

Projected Health Outcomes Associated With 3 US Supreme Court Decisions in 2022 on COVID-19 Workplace Protections, Handgun-Carry Restrictions, and Abortion Rights

Importance

Several recent US Supreme Court rulings have drawn criticism from the medical community, but their health consequences have not been quantitatively evaluated.

Objective

To model health outcomes associated with 3 Supreme Court rulings in 2022 that invalidated workplace COVID-19 vaccine or mask-and-test requirements, voided state handgun-carry restrictions, and revoked the constitutional right to abortion.

Design, Setting, and Participants

This decision analytical modeling study estimated outcomes associated with 3 Supreme Court rulings in 2022: (1) National Federation of Independent Business v Department of Labor, Occupational Safety and Health Administration (OSHA), which invalidated COVID-19 workplace protections; (2) New York State Rifle and Pistol Association Inc v Bruen, Superintendent of New York State Police (Bruen), which voided state laws restricting handgun carry; and (3) Dobbs v Jackson Women's Health Organization (Dobbs), which revoked the constitutional right to abortion. Data analysis was performed from July 1, 2022, to April 7, 2023.

Main Outcomes and Measures

For the OSHA ruling, multiple data sources were used to calculate deaths attributable to COVID-19 among unvaccinated workers from January 4 to May 28, 2022, and the share of these deaths that would have been prevented by the voided protections. To model the Bruen decision, published estimates of the consequences of right-to-carry laws were applied to 2020 firearm-related deaths (and injuries) in 7 affected jurisdictions. For the Dobbs ruling, the model assessed unwanted pregnancy continuations, resulting from the change in distance to the closest abortion facility, and then excess deaths (and peripartum complications) from forcing these unwanted pregnancies to term.

Results

The decision model projected that the OSHA decision was associated with 1402 additional COVID-19 deaths (and 22 830 hospitalizations) in early 2022. In addition, the model projected that 152 additional firearm-related deaths (and 377 nonfatal injuries) annually will result from the Bruen decision. Finally, the model projected that 30 440 fewer abortions will occur annually due to current abortion bans stemming from Dobbs, with 76 612 fewer abortions if states at high risk for such bans also were to ban the procedure; these bans will be associated with an estimated 6 to 15 additional pregnancy-related deaths each year, respectively, and hundreds of additional cases of peripartum morbidity.

Conclusions and Relevance

These findings suggest that outcomes from 3 Supreme Court decisions in 2022 could lead to substantial harms to public health, including nearly 3000 excess deaths (and possibly many more) over a decade.

Quasi-Experimental Design for Health Policy Research: A Methodology Overview

SUMMARY

Health policy impacts all aspects of the authors' field. Research on this topic informs future policy direction and serves as an impactful means to advocate for their patients. The present work aims to promote policy research in plastic surgery. To accomplish this goal, the authors discuss quasi-experimental research design. The authors include in-depth discussion regarding study techniques that are well suited to health policy, including interrupted time series, difference-in-differences analysis, regression discontinuity design, and instrumental variable design. For each study design, the authors discuss examples and potential limitations.

Differences In Nursing Home Staff COVID-19 Testing Rates And Odds Of Vaccination Across Work Shifts

COVID-19 vaccination and regular testing of nursing home staff have been critical interventions for mitigating COVID-19 outbreaks in US nursing homes. Although implementation of testing has largely been left to nursing home organizations to coordinate, vaccination occurred through a combination of state, federal, and organization efforts. Little research has focused on structural variation in these processes. We examined whether one structural factor, the primary shift worked by staff, was associated with differences in COVID-19 testing rates and odds of vaccination, using staff-level data from a multistate sample of 294 nursing homes. In facility fixed effects analyses, we found that night-shift staff had the lowest testing rates and lowest odds of vaccination, whereas day-shift staff had the highest testing rates and odds of vaccination. These findings highlight the need to coordinate resources and communication evenly across shifts when implementing large-scale processes in nursing homes and other organizations with shift-based workforces.

Evidence on the Effects of the Federal COVID-19 Vaccine Mandate on Nursing Home Staffing Levels

OBJECTIVE

To assess the federal COVID-19 vaccine mandate's effects on nursing homes' nurse aide and licensed nurse staffing levels in states both with and without state-level vaccine mandates.

DESIGN

Cross-sectional study using data from Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and Economic Innovation Group. Including nursing home facility fixed effects provides evidence on the intertemporal effects of the federal vaccine mandate within nursing homes.

SETTING AND PARTICIPANTS

The sample contains 15,031 nursing homes, representing all US nursing homes with available data.

METHODS

On January 13, 2022, the US Supreme Court upheld the federal COVID-19 vaccine mandate for health care workers in Medicare- and Medicaid-eligible facilities, with workers generally required to be vaccinated by March 20, 2022 (ie, the compliance date). We examined actual nursing home staffing levels in 3 time periods: (1) pre-Court decision; (2) precompliance date; and (3) postcompliance date. We separately examined staffing levels for nurse aides and licensed nursing staff. Because 28% of nursing homes were in states with state-imposed vaccine mandates that predated the Supreme Court's ruling, we divided the sample into 2 groups (nursing homes in mandate states vs nonmandate states) and performed all analyses separately.

RESULTS

Staff vaccination rates and staffing levels were higher in mandate states than nonmandate states in all 3 time periods. After the Court's decision, staff vaccination rates increased 5% in nonmandate states and 1% in mandate states (on average). We find little evidence that the Court's vaccine mandate ruling materially affected nurse aide and licensed nurse staffing levels, or that nursing homes in mandate states and nonmandate states were differentially affected by the Court's ruling. Staffing levels over time were generally flat, with some evidence of a modestly greater increase for nurse aide staffing in mandate states than nonmandate states, and a modestly smaller decrease for licensed nurse staffing in mandate states than nonmandate states. Finally, regression results suggest that for both nurse aides and licensed nurses, staffing levels were lower in rural and for-profit nursing homes, and higher in Medicare-only, higher quality, and hospital-based nursing homes.

CONCLUSIONS AND IMPLICATIONS

Results suggest the federal COVID-19 vaccine mandate has not caused clinically material changes in nursing home's nurse aide and licensed nurse staffing levels, which continue to be primarily associated with factors that are well-known to researchers and practitioners.