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COVID-19 Vaccination in Nursing Homes: Trust in the Tunnel Will Help Staff See the Light at the End

      The light at the end of the tunnel is in view. In recent weeks, many post-acute and long-term care residents and others have begun receiving COVID-19 vaccines. One key challenge that remains is getting staff to agree to be vaccinated. “There is so much medical misinformation on social media, where many people get their information,” said Leslie Eber, MD, CMD, president of the Colorado Society for Post-Acute and Long-Term Care Medicine. “We have to overcome this with facts, but we have to do this carefully.”
      Lori Porter, cofounder and CEO of the National Association of Health Care Assistants (NAHCA), said, “The number one thing [certified nursing assistants] need now is trusted information. Our polling shows that many CNAs say they won’t get vaccines for various reasons.” In Ohio, for example, the governor estimated back in January that up to 60% of nursing home workers there weren’t planning to take the COVID-19 vaccine. Their top concern, according to one survey, is related to side effects. Ms. Porter understands this. She said, “They’re being told to take two days off work if they feel bad. But they can’t afford to do this, so they’re afraid to get the vaccine and miss work. It’s a horrible, gut-wrenching situation,” she said.
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      Verna Sellers, MD, MPH, CMD, a geriatrician practicing in Lynchburg, VA, is receiving a COVID-19 vaccine.
      Dr. Eber participated with three other practitioners in a webinar for CNAs, and this was powerful — but not necessarily because they’re doctors. Ms. Porter explained, “CNAs can spot a phony a mile away, and these physicians spoke to CNAs like colleagues and with such esteem. This made a huge difference.” Dr. Eber explained, “Some things are basic. People want to be heard and respected.”

      Overcoming Objection: Not One and Done

      When people have objections to or concerns about the vaccine, even if they seem unreasonable, compassion and empathy are key. Dr. Eber said, “It can be frustrating when people believe these misconceptions and myths about the vaccine, but you can’t take it personally. Instead, I think of it as an opportunity to get these people to trust me a bit. We need to understand where they are coming from and what their concerns are. Then, instead of focusing on proving them wrong, we need to meet them where they are.” She stressed, “No one wants to feel uneducated, so you can’t talk down to people. Talk about facts, address their concerns using truths, and focus on having a respectful exchange.”
      Part of the problem, Lisa Sweet, cofounder and chief clinical officer at NAHCA, added, is that “in the beginning of the pandemic, leadership wasn’t always transparent with their staff about the virus. They would have a lab-verified COVID-19 patient and they didn’t want to tell staff.”
      Dr. Eber said, “When you have a foundation of trust and leadership, you can always move from there. For medical directors who already have the trust of staff, it can be easier to have productive conversations. After our second clinic, we ended up with an 80% staff vaccination rate. It’s not perfect, but it’s a good start.” She added, “If you’re looking for that secret sauce, it starts with trust, leadership, and good communication.”
      If trust has been strained or even broken during the pandemic, it is possible to repair. A few steps that can help include:
      • Acknowledge that mistrust exists. Admit to mistakes that were made in terms of withholding or communicating information and updates. Seek thoughts from the staff about what could be done differently or better while moving forward.
      • Say, “I’m sorry.” It’s important to apologize for mistakes or missteps that were made. This should involve admitting fault, expressing genuine remorse for any confusion or problems that resulted, and making a real commitment to doing better.
      • Walk the walk — model accountability. Put new processes or efforts in place that show staff that their feelings, concerns, safety, and trust matter.
      Dr. Eber referred to eight principles health experts have developed that can help increase trust, acceptance, and demand for the vaccination.
      • 1.
        Work within worldviews, identities, and moral values. Each person has a unique set of these that influence choices, behaviors, and beliefs about what is true. When you understand this, you can seek common ground with each person.
      • 2.
        Use timing to the best advantage. Share messages, news, and updates early, hopefully before your teams get a different (and inaccurate) version elsewhere. However, it is important that everyone hears a consistent message repeatedly from multiple sources.
      • 3.
        Use the right messengers for the audience. People are more likely to act when they trust the messenger.
      • 4.
        Make the content concrete, supply a narrative, and provide value.
      • 5.
        Recognize that communities have different relationships with vaccination. In some societies, people may fear vaccines but trust authority. In others, mandatory vaccinations have created distrust of government officials and organizations. Know who your teams are and where they come from, and realize that a vaccination strategy isn’t one size fits all.
      • 6.
        Reinforce positive behaviors. Recognize the workers who get vaccinated and praise them for helping to protect their residents, families, communities, and themselves.
      • 7.
        Evoke the right emotion. Avoid shaming people or playing on their fears to get them to take the vaccine. Instead, use positive emotions such as hope, love, and courage.
      • 8.
        Be explicit and transparent about motivations. People are more likely to trust the vaccine if they trust those who are encouraging them to take it.
      Dr. Eber stressed, “[People] are more likely to trust you if they see that you value them as a person. It’s not just about education and information.” In her efforts to communicate with staff, she went in on a weekend and really listened to everyone. Then she encouraged them to ask all their questions, get all the answers, and make their own decision. “For some staff members the idea of getting the COVID-19 vaccine is really scary. I was honored that they were willing to have a conversation with me and share their concerns,” she said.
      It’s important not to sugarcoat your conversations. As Dr. Eber noted, “Once you start to do this, you can’t lead everyone. You have to communicate in a way that makes it clear you care about them, you’re invested in them, and you want them to stay healthy. When people see honesty, transparency, and respect, it makes a difference.”

      Lessons Learned

      The pandemic has offered some lessons that will help leaders talk about vaccines. “We’ve learned how essential it is to have a culture that values everyone and where everyone is equal. Everyone on our teams needs to have a voice and a place at the table. These things need to be the norm and not the exception,” said Dr. Eber. When this happens, “We can have productive conversations that are mutually respectful.” She added, “Vaccine education can be a doorway to better leadership that enables better communication and respect all around.”
      Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA.

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