Why won’t some health care workers get vaccinated?

Many Americans cannot wait to get the COVID-19 vaccine. They call hotline numbers. They search online for vaccine clinics. They wait for hours in line. Yet, others with ready access to the vaccine have declined it in large numbers. Staff in long-term care facilities were prioritized to receive the vaccine, but many are choosing not to get vaccinated. Why?

Nobody is more familiar with the impact of COVID-19 than staff at nursing homes and assisted living facilities that have been ground zero for the pandemic. Large numbers of residents and staff have contracted the virus. Nearly 40% of the COVID deaths in the US have occurred among residents of these facilities. Over 1,500 nursing home staff have also died from COVID, making nursing home caregiver the most dangerous job in America.

Nonetheless, many long-term care staff continue to refuse the COVID-19 vaccine. In a recent CDC report, nursing homes had a median vaccination rate of 37.5% for staff during the first month of the federal vaccination effort; by comparison, a median of 77.8% of nursing home residents received the vaccine. This has surprised some policymakers. Recently, Maryland’s acting health secretary told state lawmakers that about one-third to one-half of staff offered the vaccine chose to have it –– nowhere near an expectation of 80% to 90%. In a bit of positive news earlier this month, a large national nursing home chain reported 61% of staff and 84% of residents had been vaccinated as of early February, still far short of many policymakers’ expectations.

An information problem or a trust problem?

Many experts attribute low vaccination rates among staff to an information problem. Indeed, a recent survey of nursing home caregivers suggests many staff worry about vaccine safety and side effects. Yet, major information campaigns including well-crafted toolkits and fact sheets have not been sufficient. The problem isn’t just a lack of information, but also who delivers this information. Direct caregivers in long-term care may lack information about the vaccine, but they also lack trust in facility leadership.

We have historically undervalued the work of caregivers in long-term care facilities. They perform a difficult job for pay at or near minimum wage, with few benefits like health insurance or paid sick leave. They often work at multiple facilities in order to earn a living wage. Many facilities are understaffed with high turnover. The vast majority of caregivers are women, and many are people of color and recent immigrants. They may be treated poorly while being asked to work long hours at low pay.

Since the start of the pandemic, this workforce has been further exploited. They have often had to work in facilities that were severely short-staffed, without adequate personal protective equipment or rapid COVID testing. Many staff did not receive hazard or hero pay despite working in the most dangerous of conditions. Not surprisingly, many staff do not trust management at the facilities where they work.

The role of trust, vaccine mandates, and cash incentives

Given the lack of trust among caregivers, staff don’t just need more information about the safety of the vaccine; they need to hear this message from a trusted source. Some facilities with better employer-employee relationships have been able to have these discussions, as a recent New Yorker article notes.

This trust between facility leadership and staff is not built overnight. Facilities lacking this culture will need to turn to a trusted source either in or around the facility. In some instances, that might be respected clinicians and staff who work in the facility. In other instances, that might be a professional organization.

Is there a role for policy in increasing staff vaccination rates? Maybe. One idea is to mandate that staff take the vaccine. The federal government has been reluctant to do that, especially because the vaccine was approved through an emergency use authorization. Although a few assisted living chains have mandated the vaccine, most companies have not chosen this route. Everyone acknowledges that mandates will have the intended effect of increasing vaccination rates among staff. However, mandates are also likely to have the unintended effect of causing some staff to leave their positions rather than get vaccinated. It all comes back to trust. Given severe staffing shortages and the challenge of recruiting new workers to these jobs, facilities can ill afford to lose more workers.

Another approach is to pay staff to take the vaccine. Some facilities have offered a free breakfast or gift cards. These rewards are nice but fairly nominal, and unlikely to move the needle much. Larger cash amounts like $500 for the first shot and $1,000 for the second shot would likely motivate more staff to get vaccinated. However, there are ethical considerations around paying staff, and funding for these payments would require government support.

At the end of the day, no matter the approach, trust and relationships will figure centrally into resolving this situation. In getting long-term care facility staff vaccinated, the messages we share matter, but so does the messenger who delivers this information.

Follow me on Twitter @DavidCGrabowski


  1. Nathanael A DePano

    Incentives outside of straight delivery of accurate information about the vaccines will only heighten the distrust of people who are already leery of the government’s zig-zaggy handling of the COVID-19 pandemic. The understandable dearth of data about long-term vaccine effects is also a major factor. I have waited this long and have remained healthy. I can wait a bit longer until such data is available.

  2. A Butterfly

    Ok so I get the mistrust issues and why, totally understandable. Ppl are worried about putting something into their bodies with potential side effects.
    I’m not saying that we should take it but you HAVE TO look at the alternative., get the virus and have side effects that won’t go away for some, or oh ya DIE. This isn’t going away any day soon.
    Has anyone considered this, almost all of us are taking in toxins in our air, water, soil, pesticides, food, chemicals inside and outside of our homes, body products, and voluntarily taking medications that have toxic, dangerous, and even worse some can kill you. We do this voluntarily most often not looking at what they can do to us. You say ya but we don’t have a choice or they have been tested and tried, but that doesn’t change the facts that they all have side effects on our bodies, but they don’t bother looking up the side effects or they resign themselves to it being a necessary part of their health care.
    BUT when a vaccine comes out that hasn’t been tested that long you aren’t sure of what it could do to you, but it could save your life……. but not if you won’t take it!
    BUT you will take all the other products prescription and or over the counter that harm you including smoking and alcohol abuse, drug abuse smoking or vaping anything into your lungs has been documented to cause harm or kill you.
    Do you see my point? I’m nervous too but we have to use our heads and consider all examples I just gave you. Like I said the meds I take to treat my ailments are probably more harmful than the shot. And you know what is more dangerous than the shot, you dieing or you giving covid to someone else who dies. It’s no different than taking your meds to keep you alive, it’s just one more thing to keep you alive or someone else.

  3. Ruth Yoder

    I did not receive my vaccine. It had nothing to do with management at my assisted living facility. It had everything to do with me not trusting the government and how fast this vaccine was pushed through. I could not get an answer to my queation, if I had covid why should I get the vaccine?

    • Eva

      Why? Because the scientific community does not yet know if having the Covid-19 illness provides immunity or not, and if it does provide immunity, how long does that immunity last, and is it effective against the new variants? At this time, for the safety of yourself, your patients, your family and the community you live in, they recommend you get vaccinated. Make sense?

  4. Krystine Loeb

    This article is spot on. As a CNA in a long term facility, we were chronically understaffed, and near or at burnout as we were also not allowed to take time off. Our management was unstable, if there at all. I live and work in Arizona, and I’m glad people around the country can also speak up for these issues.

  5. azure

    “and funding for these payments would require government support.” Why? It doesn’t seem as though the “government” (gov’t exists as city, county, state & federal levels-which level is referred to? And what part of what gov’t? Medicare? Congress? Who?) pays for the frequent testing to see if employees have been infected by the SARS-COV-19 virus, even though Medicare requires that the frequent testing be done. What puts payments to employees as an incentive for vaccination in a different category? Does Medicare, or the CDC or FDA or a state labor agency or other state or federal agency regulate, say, a decision by a nursing home to give wage employees bonuses? Hazard pay?
    There often is a lack of trust & it’s unsurprising that it’s so, given how many low wage employees are treated. Not all, but way too many.

  6. Mamta

    The reason most health workers refusing is because of trust issues. They are worried about safety.

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