Andrew Noymer, an infectious diseases epidemiologist who appears often in media pandemic coverage, interacts periodically on Twitter with my wife and colleague Jody Lanard. On September 27, 2021 he asked Jody what she thinks about whether hospitals should fire nurses or other healthcare workers (HCWs) who refuse to be vaccinated against COVID.
Jody passed the inquiry on to me, and I responded with a numbered list. Then I decided my response – somewhat revised – might be worth posting as a column.
For understandable reasons, a lot of hospital administrators, medical professionals, and public health experts are outraged at the failure of shockingly large numbers of healthcare workers to get vaccinated against COVID. It’s almost incomprehensible to them how anyone could struggle heroically to save the lives of COVID victims and still not take this exceedingly effective measure to avoid becoming a victim too. HCWs who gratuitously risk catching COVID themselves also risk infecting patients and coworkers, not to mention the risk that they will leave their colleagues in the lurch at the worst possible time. Understandable though it is, this outrage can cloud the judgment of hospital decision-makers. So the first step in deciding whether to fire HCWs who refuse vaccination is to become aware of one’s own outrage. Make sure you’re acting wisely, not acting out.
Most HCWs are unionized, and many union contracts would require something like COVID vaccination to be negotiated, not unilaterally imposed by management. Even if a contract has an escape clause for emergencies, exigent circumstances, or whatever, I would be inclined to honor the contract. Management has had 18+ months to negotiate COVID vaccination with the union (10 months if you count from the first vaccine EUA). If there’s still a clause in effect that forbids firing an employee for refusing to get vaccinated, I would not fire the employee – even if my lawyers told me I could.
A number of medical facilities (as well as schools and other institutions) have imposed “jab or job” mandates and are losing a significant portion of their workforce as a result. This is arguably a self-defeating policy on the part of management, which makes me wonder if it’s motivated more by outrage than by medical considerations. It’s at least worth considering if the institution’s mission is really better served by doing without its unvaccinated employees than by finding medically acceptable ways to keep them onboard.
This isn’t strictly relevant to the question of whether to fire a vaccine-refusing HCW, but it’s a prior question I think is important: the pros and cons of “jab or job” mandates in the first place. The evidence is strong that this policy “works”; it loses some employees, but most employees knuckle under and roll up their sleeves. However, they do so resentfully. There’s likely to be no resulting cognitive dissonance, and therefore no attitude change. That is, they don’t reconsider their antivax concerns, but rather become angrier and more convinced that they are the victims of oppression. I think HCWs forced to get vaccinated are quite likely to morph into sullen revolutionaries; among other things, I would expect them to advise patients not to get vaccinated. You’re not winning them over, in short; you’re losing them forever. In some ways, you’d be better off firing them than forcing them to get vaccinated in order to keep their jobs. (See also this recent post on COVID vaccination rewards and punishments, and overviews of the role of cognitive dissonance in risk communication here and here.)
By contrast, a less coercive choice – either get vaccinated or get tested frequently, for example – is less likely to provoke rebellion and more likely to provoke cognitive dissonance and reconsideration. The ideal sanction, in other words, is aversive enough to motivate behavior change but not so aversive that we tell ourselves we had no choice; insofar as we feel like we actually made a choice, cognitive dissonance should lead us to reach less negative judgments of what we chose to do. At least employees who feel they had reasonable options are likely to end up less hostile than those whose “choice” felt like no choice at all.
For all the above reasons, I would try hard to find a medically and institutionally acceptable way to keep employees who are unwilling to get vaccinated. Reassign them to positions without patient contact, or whose patients are all vaccinated or recovered from COVID. Make them wear N95 respirators. Make them get tested two or three times a week. Frame these not as punishments but as accommodations – and mean it – while remaining more than willing for employees to decide that the accommodations are more hassle than they’re worth, worse than getting vaccinated.
The question of whether or not to fire shouldn’t be about “making a point.” The “point” we make when we treat others harshly isn’t the one we want to make. Basically, we should never want to fire disobedient but otherwise competent employees. We should want to keep them if we can find an acceptable way to do so. We should fire them only if we have to. If you’re not incredibly reluctant to fire somebody, your own outrage may be getting in the way of your search for an acceptable accommodation, and you probably shouldn’t be firing that person just yet.
I am picturing frontline HCWs who spent much of the last 18+ months taking care of COVID patients – with nobody vaccinated for much of that time; possibly with substandard PPE; certainly at the beginning with little clinical understanding of what’s safe and what’s dangerous; and oftentimes hugely overworked and overstressed. We hailed these HCWs as heroes. Now suddenly we propose to fire them. It feels wrong.
Moreover, it feels irrational. Anyone who has spent many months caring for COVID patients has probably been infected at least once. So s/he very likely has sufficient immunity not to “need” vaccination (even though vaccination would probably boost her or his immunity). Alternatively, if s/he has managed to avoid infection throughout those many months, s/he must be a model of proper precaution-taking. Does it make sense to fire such a person for not taking an additional precaution that s/he coped just fine without over the last 18+ months? It feels weirdly ahistorical – and therefore feels like it might be bad medicine – to fetishize vaccination to the point where we’re ignoring the unvaccinated HCW’s own likely medical and work performance history. After 18 months of heroic unvaccinated frontline service, does it really make sense in the 19th month to say, “Get vaccinated or get out”? It’s probable that your unvaccinated frontline HCWs either have already been infected or are incredibly careful. Why treat them like it’s their first day on the job?
Trying to get HCWs vaccinated is not a new issue. Jody and I have been following battles over HCW flu vaccination for years. In 2009 we wrote “Convincing Health Care Workers to Get a Flu Shot … Without the Hype.” We argued that hospital managements provoke mistrust and resistance when they oversell flu vaccination, and we recommended a set of less aggressive approaches we thought likelier to succeed. (See especially #3, “Don’t rely too much on coercion and punishment.”) In 2012 we submitted comments in response to a U.S. government proposal to require HCW flu vaccination if organizations failed to achieve 90% vaccination voluntarily. We focused on two all-too-familiar risk communication issues: the dangers of overstating flu vaccination benefits, and the dangers of requiring reluctant HCWs to get vaccinated.
Copyright © 2021 by Peter M. Sandman
