How ‘Informal Leaders,’ Peer-to-Peer Focus Can Boost Staff Vaccine Acceptance at Nursing Homes

When the effort to vaccinate long-term care workers and residents began to gather momentum, hesitancy among workers became a prominent issue well before the first shots were administered.

The issue of whether or not workers — burned out by the ongoing tragedy of resident and staff deaths from COVID-19, personal protective equipment (PPE) shortages, and ongoing slow or bungled responses to the crisis by both federal and state governments — would trust the institutions now telling them to take a vaccine came up in December, shortly before the first COVID-19 vaccine received its emergency use authorization (EUA).

Touchstone Communities, which is based in San Antonio and has 28 skilled nursing facilities in the state of Texas, saw the ebb and flow of emotions around the vaccine play out even before the EUA was granted. When news of progress on the vaccines began to trickle out over the course of the summer of 2020, the initial reaction of staff members was quite optimistic, Touchstone COO Leslie Cunningham Campbell told Skilled Nursing News in an interview on January 25.


“Initially, everyone was so hopeful and optimistic about what the vaccine would bring to our population and to our team members,” she told SNN. “I think when we got closer to it, and it was real and the fact that it had happened so quickly, that’s when the team members — mostly the team members — really started to have concerns and questions. Just a lot of questions about: How do we know this is safe? How did this get developed so quickly?”

Many of Touchstone’s employees reported concerns similar to those of workers at skilled nursing facilities in other states. The speed of the vaccine’s development, concerns related to fertility and having children among the SNF world’s predominantly female frontline workforce, and the side effects all came up; Touchstone used those to generate a set of frequently asked questions and publish those broadly across its portfolio, Campbell said.

In terms of “global” initiatives for the entire operator, Touchstone held listening sessions and put together educational videos delivering the scientific facts of the vaccines from “a compelling, expert physician,” she told SNN.


“But then we really left it to our frontline leaders to decide what works best in our individual centers,” Campbell added.

This speaks to one of the concerns flagged earliest around staff hesitancy to get vaccinated: the issue of trust.

In December, after the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommended prioritizing health care workers and residents in long-term care facilities for the first round of COVID-19 vaccines, the CEO of an organization representing certified nursing assistants warned of a disconnect between frontline workers and their leadership.

“My concern is not necessarily the vaccine, if it’s proven safe,” Lori Porter, the CEO and co-founder of the National Association of Health Care Assistants (NAHCA), told SNN on December 2. “My fear is that if we don’t educate them, if we allow the facilities to provide the education on the vaccine, there is a trust issue. CNAs do not trust their leaders.”

On February 1, the CDC released a Morbidity and Mortality Weekly Report (MMWR) that confirmed a wide disparity in vaccine uptake between residents and staff. Out of 11,460 SNFs with at least one vaccination clinic conducted during the first month of the CDC’s Pharmacy Partnership for Long-Term Care Program, a median of 77.8% of residents had at least one dose — compared with a median of 37.5% of staff members.

“Barriers to SNF staff member vaccination need to be overcome with continued development and implementation of focused communication and outreach strategies to improve vaccination coverage,” the report said.

Identifying ways to address the issue of trust took various forms at Touchstone, Campbell told SNN. At the onset of the pandemic, the company had developed a centralized COVID-19 support team with the task of distilling information into practical guidelines and communication for frontline workers, she said. The operator also held daily COVID-19 briefings and weekly “all-hands” meetings – and when discussions of the vaccine first began to surface, those briefings and meetings began to cover the news.

In December, when the EUAs for Pfizer’s (NYSE: PFE) COVID-19 vaccine on December 11 and to Moderna’s (Nasdaq: MRNA) on December 18 were granted by the Food and Drug Administration (FDA), Touchstone ramped up its communication efforts accordingly, Campbell told SNN.

That included one center designating workers as “hall leaders,” who were responsible for doing one-on-one Zoom outreaches with patients and residents and the responsible parties for them to answer questions and address any concerns; that effort was led by nurses, Campbell noted. At another center, the director of nursing (DON) and medical director held small-group town halls and met informally with team members to answer their questions.

“The clinical leadership was really important here,” Campbell said. “And we endeavor to equip clinical leaders, whether formal or informal, on all three shifts just to be advocates for the vaccine … and those team leaders, those informal leader sometimes are more powerful than the actual leaders of the facility — that peer-to-peer ability to share knowledge and insight and influence in that way.”

But in some cases, Touchstone had to think outside the box when it came to finding trusted sources. All of its facilities have had their first vaccine clinics; as part of its efforts to address worker hesitancy, Touchstone tracked facilities where the vaccine acceptance rate among staff was low at the first clinic to conduct a root cause analysis of what was happening there — and the causes of the low acceptance rate.

Touchstone also conducted surveys before the first vaccine clinic, so it had a sense of which facilities might be at risk for low uptake among workers. Leadership emerged as a critical factor, Campbell said.

“One of our rural communities where we knew we were at risk [of a low acceptance rate], we knew the local leaders were somewhat new — very committed, but new, and hadn’t really garnered the real trust of the team members yet, because they were new,” she told SNN. “So we tapped into some influential community members who had involvement in our center before the pandemic, and they began to really talk up the opportunity and be available as a resource to team members, to residents and family members in the community. And that was really effective.”

Other examples of focusing on the local needs of each facility included making sure that hotlines and communications available in both English and Spanish, since Touchstone has “quite a presence in the Rio Grande Valley in deep south Texas,” with a large majority of its team members speaking only Spanish.

For Touchstone, the result of its efforts has been to have more than 55% of its team members sign up to receive the vaccine; more than 80% of residents who are not currently positive and isolated for COVID-19 have opted in, Campbell told SNN.

For her, the experience has shown the value of centralizing as much as possible to relieve some of the burden of fighting COVID-19 that the individual centers carry, as well as the value of transparency in communication; both establish a foundation for trust.

“Another thing is the peer-to-peer support system, and how important that is for adoption [of the vaccine], along with the fact that leadership matters,” Campbell said. “And yes, that’s the administrator, it’s the DON, it’s me leading the charge from the corporate office … but it’s also that informal leadership that’s equally persuasive and powerful, and tapping into those informal leaders in each community.”

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