This instability had severe consequences for nursing homes, where the quantity and consistency of staffing are crucial for both patient care and infection control required to prevent outbreaks among highly vulnerable residents. In the first year of the pandemic, over 1,300 nursing homes had infection rates among patients of over 75 percent, and mortality rates at these high-infection facilities averaged over 20 percent. To make matters worse, COVID-19 outbreaks within nursing homes were found to spur staff departures. This may have created a vicious cycle where decreased staffing after an outbreak increased the risk of another outbreak.
Vaccines had the potential to help break this vicious cycle, yet facility managers faced a difficult problem: Vaccination rates among staff lagged behind those of patients. Moreover, vaccine hesitancy—both in general and specifically for COVID-19—is strongest among nonwhite and low-income individuals, the dominant demographic for the low-wage health staff that make up most nursing home personnel. Efforts to increase vaccine coverage were strikingly difficult; one experiment involving 133 facilities and nearly 18,000 staff found no effect of soft-touch approaches—such as educational materials, town hall meetings, and messaging from community leaders—on increasing vaccinations among staff.
Despite evidence that vaccine mandates are effective at increasing vaccination coverage, facility administrators were reluctant to implement mandates. Many feared that mandates could worsen already high turnover or even result in staff shortages. Facilities risked losing large numbers of vaccine-hesitant staff, which could have even snowballed into losing vaccinated staff if the departures of noncomplying staff increased the workload and stress for the remaining workers. While there is evidence that state-imposed vaccine mandates for health care workers are effective and do not cause large turnover, an employer mandate is different because employees hesitant to take the vaccine could plausibly find a job at a nearby facility without a mandate. Interviews of facility administrators suggest that while some nursing homes implemented their own vaccine mandates, most facilities did not, largely due to fears that staff would leave for facilities without a mandate.
Our research examines the effects of vaccine mandates on staff turnover, patient care, and patient health at nursing homes whose administrators chose to implement mandates. Our analysis uses detailed payroll data from 2020 and 2021 on nearly 500 million daily nursing staff shifts of about five million staff members; data on the announcement and introduction of employer vaccine mandates at nursing home chains; data from the Centers for Disease Control and Prevention on vaccination coverage, COVID-19 infections, and COVID-19-related deaths among residents and staff at individual facilities; and data on a wide variety of patient outcomes associated with the quality of care, such as injuries from falls and bedsores.
Our findings reveal that employer vaccine mandates significantly increased the number of staff who became vaccinated. This had life-saving effects on the health of nursing home residents, who saw reductions in both COVID-19 cases and mortality. For every two facilities that imposed a mandate, the mandates saved approximately one life. Given that a typical facility has only 100 residents, this is a large effect.
Though mandates did increase staff turnover and decrease the time staff spent on patient care, the magnitude of these effects was small. For example, the mandates reduced patient care by about two minutes per patient per day, which is only 1.4 percent of the average time spent with each patient per day. Also, most staff who left were part-time and working less than 20 hours per week. Turnover among such staff is already common and likely to be less disruptive than turnover of full-time staff. Additionally, the concentration of nursing homes in one area was not correlated with mandate-induced turnover, suggesting that nearby alternative employment options were not a major factor in whether vaccine-hesitant staff chose to comply with the mandates.
Furthermore, our research finds very limited evidence of reductions in patient care when examining conditions typically associated with poor-quality care, such as injuries from falls, urinary tract infections, and bedsores. Finally, our findings reveal that employer vaccine mandates may exacerbate inequalities in health care. Facilities in wealthier locations with a higher concentration of white residents were more likely to issue mandates; as a result, lower-income patients and patients of color were less likely to benefit from employer-imposed mandates.
