Many of the staff and residents in Shunda Whitfield’s St. Louis County nursing home were sick before they even realized what was going on. 

It was April 2020, and masks weren’t yet standard practice. Little was known about COVID before it swept through nursing homes, and as a certified nursing assistant, Whitfield said she “didn’t have a time to duck or dodge.”

She contracted COVID-19 in late April and had to take a month off work to recover. She took another two months to battle a flare-up of Lupus, an inflammatory autoimmune disease with no cure that Whitfield, 51, was diagnosed with five years ago. 

Her doctor called nearly every day, worried she might take a turn. Her grandkids couldn’t understand why they could only speak to her through the door.

“What if something goes wrong during the night, and no one hears me? Or I go to sleep and my breathing gets really funny and nobody knows it?” Whitfield recounted thinking. “Would my system fight this off?”

When Whitfield eventually recovered, she said she was paranoid to return to her job and worried the virus still lingered in the facility. But despite her fears, and the fact that as a nursing home employee she was eligible for a vaccine back in December, it wasn’t until three months ago that Whitfield felt comfortable enough to receive her first dose of Pfizer’s COVID vaccine.

“All the way to sitting in the chair,” she said, “I was asking questions.”

The uncertainty Whitfield wrestled with — how would the vaccine interact with her underlying conditions, did she already have immunity from having COVID, what exactly did the vaccine consist of — encapsulates the difficulty nursing homes across Kansas and Missouri face in persuading vaccine hesitant staff to get the shot. 

Whitfield is among the almost 47% of Missouri nursing home staff who have chosen to get the vaccine — still a minority despite being among the very first eligible for the shot.

Missouri’s vaccination rate for nursing home staff is 3rd worst out of all 50 states, Washington, D.C., Guam and Puerto Rico, according to data compiled by the Centers for Medicare and Medicaid Services. Only Florida and Louisiana trail Missouri. 

In Kansas, just over 56% of workers are vaccinated. The state ranks 35th on that list.

Both states trail the national average of 59.3%. 

Nursing home residents, isolated for months from their loved ones, have gotten the shot far more readily. In both states, more than 80% of residents are vaccinated against COVID-19.

That doesn’t account for long-term care facilities that are licensed by the states, like assisted living facilities. Vaccination rates in those facilities aren’t tracked in either Kansas or Missouri.

It was a simple decision for Joe Faver, a resident at The Neighborhoods by TigerPlace in Columbia, Mo., who received his first vaccine dose Friday.

“I don’t want to spread it to anybody,” Faver said.

Nursing homes were some of the first places to bear the brunt of the COVID-19 pandemic, forcing residents into isolation, only able to see family from a distance as outbreaks haunted seniors.

Now, the vast majority of nursing home residents are vaccinated, allowing some homes to reopen communal dining rooms and return to less restrictive visitation policies. 

But as the Delta variant spreads uninhibited among the unvaccinated and, in rare cases, breaks through COVID vaccines, unvaccinated workers in long-term care facilities raise the risks of a return to the darkest days of the pandemic. 

“We’re surrounding our most vulnerable residents with a lot of people who are unvaccinated, which is very scary,” said Marjorie Moore, the executive director of VOYCE, a St. Louis nonprofit that advocates for quality living across long-term care.

Lagging staff vaccinations 

It’s difficult to discern a pattern among the health care workers who don’t get vaccinated. 

Some, like Whitfield, are older workers with underlying health conditions who worry about how they’ll react to the vaccine. Several homes reported they were struggling to convince their young female employees who worried the shot would affect their fertility. Doctors and experts have said the science doesn’t support that and there is no evidence that the vaccine causes infertility.

Many staff are also part-time employees who sometimes work at several different facilities and can’t afford to take time off to recover from potential side effects, Moore said.

Kelly Sommers, director of the Kansas State Nurses Association, said pervasive misinformation about the vaccine has been difficult to overcome. She wants to see more conversation about why nurses aren’t getting the vaccine and to provide incentives or lower barriers — for example, giving staff additional time off to recover if they have side effects from the vaccine — to encourage them. 

“It was nurses at the beginning who were the ones out there getting the vaccine,” Sommers said. “And so now, somewhere, we’ve hit a roadblock that I think is easily solvable.”

Even within nursing home chains with multiple locations, vaccination rates can vary widely from facility to facility. Among Good Samaritan Society’s dozen nursing home locations in Kansas, vaccination rates for staff run from 18% to more than 80%. 

Whitfield says she’s tried to talk to coworkers about getting the vaccine. Her employer recently brought a clinic to them, extending the invitation to get a shot to staffs’ families as well. But ultimately, everybody is “at a different level, at a different time,” she said.

Requiring the vaccine

For many home administrators, it seemed important to emphasize they were not requiring their staff to get vaccinated. Even though their nurses and support staff are caring for people who are especially vulnerable to the disease, they felt it was their workers’ choice what to do.

In some cases, their relentless education initiatives worked. Staff members who held off at first came around. Some members of Cammy Boone’s staff at Arkansas Presbyterian Manor in Arkansas City, Kansas, just wanted to give it some time and see whether their coworkers suffered any reactions to the vaccine. 

“As they see that that’s not been the case, I do think they will go ahead and eventually end up getting it,” she said. 

Boone, whose facility has vaccinated 86% of residents and 51% of staff, would like to see her entire staff get the vaccine.

But vaccination rates among staff haven’t changed significantly since the Centers for Medicare and Medicaid started reporting the numbers in late May. At that time, an average of 55% of health care personnel in Kansas and 43% in Missouri were vaccinated. Now, those figures are 56.2% and 46.8%.  

Shauna Hickem, administrator of South Hampton Place in Columbia, Missouri, was more fortunate. At her facility, 78.7% of her current staff have taken the shot. 

“It’s just the ones who are absolutely not going to take the vaccination,” Hickem said. “You know, you can only ask them so many times.”

On Friday morning, Kali Lindsay, a 19-year-old dietary aide at The Neighborhoods by TigerPlace in Columbia, was the first to arrive for her second shot.

Lindsay knew she wanted to get vaccinated, and being able to get a shot at work made it convenient for her to do so. Her grandma contracted COVID from an outbreak in a Kansas nursing home and was later hospitalized and died. Lindsay said she wanted to make sure someone else’s grandma wouldn’t get sick from her.

“I work with a really at-risk group of people,” Lindsay said. “A cold can do some damage to them that it wouldn’t do to a 19-year-old, so I can’t imagine what COVID could do to them that it wouldn’t do to me.”

Nearly 50% of staff at The Neighborhoods by TigerPlace are fully vaccinated, according to CMS data. Amy Byergo, the facility’s executive director, said the short-term goal is to boost that figure to 65%.

The facility has rebooted its efforts, searching for peer advocates among staff and recruiting the medical director to host a Q-and-A session. While Byergo knows they are better equipped than a year ago, the Delta variant makes it feel “a lot less predictable.”

During July, the facility had a series of cases among nine residents — and more than half were among the fully vaccinated.

“There wasn’t any real pattern either,” Byergo said, noting the first four cases were each in a different unit of the facility.

D&H Drugstore has brought a vaccine clinic to the facility about every other week since May, and has vaccinated a handful of residents and staff each time, said Regina Murdock, a registered nurse with the pharmacy. After 45 minutes, Murdock had finished giving shots to the three people who chose to get one at the facility Friday. 

For her, that’s three people that hopefully won’t contract COVID.

Good Samaritan Society, a chain of nursing homes with a dozen locations in Kansas, elected last month to require the vaccine for its workers. 

Starting Nov. 1, all employees without medical or religious exemptions must be vaccinated to remain employed with the organization.

Aimee Middleton, executive director of Good Samaritan Society, said the organization made the decision carefully and “based on overwhelming science” at a time when the “virus is still a very real threat.”

“The vaccine is our way out. It is saving lives,” Middleton said. “The science at this point is undeniable.” 

And while the mandate could mean parting ways with employees at a time when nursing homes are already struggling with staff shortages, Middleton said the mandate might actually attract more workers to Good Samaritan Society’s homes. 

“They’ve been through an extremely tough year … so I think there are a lot that are very thankful to take this step,” she said. 

Just a few days after Good Samaritan’s announcement, a coalition of organizations representing doctors, nurses and other health care workers and scientists called on health care and nursing home employers to mandate vaccines. 

“As we move towards full FDA approval of the currently available vaccines, all health care workers should get vaccinated for their own health and to protect their colleagues, families, residents of long-term care facilities and patients,” the groups said in a joint statement.

The American Nurses Association signed that statement, and both Kansas and Missouri chapters have issued statements of support saying nurses have an ethical responsibility to the people they serve.

Isolation for residents

Throughout the pandemic, nursing homes suffered some of the most severe effects of the virus. 

Of all those who died of COVID in Missouri as of late July, 35.5% occurred among nursing home residents and staff, according to data compiled by Saint Louis University researchers. In October, nursing home COVID deaths accounted for nearly half of the virus’ victims in Missouri. 

While initial lockdowns and fear of the virus meant isolation for most people, nursing home residents endured restrictions on gathering with their loved ones for much longer. Some homes just recently relaxed visitation protocols. 

Crystal Packard, administrator of the Good Samaritan Society home in Parsons, Kansas, said the facility started allowing visitors in May after months of only allowing residents to see their families in a tent outside.

“I can remember the first one, I’m getting teary thinking about it. She hugged her mom for the first time in a year,” Packard said as she started to cry. 

In Whitfield’s facility, things were just starting to feel a bit more normal. Residents were no longer served meals on styrofoam plates restricted to their rooms. Visits had resumed, albeit with appointment times. But now with cases spiking, it’s back to stringent masking and few visitors.

Getting to escape that isolation was a huge motivator for residents to get vaccinated, said Camille Russell, Kansas’ long-term care ombudsman. Nursing home staff didn’t face those same restrictions.

“People in nursing homes have the same human rights, the same civil rights that you and I do, and yet, they have not been afforded those rights,” Russell said. “So you have two populations spending a lot of time in a nursing home, and the people that work there continue to maintain their rights. The people that were living there were restricted.” 

The restrictions on visitors, she said, exacerbate the potential for neglect by turning away people who could help care for residents so long as they follow good infection control practices. 

After shutting down in March 2020, guidance on visitations in Missouri’s long-term care facilities was relaxed in late September. Lisa Cox, a spokeswoman for Missouri’s state health department, pointed to newer state guidance issued in May 2021 that recommends outdoor visits over indoor ones and states that a single new COVID case in a facility should be considered an outbreak.

But while the guidance acknowledges testing and vaccinating visitors can help mitigate the spread, it says they “should not be required to be tested or vaccinated (or show proof of such) as a condition of visitation.”

For Sharla Hopper, administrator at Oswego Health and Rehab, the resurgence of COVID cases this summer makes her worry about the possibility of once again restricting residents. 

“That would be very hard — very hard,” Hopper said. “Their mental health was not great after that.” 

When Moore looks back on the pandemic, she didn’t think outbreaks in nursing homes would still be a worry a year and a half into the virus’ spread. To her, the vaccines meant a return to hugs for residents and their families.

But now, cases are rising, homes are short-staffed and it can be difficult for staff to always take family members’ calls. It can sometimes feel like those early days where family members couldn’t even reach their loved ones, she said. 

“These are folks that fought our wars for us. They’ve done so much for our community. In so many ways, it seems to me that something we can do for them to protect them is to take the vaccine,” Moore said. “That seems like a really easy ask to me.”