We interviewed 38 VHA EOH providers including 18 physicians, 16 nurse practitioners (NP), and 4 registered nurses (RN), from 26 of VHA’s medical centers throughout the US (see Table 1). Interviews lasted approximately 30-60 minutes. Respondent medical centers represented diversity of geographic regions (6 Northwest, 8 Mid-Atlantic, 4 Midwest, 3 South, 1 Southwest, and 4 West), site size (7 small, 8 midsize, and 11 large), and urbanicity (13 urban and 13 rural). Rapid thematic analysis elucidated 5 key themes for vaccine delivery/implementation across sites: leverage diverse skillsets through multidisciplinary teams; invest in process and resources; expect vaccine buy-in to occur over time; overcome misinformation with trustworthy communication; share learnings across teams/sites. See Appendix A for overarching themes, specific strategies, and example occupational health provider quotes.
Theme 1. Leverage diverse skillsets through multidisciplinary effort for vaccine implementation
EOH providers perceived COVID-19 vaccination as an unprecedented, urgent problem requiring diverse skillsets (clinical, leadership/incident command, public health, bioinformatics, administrative, etc.) to plan and execute effectively. Participants noted the specific strategy of creating multidisciplinary COVID-19 vaccination teams with clear goals and roles as a major part of vaccine delivery success. Conversely, misalignment of goals and inflexible reporting structures slowed implementation and created unnecessary conflicts across siloed disciplines. At one site, managers of four disciplines (Information Technology - IT, Nursing, EOH, and Management) needed to connect to reduce conflict around vaccination related tasks. One NP reiterated: “It’s multidisciplinary… employees from social work and education have been very responsive.”
VHA leveraged existing bureaucratic structures, such as the COVID-19 emergency response “incident command” site leadership teams, to rapidly deploy multidisciplinary teams. Diverse skillsets from these COVID-19 vaccination teams helped overcome logistical barriers. Vaccine dissemination was “just not a one person job.” One physician explained, “if we could have had anything else, it would have been to have more of an employee health team when this [vaccine campaign] rolled out.” Providers valued bringing together multiple disciplines, departments, and organizational levels to leverage diverse expertise, including both clinical and non-clinical parties.
Beyond multidisciplinary teams, integrated workflows allowed team members to share task load and create efficiencies. An ideal process might include techs/nurses documenting vaccines, pharmacy administering vaccines, and physicians monitoring for post-vaccine adverse events. When designating stable vaccine-specific teams was not possible, providers benefitted from clearly delineated tasks that recognized interdepartmental coordination and collaboration. Through leveraging interdisciplinary expertise, vaccination teams were positioned to become “really well-oiled machine[s],” rapidly distributing vaccines to HCP.
Theme 2. “Focus like a laser”: invest in processes and align resources with priorities
EOH providers reported that the COVID-19 vaccine roll out was layered on already overwhelming COVID-19 demands: “You need to be an octopus to get everything done.” The need for focus was critical, particularly during early implementation. Participants noted specific supporting strategies of: creating detailed processes, for instance a logistics plan to prevent wastage and allocate excess vaccine doses; addressing time trade-offs for personnel involved in vaccine clinics by suspending everything non-essential; designating process/authority to shift personnel where needed; and proactively involving leaders to support resource allocation/alignment
Detailed processes were critical due to vaccine complexity: “It’s not like the flu shot where we can just go and grab a pre-filled syringe and administer it at any point in time.” One site's greatest success was a “great process”: “our wastage has been incredibly low because we planned very well for this.” Their plan involved having morning walk-in clinics to support shift-change vaccinations, and a systematic approach to site-wide communication about ad hoc opportunities to use opened but unused doses. This allowed time throughout the day to find extra vaccine recipients once a vial was open in the morning.
Frontline staff appreciated when leaders supported resource allocation and were available to “approve” extra hands and “suspend” other activities, proactively addressing time trade-offs. Specifically, everything “worked better” when there was designated process/authority to re-assign personnel to high-need situations. Indeed, proactively involving leaders in supporting resource alignment was “critical”: “the right kind of support… was more leadership support... They had to approve the extra hands.” Conversely, when authority for assigning vaccine tasks was unclear, problems arose: “My manager was not giving me any management responsibility…I couldn’t really tell anyone what to do. So that caused some problems” (NP).
Theme 3. Expect and strategically prepare for vaccine buy-in occurring over time.
Even among EOH providers, some reported “wait[ing]” on vaccination, in addition to noting some HCP reluctance. EOH providers perceived vaccine reluctance to be related to various factors beyond mistrust, including “health literacy” and “ideology.” EOH providers noted “how politicized COVID has become,” and how “it's hard to disentangle the political aspects from the public health aspects.”
Specific strategies to account for some vaccine hesitancy included preparing for some HCP slow buy-in, aligning buy-in facilitation with identities and motivation, and encouraging word-of-mouth and hyper-local testimonials. EOH providers disclosed that expecting slow buy-in among some HCP primed them to think strategically about facilitating vaccine acceptance over time. Important approaches to facilitating HCP buy-in included being alert to individual employee concerns and background, and aligning motivations with identities. For individual employee concerns, EOH providers reflected on belief systems and/or personal experiences that might have guided vaccination choice, allowing them to better meet HCP where they might be at in their thinking: “maybe due to their ethnicity or culture and past experience, they’re more fearful of getting vaccinated.” By attempting to understand HCP perspectives, EOH providers could foster vaccination buy-in through conversations that aligned HCP personal motivations with important identities, for instant parent (e.g., “Do you want to bring this home to your kids?”).
Hyper-local testimonial, and word-of-mouth accounts from EOH providers and HCP peers was also a strategy to support acceptance: “The buy-in came because people were getting it and not having side effects, and then it was sort of like a tsunami... ‘Okay, well you got yours; I’ll get mine’.” Some EOH providers emphasized the importance of sharing their own personal story-- reasons why they had chosen to receive the vaccine (e.g., to see elderly parents, because they had witnessed even very careful co-workers contract it at work, because someone they knew personally had died) and their experience with vaccination. EOH staff reported that with such efforts, previously reluctant employees accepted vaccination. One MD described the process: “The vast majority of employees [got] vaccinated [right away], followed by a long trail, a slow trickle of employees that’s been pretty steady.”
Theme 4. Overcome misinformation through trustworthy communication
EOH providers noted feeling that they were “swimming upstream” against massive amounts of misinformation online, particularly on social media or targeting specific groups: “I think there’s a terrible misinformation campaign on the internet...many of the minorities who suffered a lot through the COVID pandemic are adversely affected by this misinformation.”
To address vaccine reluctance related to misinformation, EOH providers enumerated specific strategies that embrace trustworthy communication and promote trust-building, including tailoring communication to individuals and addressing COVID vaccines “in every encounter”; leveraging proactive institutional messaging (e.g., townhalls, Q&As) to reinforce information access and clear communication; and inviting open bi-directional conversations about hesitancy. One EOH provider noted, “take it one person at a time” in tailored communication to individuals, and suggested trust-building by addressing personal HCP concerns and fears “in every encounter”: “if someone comes in to get a COVID swab, I think we should be talking about the vaccine” (MD). On a larger scale, EOH providers had a strategy of communicating clear institutional messages for HCP through townhalls, email campaigns, educational presentations, and/or Q&A sessions that also allowed bi-directional communication (“We had several townhalls to allow employees to ask questions.”). EOH providers recommended expecting decisions to occur over time and through multiple bi-directional communications, including invited “shared decision-making” conversations that empower HCP.
Theme 5. Foster sharing and learning across teams and sites
EOH providers reported exhaustion from the constant experience of “reinventing the wheel,” resulting in the desire to learn from the ongoing experiences of other staff at their site and beyond: “it would have been so nice if people brainstormed together.”
EOH providers reported a primary strategy for sharing learning, which was to create or leverage infrastructure for cross-site learning and information sharing. Within their own sites, EOH providers cited email campaigns and memos from local site champions (who represented various disciplines and typically aided local vaccination campaigns) as key local sources for sharing information. VHA supported EOH teleconferences across multiple sites which were a well-received innovation to foster shared learning. For the flu mandate, EOH providers reported that the VHA allocated central resources to answer potential HCP questions.
Among EOH providers, a VHA-wide listserv was used to raise questions and share information about relevant topics, including the flu vaccine mandates and COVID-19 vaccine launch. As one respondent noted, “the listserv has been a big advantage...they can ask a question, and anybody can answer those questions.”