“It isn’t about health, and it sure doesn’t care”: a qualitative exploration of healthcare workers’ lived experience of the policy of vaccination mandates in Ontario, Canada

Introduction

When coronavirus disease 2019 (COVID-19) vaccines first became available in Canada and in other countries, healthcare workers (HCWs) were identified as a “priority group” for vaccination on grounds of their direct contact with vulnerable patients. Since then, anything less than universal vaccine uptake among HCWs has been framed as problematic [see for instance (1-3)], and achieving universal vaccination of HCWs deemed necessary—in the case of the World Health Organization (WHO) even an “equity” issue (4)—by most observers, health agencies, and researchers. Indeed, many influential health leaders in Canada have presented workplace mandates as critical to the protection of the healthcare workforce and to high quality of care (5-7).

Supporters of COVID-19-mandated vaccination policies for HCWs have put forth several arguments. For instance, they have underscored HCWs’ professional and moral duty to “put patients first”, implying that unvaccinated HCWs fail in these duties, while asserting that COVID-19 vaccines “have so few adverse effects that there is little risk to a vaccinated person’s health” [see for instance (8) (pgs. 1–2)]. Supporters have also highlighted bioethical principles, such as nonmaleficence or “do no harm”, and assumed that HCWs, with a fiduciary duty to “do the best action to achieve the ‘most good’ for society” (9) (pg. 246), should, to that effect, embrace vaccination (10,11). Finally, they have justified vaccine mandates on the grounds that “healthcare environments are held to a higher moral standard of safety” (12) (pg. 908), and that there is an “extra onus” on HCWs to “protect themselves from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in order to protect patients” (13) (pg. 1305). Universal vaccination of HCWs, achieved via mandates if necessary, has thus been framed as “essential for the health, safety and quality of life” of patients, especially vulnerable ones, such as those in long-term care settings (14) (pg. 1967).

In contrast, other researchers have identified negative impacts of mandated vaccination on healthcare capacity, patient care, and HCWs well-being. For example, Gur-Arie et al. noted the potential of mandates to add “occupational burdens to HCWs […], exacerbated during the COVID-19 pandemic” and to contribute to their “mass-exodus” (15) (pg. 341). There is also evidence that the joint effect of dismissals, early retirements, career changes, and vaccine injuries disabling some compliant HCWs from adequately performing has exacerbated existing labour shortages in an already overburdened healthcare sector (16-22). Other research has also challenged the scientific rationale informing vaccination mandates, highlighting the inability of COVID-19 vaccines to prevent transmission or infection (15,23), revealing similar viral loads among vaccinated and non-vaccinated persons (24), and underscoring significant evidence of serious adverse effects (25,26). Researchers in health care settings have also documented the contentious nature of vaccine mandates, especially those requiring vaccination as a condition of employment, noting that mandates have been challenged by a large number of HCWs, despite the significant costs of doing so—loss of reputation, employment, practice licenses, and personal relationships (27-30). Finally, the problematic ethical implications of mandates have also been noted. For instance, a systematic review of COVID-19 vaccine mandates for HCWs reported “polarised opinions” related to individual choices, human rights, professional duties, ethical responsibilities and personal risks (31) (pg. 12), leading some researchers to conclude that rather than contributing to equity, vaccine mandates may have disproportionately harmed marginalized and racialized groups of HCWs (15).

The negative considerations of vaccine mandates for HCWs notwithstanding, not only public health leaders, but also the expert literature, have largely sidestepped these challenges, assuming that COVID-19 vaccination is safe, effective, and necessary to protect vulnerable patients, pathologizing hesitancy to vaccinate, and focusing almost entirely on investigating, and elaborating interventions to overcome, this reluctance (32). This has been the case even for researchers sympathetic to non-compliant HCWs, some of whom have admitted to the coercive nature of vaccine mandates while maintaining their value and portraying non-compliant workers as either lacking education or misinformed [see for instance (33-36)].

While these dominant, overwhelmingly supportive views on vaccine mandates in the healthcare sector have been well-documented, scant attention has been paid to the lived experience and views of those affected by the policy, namely, HCWs themselves. To help fill this gap, we qualitatively examined the nature and grounds of vaccination decisions and views on the policy of mandated vaccination among HCWs by thematically analyzing open-ended entries in a cross-sectional survey exploring these issues among HCWs of mixed vaccination statuses in the province of Ontario, Canada. Our study is part of a broader mixed-methods project appraising the impact of the COVID-19 policy response on HCWs and on health systems (Open Science Frame Registration https://osf.io/z5tkp). We present this article in accordance with the COREQ reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-13/rc) (37).

Methods

This article reports the reflexive, thematic analysis (38) of one optional open-ended question (“Are there any other issues that you believe would help us to further understand the impact of the policies on healthcare workers and patient care? If so, please elaborate”) and of comments entered into open-ended options within a cross-sectional survey of Ontario HCWs, conducted between February and March of 2024 and described in an earlier publication (39). The research team consisted of three female investigators: a nonpracticing medical doctor with a Doctorate in Sociology and employed as a professor of health policy, one health researcher with a Master of Arts in Anthropology, and one health researcher pursuing a Master of Arts in the Health Sciences, with a joint experience in medical sociology and health services research of over four decades. Eligible participants included anyone working or having worked in a healthcare setting in the province of Ontario, currently or prior to the introduction of vaccine mandates, whether engaged in patient care, administration, or support roles. HCWs of all vaccination statuses and no restrictions of profession, experience, age, gender, socioeconomic status, and race/ethnicity were invited to participate (39).

While probability sampling ensures that every individual in the target population has an equal chance of being selected, making it more representative (40), in the interests of limited time, resources, as well as our own research goal (i.e., to explore the views of HCWs in Ontario rather than other social groups), we applied non-probability sampling methods, specifically, a purposive and snowball sampling approach (41,42), inviting participants through social media (e.g., X/Twitter) to pass recruitment materials to other eligible HCWs, and further advertised the study via the professional networks and contacts of the research team. Invitations were redistributed at 7-day intervals. Snowball sampling is particularly useful when participants can recruit others from their networks and is often employed when studying specialized populations (43,44). In purposive sampling, as in qualitative research more generally, researchers choose informants who are considered experts on the topic being studied (44). These sampling methods were jointly used to identify HCWs in the province of Ontario during the COVID-19 crises, regardless of employment status at the time of the survey.

Potential participants were provided an information letter and consent form, including details on the research team, the study aims, methods, potential benefits and risks, and information about confidentiality and consent. They were informed of their right to withdraw consent at any time without consequences. The online survey questions were only accessible to participants after providing their freely informed consent. The study was conducted following the Declaration of Helsinki (as revised in 2013) and was approved by the York University Office of Research Ethics (No. 2023-389).

Statistical analysis

Data from open-ended responses were extracted from the survey (originally in Google Forms and later transferred to a Word document) by one researcher and were read in their entirety by the full team. Two researchers coded the data through an iterative process involving inductive and deductive (i.e., based on research questions) codes (45), and the team met regularly to discuss findings and their interpretation. We did not perform any statistical analysis of the specific subsample included in this qualitative study because such analysis was not fitting to the data or our goal of reporting lived experience. Elsewhere we have reported descriptive statistics of the original survey (39).

Results

In total, 245 HCWs of an initial 468 respondents either filled out the optional open-ended question in the initial survey or elaborated on open-ended options to closed questions. Most respondents had remained unvaccinated or had not fully complied with vaccination requirements. Participants who lost their jobs described immense personal losses. Regardless of vaccination or employment status, however, their perspectives on vaccination policies/mandates were resoundingly negative. All but one respondent provided accounts of the harmful impacts of vaccine mandates on themselves, colleagues, and patients, and expressed frustration with policies in conflict with their medical training, workplace procedures, and bioethical principles. Our thematic analysis of the qualitative survey data identified six key themes, including: (I) policies at odds with scientific evidence, medical training, and usual professional practice; (II) policies at odds with medical ethics; (III) unaccounted or dismissed personal hardships; (IV) unaccounted or dismissed physical harms; (V) discrimination based on vaccination status; and (VI) negative impacts on patient care. In the following section, we elaborate on these themes and include verbatim quotations, with only minor editing for readability, to illustrate the views and experiences of HCWs.

Policies at odds with scientific evidence, medical training, and usual professional practice

Respondents described the policy response to COVID-19 as conflicting with their medical training and usual professional practice. Many also stated that vaccine mandates were unsupported by scientific evidence—particularly the lack of evidence for the ability of the vaccines to prevent disease transmission. One respondent commented that “the Pfizer trials weren’t even completed” when vaccination was mandated, and yet as part of their termination process this respondent was required to watch a public health “educational” video asserting that vaccines “were guaranteed (to) stop transmission and prevent illness and that side effects were pretty much non-existent, but none of that was completely true” (unvaccinated HCW). Another respondent described the vaccination policy as “unscientific and useless”, and noted that there was an “explosion of positive cases” among the remaining, fully vaccinated staff after the vaccine mandate was implemented (vaccinated HCW, completed primary series). Similarly, one respondent explained that “many of us did not take the vaccine because we knew unequivocally that this vaccine would not reduce infection and/or transmission” and recounted how they had acquired hospital data through a freedom of information request which “(demonstrated) that the staff COVID-19 infection and absenteeism rate went through the roof AFTER the mandate was put into action” (unvaccinated HCW).

Some respondents reported being terminated for not complying with vaccine mandates, often despite having worked throughout 2020 and even into 2021, prior to the introduction of mandates, and often over and above the call of duty. They also described being healthy yet losing their jobs for non-compliance, while vaccinated HCWs who tested positive were permitted to work. Respondents also lamented the fact that vaccination policies typically considered two doses of vaccine as sufficient for maintaining employment, long after evidence—even from Pfizer itself—had indicated that two doses were insufficient to protect from infection. For example, one respondent elaborated on how, in light of the evidence for waning vaccine immunity, policies permitting staff who had received just the primary series (two doses of vaccine) to continue working, while excluding non-vaccinated staff, were “nonsensical”, particularly when the healthcare system is “falling apart due to a lack of staff” (unvaccinated HCW). Another respondent disclosed that they had worked “through the worst of the COVID-19 epidemic, unvaccinated”, but were terminated in early 2021, to which they exclaimed: “I guess I was good enough when it was really busy, but (when) I refused to get vaccinated (I became) dispensable” (unvaccinated HCW).

Respondents also criticized how natural immunity acquired from previous infection was ignored in vaccination policies (partially vaccinated HCW, partial primary series). For example, one participant noted that “They dismissed natural immunity even with a blood test” (unvaccinated HCW). Many respondents were baffled by what they considered a lack of evidence-informed policy. As one nurse put it, in their 10 years of experience “this was the first and only drug” they did not receive training for—as they explained, there were “no seminars, no online training, no policies and procedure (…) questioning [the] product was shamed and shunned” (unvaccinated HCW). In the words of another respondent: “None of it made any sense!” (unvaccinated HCW).

Only one respondent to the open-ended question supported the implementation of workplace vaccine mandates, which they viewed as evidence-based and necessary to protect patients and the public. This HCW argued that “as public health workers, having knowledge of vaccines” and a conception that “(we) can easily spread viruses, we should be vaccinated for our own and our communities’ safety” (vaccinated HCW, boosted twice or more). Further, they stated that they “strongly” believed that “refusing to vaccinate without a valid reason is a reason to not work in healthcare”, and described HCWs who opposed COVID-19 vaccines as believing in “conspiracy theories”. In sum, all but one respondent underscored their opposition to COVID-19 vaccination mandates for HCWs, with some also noting lack of evidence for safety or efficacy and detailing other policy changes in healthcare settings that they perceived were at odds with fundamental medical ethical principles. It is to the description and analysis of these changes that we now turn.

Policies at odds with medical ethics

A salient theme among respondents was the breach of ethical principles, especially informed consent, within “vaccinate or terminate” policies. For example, one respondent shared their views that, by implementing mandatory vaccination “without knowing anything in terms of long-term studies, effectiveness and safety”, hospital administrators and leadership had abandoned key bioethical principles (unvaccinated HCW). Another respondent argued that “informed consent and bodily autonomy (are) the foundation that healthcare is built on”, yet these were principles that “no one seemed to care about” (unvaccinated HCW). One respondent even asserted that “the central theme of this entire tragedy is the importance of preserving the right to informed consent in all healthcare decisions in all situations at all times” (unvaccinated HCW).

Respondents often commented on the failure to obtain informed consent, not only from them but from patients and the public. For example, one respondent argued that “without fully informed consent, there is little justification for referring to what was being done in Ontario as ‘healthcare’” (unvaccinated HCW). Another respondent, a registered nurse, added that “patients could not give their informed consent…because the long-term side effects were (unknown)” (unvaccinated HCW). Some respondents offered further details to support their claim that there was no adequate information about COVID-19 vaccines to make an informed decision. For example, one nurse exclaimed that “The product inserts (for COVID-19 vaccines) were blank!!” and added that “there was never enough true, unbiased data to make a decision with informed consent” (unvaccinated HCW). As articulated by the following participant, incomplete or conflicting evidence notwithstanding, health leaders assured both HCWs and patients that COVID-19 vaccines were safe and effective. As one respondent, whose comments form the basis of the title of this manuscript, compellingly stated:

“(Health leaders) all abandoned the sacred principle of ‘informed’ consent because instead of truthfully saying ‘we don’t know yet’ with regard to the safety and efficacy of a Big Pharma product, they claimed certainty. Any thinking person could discern that there hadn’t been enough time or research to claim certainty. In shattering their own credibility and the trust of both HCWs and patients, they showed us all just how corrupted ‘healthcare’ is—in that it isn’t about health, and it sure doesn’t care” (unvaccinated HCW).

Finally, some respondents reported their experience of witnessing colleagues coercing patients to get vaccinated, which they argued violated patients’ right to informed consent. For example, a midwife recounted their distress when observing colleagues “go from providing excellent informed-choice care to suddenly pressuring…vulnerable pregnant clients to get this mystery shot”, describing this experience as “disturbing to say the least” (unvaccinated HCW). Likewise, another respondent commented: “I witnessed (a) doctor coercing a patient into taking the second shot, despite having (had) horrible side effects after the first one” (unvaccinated HCW). One participant expressed their disdain at HCWs who forced vaccination upon others, stating that: “(healthcare) professionals allowed themselves to be used as political pawns to coerce and frighten citizens into participating in (a) medication trial” (unvaccinated HCW). Yet another respondent criticized the hospital policy of refusing to admit infected, i.e., polymerase chain reaction (PCR) positive, patients and instead sending them home to quarantine for 2 weeks, stating that “this decision goes against the ethos of prescribing any reasonable medical intervention to help patients and staff” (unvaccinated HCW).

Unacknowledged or dismissed personal hardships

Another salient theme was that of unacknowledged or dismissed personal hardships—unacknowledged or dismissed, that is, by the authorities imposing the mandates. Thus, respondents relayed their experiences of employers terminating them due to non-compliance with the policy of vaccination, in full or in part, with no consideration of the personal impact of terminations, and despite the significant financial consequences that ensued. They recounted substantial and ongoing loss of income, including specific hardships, such as feeling coerced into early retirement, being denied severance, having to spend their lifetime savings, struggling to pay their mortgage, needing to sell off assets, being denied unemployment insurance, and relying on support from partners, relatives, or friends.

One respondent said, “being unvaccinated left me below poverty (as a single mom with two kids) and I am still unable to find work in my line of healthcare to this day, as the mandates still continue” (unvaccinated HCW). A scheduling coordinator who worked alone in an office, and later from home, disclosed how they were terminated for not complying with a workplace vaccination policy, and as a result “lost out on two years of income”, as well as employer contributions and a full-time position that became available after they were terminated (unvaccinated HCW). A registered nurse, terminated for non-compliance, also relayed the financial hardship they experienced:

“From 2020–2021’s end, I worked in a Covid Unit. Unvaccinated. When I refused to get vaccinated, I got fired. 25 years as an RN in a country that says we are short of nurses to care for patients I got fired. I had to sell my house. It felt like I suddenly was dropped into 1930’s Germany, and I was the wrong race. The sheer prejudice from people who didn’t agree with my choice of what I put into my body was overwhelming. It’s changed my whole worldview. I will never forgive this. Ever” (unvaccinated HCW).

Like this respondent, many others also expressed feeling betrayed by their employer despite years of devoted service to their profession. One participant reported, “I was fired while on a sick leave, denied benefits, EI (employment insurance) and WSIB (workplace safety and insurance board insurance). I lost my house, almost lost my mind! 22 years with the same employer and I got fired.” (unvaccinated HCW). Some respondents who were terminated also felt a profound loss of identity due to the loss of their occupation and role as a HCW, and many revealed experiencing poor mental health as a result. One respondent stated that HCWs had “lost their minds and their ethics over Covid vaccines,” and reported how they were “forced to take a dose despite being in a low-risk group when they knew (the vaccine) didn’t stop transmission” (partially vaccinated HCW, partial primary series). As a result, they said, “Now I feel lost, my identity gone.”

Another respondent explained, “our pride and passion for the job, that was already hanging by a thread, was irreparably, maliciously severed” (unvaccinated HCW). HCWs who were terminated suffered mental, emotional, and social hardships, sometimes requiring counselling due to the extreme distress. For example, one respondent explained: “I decided to get counseling because of anger and depression of losing my job and of discrimination. Friends snubbed me. EI denied me after 53 years of working” (unvaccinated HCW). Another respondent said that they felt they had developed “some form of PTSD because of vaccine mandates”, concluding that these had “impacted almost every area of (their) life” (unvaccinated HCW).

Multiple respondents described the experience of losing their job as “life-changing”, leading them to feel a complete loss of trust in the healthcare industry and the government. For example, one respondent said: “I feel like (the vaccine mandates) crushed my spirit and made me not enjoy working in healthcare anymore,” adding that they felt as though they were “working for a corrupt system”, “everyday” they thought of leaving (unvaccinated HCW). One respondent, terminated for non-compliance with mandatory vaccination, commented that they “will never (again) trust a union” or “the health care industry” and that their “views (had) changed towards everything” (unvaccinated HCW). One partially vaccinated respondent who had experienced adverse effects preventing further vaccination and, as a result, was terminated, explained the immense personal losses and the profound loss of trust they experienced:

“I was terminated from my job for not getting (the) second vaccine even though I was off work for 2 years due to vaccine harm. I lost everything—my marriage, my health, my home and friends. This has been a devastating experience. I no longer trust hospitals, doctors and our government (partially vaccinated HCW, partial primary series).”

Some fully vaccinated respondents also disclosed significant personal hardship related to vaccination policies. Specifically, those who felt coerced to be vaccinated described emotional distress because they could not afford to “be terminated without pay or unemployment insurance” (unvaccinated HCW). Some respondents, who revealed that they could not afford to not comply and, as a result be terminated, recounted waiting until the final day to get vaccinated, or until they witnessed their employer fire other colleagues. One of them commented: “I was forced and coerced against my will. I had to keep my job as I’m a single parent and honestly, I’m angry about it. I felt like I had a gun to my head” (vaccinated HCW, completed primary series).

Unacknowledged for or dismissed physical harms

A salient theme was the belief, often conviction, among many respondents that unacknowledged or dismissed health problems among their vaccinated colleagues, such as increased rates of illness and disability, may be related to the vaccine. For example, one respondent posed the question: “How many people (are) still employed but are on sick leave from vaccine injuries?” (unvaccinated HCW). Another one noted that their colleagues “got sick more often after getting (the) vaccine, and had side effects (e.g., post-menopausal co-worker started vaginal bleeding)” they thought were vax related, but they did not admit it (unvaccinated HCW). In contrast, some vaccinated respondents did disclose adverse effects that they had experienced, and attributed it to the COVID-19 vaccines, including having a “severe reaction—facial drooping after the second dose”, “develop(ing) breast cancer in the breast on the side (of) the shots”, “changes to menstruation”, and “heart issues”, and speaking to their family physicians about them, yet being “ignored” or “told it wasn’t from the vaccine. Completely gaslit” (vaccinated HCW, completed primary series). One respondent who had voluntarily received the first vaccine dose disclosed that they had experienced a severe adverse reaction, requiring them to go on short term disability and causing them to feel “suicidal at some points”, yet when they were denied a medical exemption to decline the second dose, they ultimately left their healthcare institution (partially vaccinated HCW, partial primary series).

Similarly, many respondents reported suspecting that health problems among patients may be linked to COVID-19 vaccination and appeared frustrated that the causes of these problems were not investigated, or if they were, they were assumed without further examination to be unrelated to vaccination, whether by those tending to sufferers or by sufferers themselves. So, for instance, one respondent stated that there “are many, many people experiencing vaccine-related negative effects (and many experiencing negative events that we now know could be vaccine-related), but those people do not attribute those to the vaccines” (unvaccinated HCW). Another respondent, a long-term care worker, said that “very little attention was paid to adverse events in residents of long-term care. Deaths were never linked to the so-called vaccine” (unvaccinated HCW). Yet another one explained that “any medical concerns with unknown cause are (arbitrarily attributed to) long Covid rather than exploring other possible causes (like vaccination)” (unvaccinated HCW). A physician who witnessed post-vaccination harms among their patients commented:

“I know for a fact the vaccine killed many of my patients. I also suspect (it) has caused hundreds of secondary effects, i.e., cancer, autoimmune disease, transverse myelitis, GBS [Guillain-Barre Syndrome], strokes, and increased heart attacks and arrythmias. I have 14-years-old with A-FIB (atrial fibrillation). No one is talking about it!? There was a systemic program to ensure compliance was enforced and any dissent was punished. There was NO interest in adverse effects.” (vaccinated HCW, completed primary series).

One respondent who “worked with people on the Covid floor (who) had tested positive for COVID-19” said that when “vaccines (were) introduced we had healthy people dying, paralyzed, severely sick…there (were) more patients in the hospital after the Covid vaccine than there were with Covid” (unvaccinated HCW). One respondent expressed their “concerns over the ongoing silence around adverse events causing patient symptoms (specifically in the case of cardiac events)” (unvaccinated HCW), while another participant explained that patients would “confide their (vaccine) injuries” yet HCWs were powerless to help, even if they wanted to. Notably, those concerned about vaccine safety commented that they “were not allowed to talk about it” and that “safe and effective was heavily repeated”, which they framed as “not science…(but) propaganda” (unvaccinated HCW). This sentiment was echoed by another participant who said: “There was no scientific debate allowed, every voice heard echoed the same slogan ‘it’s safe and effective’ (and) if you didn’t say the same thing, you were canceled or ignored or shamed” (unvaccinated HCW).

Discrimination according to vaccination status

Many respondents vividly described the discrimination they experienced from employers, the larger society, and even colleagues due to their vaccination status and choices. For example, one respondent shared that “employees (who) were not vaxxed were told they were a danger to the rest of the staff” (unvaccinated HCW). Another one noted that: “We were shunned, humiliated, ostracized, we were called grandma killers, the Toronto Star (a Canadian English-language daily newspaper of liberal/progressive political persuasion) published a paper saying the unvaccinated should die!” (unvaccinated HCW). For many respondents, the discrimination they experienced or observed was too much to bear, causing them to lose immense trust in the healthcare system or even leave their profession. For example, a nurse explained: “one nurse friend took the vaccine under duress and worked only a few weeks because of the strong negative attitude towards unvaccinated patients and staff” (unvaccinated HCW). Another respondent noted the hypocrisy of “job postings (that) pay lip service to inclusion and diversity and non-discrimination”, while openly discriminating against HCWs with non-conforming health care needs or preferences (unvaccinated HCW).

As well, a salient theme within the theme of discrimination was the animosity within the staff because of mandated vaccination, which created a “toxic, divisive and scathing and shaming work environment” (unvaccinated HCW), where many non-compliant respondents were rejected even by long-time colleagues and friends. As one respondent put it: “I felt very judged for the decision I made, as if I was the reason patients were dying” (unvaccinated HCW). Another participant relayed how they were “made to feel as if (they were) nothing and had contributed nothing during a decades long career”, describing “divisiveness and anger between vaccinated and unvaccinated healthcare staff”, which they felt to be “as bad as the terrible and coercive management response” (unvaccinated HCW). As a result of the toxic and discriminatory work environment, some respondents with many years of experience had left the profession. For example, one nurse who was previously employed in a neonatal intensive care unit (NICU) said: “being villainized and the extreme sense of alienation with my former team-mates after 40 years of working together in the very close and interdependent environment of the NICU makes the return to the NICU inconceivable” (unvaccinated HCW).

Many respondents also observed serious discrimination against patients who were unvaccinated, which significantly impacted the quality of patient care. So, for instance, one respondent suggested to “do a poll on how many (HCWs) are traumatized by hearing colleagues tell unvaccinated patients I hope you die” and stated that “the ruthless statements people made forever haunt me” (vaccinated HCW, completed primary series). Another respondent commented that “the way colleagues treated those [who were] unvaccinated was stomach-turning” (vaccinated HCW, completed primary series). A nurse who worked in an emergency room reported how unvaccinated patients were discriminated against when “the triage nurse would literally tell the waiting room nurse to put them at the end of the line regardless of their acuity rating” (unvaccinated HCW). Yet another respondent commented: “I saw patients verbally scolded for not being vaccinated. I have family members who were not fully vaccinated and were treated like second-class citizens.” (vaccinated HCW, completed primary series).

Respondents provided further examples of how unvaccinated patients were treated poorly, including denying in-person patient care due to vaccination status and more generally “not treat(ing) patients with diligence and respect (in word and deed) when the patient was not vaccinated” (unvaccinated HCW). Additionally, a salient example of discrimination against unvaccinated patients reported by several respondents was denying patients “life-saving transplants if they didn’t receive the Covid vaccines” (unvaccinated HCW). Furthermore, another respondent exclaimed: “Unvaccinated patients are still being denied lifesaving treatment and surgeries due to their status. Discrimination!” (unvaccinated HCW). Respondents also chronicled how unvaccinated people were denied access to visit loved ones in hospital care, negatively impacting the quality of care of patients of all vaccination statuses. For example, one respondent recalled that women in labor were prevented from being with their unvaccinated partners during the birth of their child:

“I worked labour and delivery, and for a while, partners were not allowed at (appointments). And if the partner (wasn’t) vaxxed (they were) not allowed at births.” (unvaccinated HCW).

Similarly, one respondent reported how they were unable to attend appointments with their elderly mother who had cancer because they were unvaccinated and how their mother was “harassed daily by staff at check in and isolated during hospital stays” because she also was unvaccinated (unvaccinated HCW). Finally, one respondent described feeling “disturbed” after witnessing unvaccinated people being refused access to visit a dying loved one and “coworkers (RNs) saying that unvaccinated parents should not be allowed into the hospital to be with their baby or child” (unvaccinated HCW).

Negative impacts on patient care

In addition to unacknowledged physical harms and severe cases of discrimination against patients, respondents also noted that vaccine mandates had led to a “critical shortage of healthcare workers” when HCWs were either put on leave or terminated, with negative impacts on patient care, for instance, delayed treatments (unvaccinated HCW). Some respondents expressed surprise that hospital administrators would implement mandates when they were well aware of the impact on healthcare capacity. As one respondent compellingly put it: “I’m shocked that hospitals which were already seriously understaffed and knew the risks of burnout on patient, safety and quality care, proceeded with Covid vaccination mandates that left the remaining staff with no replacements and put the public at peril” (unvaccinated HCW).

According to many respondents, because of vaccine mandates and terminations for non-compliance, hospitals were “working short staffed continuously putting both the patients and staff at risks for safety” (unvaccinated HCW). One vaccinated respondent who continued to work for the hospital observed the negative consequences of vaccination policies on patient care, noting that “so many health care workers were terminated due to the mandates” that “the greatest impact on patient care (has been) the lack of staff to care for them” (vaccinated HCW, completed primary series). Another respondent employed in an operating room (OR) articulated how vaccine mandates negatively impacted healthcare capacity, explaining that:

“(Despite) the hospital CEO ‘guaranteeing’ to the public that vaccination policies would not impact patient care, when employees were fired due to vaccination policies, two ORs were closed and have not been reopened yet, over two years later. 2 ORs × 5 days per week, that’s about 250 less surgical days per year than previously... How can that NOT impact patient care?? Especially in a system that was barely keeping up with demand even prior to Covid.” (unvaccinated HCW).

In addition to reducing healthcare capacity, respondents highlighted how the termination of experienced HCWs had directly worsened the quality of patient care, with one of them noting that the “majority of fired workers also were older and experienced” and that “this impact is overlooked” (unvaccinated HCW). One such terminated respondent explained: “I did everything to provide the best care and as safe as possible. In the peak, I was my patient’s family” (unvaccinated HCW). Similarly, a nurse who was terminated for non-compliance commented that based on their “experience and observation, Ontario has lost some of its ‘best’ health care providers” and described how prior to the COVID-19 crises they were “known as one of the ‘better’ nurses in my unit” who provided “compassionate care to each patient” (unvaccinated HCW).

Another reason provided by respondents to explain the deterioration of patient care was the hiring of junior, less experienced nurses, including nursing students, that they viewed as causing “many safety risks to patient care, as there aren’t enough experienced/senior staff to train the junior staff properly” (unvaccinated HCW). Similarly, another respondent said: “for many months to a year or more, unqualified staff (have been) preforming duties that only certified staff should have performed” because of short staffing due to terminations—which they described as an “abandonment of best practices” and the provision of “poor quality care” (unvaccinated HCW).

COVID-19 policies, including but not limited to mandatory vaccination of HCWs, appeared to have disproportionally affected vulnerable patients, such as the elderly in long-term care settings. For example, one respondent highlighted the negative impacts of isolation on elderly patients, noting that “isolating patients and elderly in retirement homes from family members was detrimental to their mental and physical health” (unvaccinated HCW). Likewise, a long-term care home worker disclosed how early in 2020, due to concerns over scarce resources, HCWs were instructed “to conserve supplies (such as gloves and gowns), essentially not giving extra care to the residents that were ill”, while the residents were “shut in their rooms lacking care and human interaction” (unvaccinated HCW). Disturbingly, one respondent noted that “Healthcare workers were forced to not allow families with dying patients and therefore took on the toll of being the last (and) only person that dying patients were with” (unvaccinated HCW).

Discussion

Respondents in our study, regardless of vaccination status, overwhelmingly experienced workplace COVID-19 vaccine mandates as negative, recounting multiple hardships—emotional, psychosocial, financial, and physical—when vaccine mandates were implemented. Most respondents did not comply with them, in full or in part, and as a result, many were terminated and experienced extreme financial losses, conflicts with colleagues, friends, and family, and poor mental and emotional health. Specifically, terminated respondents also expressed feeling a profound loss of their identity and role as HCWs, no longer recognizing or trusting the profession and healthcare institution to which they had been dedicated, sometimes for decades. Many also noted that mandated vaccination ignored contradictory scientific evidence, including the age-stratified risk of serious disease; the inability of COVID-19 vaccination to prevent infection, transmission, or serious outcomes; as well as the potential for serious adverse effects—we elaborate on these points shortly.

As well, many respondents articulated how their safety concerns and medical training were regularly dismissed in favour of a dominant, “safe and effective” narrative promoting vaccination, even against their best clinical judgment. Many also witnessed negative impacts on both access to and quality of care because of COVID-19 policies—particularly vaccine mandates—in healthcare settings, which led to discriminatory treatment against them and against patients. Finally, respondents also relayed how vaccine mandates conflicted with fundamental principles of ethical medical practice, especially the principle of informed consent, reporting on their distress as a result of witnessing violations of this principle. Unsurprisingly, given this experience, most participants, regardless of vaccination status, opposed Covid vaccination policies or mandates for HCWs. However, one vaccinated respondent supported the mandate, arguing that HCWs should be vaccinated to protect themselves and their communities—implying that unvaccinated HCWs represented a threat to themselves and to patients, whereas vaccinated ones did not—and that refusing vaccination disqualified such HCWs from frontline healthcare roles.

While in our study, opposition to COVID-19 vaccine mandates was high, other studies of HCWs have reported ranges of support from very low to very high. For example, a systematic review and meta-analysis of studies examining HCWs’ attitudes towards COVID-19 vaccine mandates for HCWs found that as many as 84% of HCWs and as few as 11% of HCWs supported mandates (46). As well, the authors observed as a “very important finding” that the review may be biased due to the inclusion of many small “high risk of bias” studies reporting very high rates of acceptance (over 80%) of COVID-19 vaccine mandates, further noting that small studies with poor methodology often lead to data asymmetry, with editors favoring significant or positive results for publication (46). They also granted that “safety concerns were prominent among HCWs”, even if, in their view, the “benefits of COVID-19 vaccination clearly outweigh the risks” (ibid, pg. 18), although they offered no evidence to support this assertion.

Another systematic review examining the impact of mandates on uptake concluded that mandates were “effective” in increasing uptake and did not lead to “major disruption of health services”; however, the authors admitted that “less well-resourced areas may have been more impacted” and that “there is insufficient literature on the impact of the vaccine mandate on reducing SARS-CoV-2 infection among HCWs” (47). Their conclusions that mandates were “broadly successful in increasing vaccine uptake” notwithstanding, the authors offered no evidence that mandates had stopped or reduced transmission rates, the scientific rationale for implementing them; they also did not discuss methodological biases in their sampling methods, for instance, the criteria to select for analysis “studies that included individuals working on-site at a healthcare facility or delivering healthcare services at clients’ homes or in community settings (or) providing administrative and support roles in health facilities” (ibid, italics added) (pg. 1024), which limited their ability to capture the circumstances of terminated HCWs no longer engaged in any of those tasks.

In addition, we observe that despite high support for mandates reported in some studies, rates of support are still lower than the vaccination rates among HCWs reported in the literature, of over 80% overall and over 90% among some health professions (e.g., physicians) (48). We propose that this gap may be a measure of the percentage of vaccinated HCWs who reject mandates for ethical reasons or of HCWs who oppose mandates but were nevertheless coerced into vaccination because they could not afford losing their jobs or withstand the emotional distress of being stripped of their professional identities of a lifetime. While in this study, it was not our goal to test this hypothesis, we identified some evidence to support it in the high rate of HCWs, including the minority of vaccinated ones, who reported feeling unfree to decide against vaccination. If this were the case, our finding would challenge the widespread assumption that high vaccination rates indicate strong support for the practice. We also note that acceptance of mandates for HCWs also varies widely among countries, with one nationwide UK study of close to 18,000 HCWs reporting only one in six, or 18%, support for the policy (3).

Evidence of discrimination among staff and patients in healthcare settings has been reported in other studies. A qualitative study of HCWs in Belgium found that both vaccinated and unvaccinated HCWs witnessed the provision of “suboptimal care” of unvaccinated patients and “ruptured social relations with peers and patients holding divergent vaccine sentiments” (49) (pg. 888). A study by Sinsky et al. of HCWs exploring their attitudes toward unvaccinated patients also reported decreased empathy and increased negative emotions towards unvaccinated patients. The study found that many physicians in their survey reported moderate or greater reductions in empathy (56.2%), greater resentment (48.5%), and greater anger (43.6%) towards unvaccinated patients compared to vaccinated patients, especially among physicians in critical care and emergency medical settings (50). However, rather than discussing these findings in the context of COVID-19 policy and public health messaging that promoted divisiveness based on vaccination status, and encouraged the segregation of unvaccinated individuals, the authors framed the “erosion of compassion and empathy” as resulting from the “politicization of medical care”, burn out, and compassion fatigue, particularly from caring for seemingly recalcitrant patients who have “reject(ed) medical science” (50) (pg. 1626).

Financial losses, as well as loss of trust in the health system and the health profession more generally observed in our study, have also been reported in the literature. For example, in their critical review on the “ethics of nudging”, Junger and Hirsch described the dehumanization of the “unvaccinated”, and the “social atmosphere of hatred and agitation” against people who decided against COVID-19 vaccination, “so they were even threatened with financial disadvantages” (51) (pg. 11). Similarly, in their analysis of COVID-19 vaccine mandates, passports, and restrictions, Bardosh et al. concluded that “mandatory COVID-19 vaccine policies have had damaging effects on public trust, vaccine confidence, political polarisation, human rights, inequities and social well-being” (16) (pg. 1).

Policies at odds with usual medical training and fundamental bioethical principles have also been reported. For instance, counter to the proponents of mandatory vaccination, who have claimed that vaccine mandates are “a way of nudging people to do the right thing” (8) (pg. 1), critics have noted that “nudges”—or in the case vaccine mandates, “pushes and shoves”—are coercive, because they require either full compliance or the risk of job loss and social ostracization. As described by Junger and Hirsch “being given the choice of either getting vaccinated or losing your job instead is not a free decision in the sense of voluntary informed consent, which is the bioethical basis for any medical intervention” (51) (pg. 10).

Ignorance, neglect, or outright suppression of evidence that contradicts the policy of mandated vaccination have also been reported in the literature. To mention a few such instances, the failure of COVID-19 vaccination to protect either HCWs or patients and their ability to cause significant harm are well documented. For instance, studies conducted specifically with HCWs have reported high rates of local side effects following COVID-19 vaccination (52-54), and systemic issues such as Bell’s palsy and hearing loss (53). Other studies have also reported menstrual cycle changes among women following COVID-19 vaccination (55) and local side effects among women who received a COVID-19 vaccine during pregnancy (56). More recently, one study of over 99 million participants indicated an observed vs. expected (OE) ratio for acute disseminated encephalomyelitis of 3.78, for cerebral venous sinus thrombosis of 3.23, and for Guillain-Barré syndrome of 2.49, and an excess risk of serious adverse events of special interest, including death, between 10.1 and 15.1 (25). Yet this evidence is all but ignored by the literature promoting vaccine mandates for HCWs as “an effective policy tool for past and future pandemics” (57).

Likewise, multiple cases of “breakthrough” infections, i.e., cases of failures of the vaccine to stop transmission, have occurred and have been reported among fully vaccinated people in healthcare settings. Examples include a “super-spreader event” among fully vaccinated patients and staff in an acute care hospital (58), an outbreak in a nursing home with fully vaccinated staff and residents (59), an outbreak among residents in a long term care home in which nearly all (97.3%) were vaccinated (60), and an outbreak in a medical centre that started with a vaccinated patient and spread among a highly vaccinated (96.2%) patient population and staff (61).

As COVID-19 unfolded, significant evidence accumulated that called into question claims about vaccine effectiveness. For instance, Chemaitelly et al. found that while mRNA vaccines provided moderate protection against symptomatic infections from Omicron BA.1 and BA.2 in the first three months, this protection quickly diminished to nearly zero after that (62). Booster doses temporarily restored effectiveness, but it declined again over time. Similarly, Eythorsso et al. found that reinfection rates during the Omicron wave were unexpectedly high, particularly among younger adults, with those who received two or more vaccine doses having a higher risk of reinfection (63). Feldstein et al. reported that prior infection provided significant protection against reinfection in young children, while vaccination alone did not (64). Finally, Shrestha et al. observed that individuals with more vaccine doses had an increased risk of contracting COVID-19, challenging the belief in the benefits of repeated vaccinations (65).

In sum, these and multiple other studies challenge official claims that COVID-19 vaccines prevent or dramatically reduce transmission, presented as the scientific rationale for mandatory vaccination. However, as noted by Junger & Hirsch, proponents of mass, mandatory vaccination offer “one-sided arguments and viewpoints”, use “soft power techniques such as nudging” to persuade the public, assign “inflated efficacies compared to the actual empirical results” of studies on mass vaccination, and label “misinformation” anything that contradicts the official narrative (51) (pg. 11).

In line with another salient study finding, the negative impact of workplace vaccine mandates on healthcare capacity and patient care has also been well documented. Indeed, with healthcare capacity in Canada already stretched prior to the COVID-19 crises, the loss of HCWs due to mandates has exacerbated the crisis. Thus, while Canadian public health officials and experts have often minimized the impacts on labour shortages (66,67), evidence from several jurisdictions indicates that some of them were compelled to reconsider workplace mandates due to potential workforce shortages. For example, in 2021, Quebec reversed its decision to require vaccination or termination of HCWs based on the anticipated hospital labour shortages it would cause (16).

COVID-19 vaccine mandates in healthcare settings appear to have also exacerbated healthcare labor shortages beyond Canada. For instance, a working paper from researchers from the National Bureau of Economic Research in the United States found that state level vaccine mandates for US HCWs increased staff shortages—the probability of working in healthcare declined by 6%—and that mandates resulted in a greater loss and slower replacement of workers in healthcare-specific occupations compared to non-healthcare occupations (68). One study conducted in Oregon reported increased staffing challenges due to vaccine mandates in primary care settings with disproportionate effects for rural settings and with greater negative impacts than previously reported with other vaccination mandates in hospital settings (69). In the United Kingdom, the National Health Services (NHS) was forced to reconsider, and eventually to drop, vaccination mandates for HCWs, because of their anticipated negative impact on already strained healthcare resources (16,70).

This study has limitations, many inherent to the controversial nature of the object of study, in that the impact of vaccination policies on HCWs is very hard to document because, as we and others have argued (71,72), experiences that do not fit official COVID-19 policy and narratives tend to be misrepresented, demonized, dismissed, or suppressed. These experiences, however can be gleaned from the websites of independent organizations. For instance, in Canada, the National Citizen’s Inquiry, a “citizen-led and citizen-funded effort to examine Canada’s response to COVID-19”, spanned 2 years, eight cities, and over 300 testimonies and included testimonies from HCWs (73). Similarly, React19, a nonprofit organization co-funded by two vaccine injured persons, one of them a medical doctor, hosts a collection of peer-reviewed articles providing evidence for adverse effects post COVID-19 vaccination, and offers continuing “financial, physical, and emotional support for those suffering from long term COVID-19 vaccine adverse events globally”, many of them HCWs, including the organization’s own co-founder (74).

Another limitation of our study, common in qualitative research, is that we relied on a non-probability sample, thus, our findings are not generalizable to all HCWs. The debate about whether or how qualitative research should be generalizable highlights the differences between research approaches: quantitative research emphasizes statistical generalization based on probability, while for qualitative research, which employs smaller samples and focuses on understanding social realities from participants’ perspectives (called the “emic approach”) (44), the primary goal is not generalization but transferability, where readers apply research findings to their own experiences or contexts (75,76), and which requires the careful, detailed description of these contexts by the researcher (77), as we have attempted to do. Although qualitative research is criticized for its small sample sizes and potential researcher bias, it offers rich, detailed data that quantitative methods are unable to provide, helping to explore diverse cultural experiences and beliefs (41), thus is of particular value in healthcare research, as it is now widely recognized (78).

Yet another limitation is that while recruitment was open to participants of all vaccination statuses, most respondents were unvaccinated, and only one expressed support for the policy of mandated vaccination—perhaps unsurprisingly given the reported negative experiences of most respondents. Had we attempted to recruit primarily vaccinated HCWs, we may have found higher rates of support for vaccine mandates, but our recruitment approach had no such restriction. With that being said, we theorize that unvaccinated respondents may have been more likely to participate in a study on vaccine mandates because of the impact of the policy on their lives and livelihoods and the lack of opportunities to have their voices heard; our examination of the literature indicates that most studies recruiting strategies target HCWs within healthcare establishments, thus biasing samples by excluding laid off workers, thus the interest of the latter in participating in our study.

Further, given that workplace vaccination mandates included penalties such as loss of job for refusals to comply, in full or in part, it is also very likely that, as with our very small number of vaccinated HCWs, high rates of vaccination among HCWs measure less support for vaccination than the coercive nature of the policy. Future research should explore the trends identified in our study, both the qualitative and quantitative portions, such as the experience and high rates of coercion among all HCWs and of adverse effects reported by the minority of vaccinated HCWs (39).

Conclusions

In conclusion, our data indicate that a discriminatory system has been imposed on HCWs who have not complied, in whole or in part, with workplace COVID-19 vaccination policies, a system that suppresses the voices and perspectives of these HCWs, and violates their rights to “pursue both their material well-being and their spiritual development in conditions of freedom and dignity, of economic security and equal opportunity” (79). While critics may counter that differential treatment of these HCWs is justified because they threaten health systems and patients, as we have argued, a preponderance of evidence challenges this assertion. Additionally, the right to informed consent, enshrined across classic documents (80-82), includes the right to be fully informed about the risks and benefits of, and alternatives to, any medical intervention, to be offered the alternative to do nothing, and to be able to choose free from coercion. Finally, mandates are at odds with the principles of equity, diversity, and inclusivity, which are held normatively in high esteem by the same health care institutions that appear to be subverting them in practice (83,84). These ethical violations, compounded by the mounting lack of evidence of effectiveness of COVID-19 vaccination to stop viral transmission—this effectiveness proposed as its scientific rationale—call for an urgent reconsideration of the practice.

Acknowledgments

C.C. thanks the many professional and lay organizations, students, trainees, and friends who have afforded spaces of reflection and debate over the past years, and especially Julian Field, for his invaluable editorial feedback and continuing support. N.H. thanks her family and friends for their encouragement and support, and C.C. for her mentorship. R.M. thanks her friends, family, and C.C. for their support and guidance. All authors are grateful to the participants for sharing with us their life experiences and making this study possible.

Footnote

Reporting Checklist: The authors have completed the COREQ reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-13/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-13/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-13/prf

Funding: This work was supported by a New Frontiers in Research Fund (NFRF) 2022 Special Call, NFRFR-2022-00305. The funders played no role in the conception, conduction, or publication of this study.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-13/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted following the Declaration of Helsinki (as revised in 2013). The study was approved by the York University Office of Research Ethics (No. 2023-389). Potential study participants were provided an information letter and consent form, including details on the study aims, methods, potential benefits and risks, and information about confidentiality and consent. They were informed of their right to withdraw consent at any time without consequences. The online survey questions were only accessible to participants after providing their freely informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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