COVID-19 vaccination decisions and impacts of vaccine mandates: a cross-sectional survey of COVID-19 in Alberta, Canada

Introduction

Vaccination mandates for healthcare workers (HCWs) in the Canadian province of Alberta unfolded within a broader environment of highly polarized political discourse and contested public health responses during the coronavirus disease 2019 (COVID-19) period. Early in the national vaccine rollout, Alberta exhibited the highest levels of vaccine refusal in the country: by April 2021, 28% of Albertans—nearly twice the national average—reported that they were unsure or unwilling to be vaccinated (1). By September 2021, as Premier Jason Kenney warned of a “pandemic of the unvaccinated” straining the healthcare system (2), and one physician publicly claimed that unvaccinated patients were testing HCWs’ “bank of compassion” (3), vaccination uptake remained well below the national rate (4).

Against this context of uneven vaccination uptake and heightened public debate, Alberta Health Services—the provincial public health authority responsible for delivering healthcare services—introduced a vaccination mandate for employees, contractors, and visitors to healthcare institutions, framing it as broadly supported based on high reported vaccination rates among staff (5). However, implementation encountered tensions within the healthcare workforce and between HCWs, public health authorities, professional colleges, and unions, as well as between policy goals and workforce realities, with deadlines extended due to anticipated staffing shortages, particularly in already underserved regions (6). As mandates were rolled out, protests occurred outside healthcare facilities; a small number of clinicians requested testing alternatives and objected to what they perceived as the scapegoating of unvaccinated individuals (7), while others raised concerns about the erosion of informed consent and were subsequently criticized by Alberta’s medical college for spreading “misinformation” (8).

By early 2022, Alberta’s policy direction had shifted markedly. Premier Kenney was reported as stating that vaccinated individuals were “effectively just as likely” as the unvaccinated to transmit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and that mandates were therefore “no longer useful”, requesting that Alberta Health Services reconsider the policy (9). Under Premier Danielle Smith, who campaigned on ending mandates, this shift intensified, and a committee was established to review pandemic policies (10). These developments—including selected recommendations by the task force, such as halting COVID vaccination for healthy children—were met with strong reactions from political and medical actors, who characterized them as “abusive, anti-science, and conspiratorial” (11). By July of that year, Alberta rescinded its vaccination mandate (12).

Alberta’s trajectory—characterized by the coexistence of sharply divergent and publicly contested perspectives documented in policy and public discourse—reveals a particularly intense tension within the healthcare workforce regarding COVID-19 vaccination mandates. Much of the literature has framed this tension as a problem of “vaccine hesitancy” or insufficient “vaccine confidence” among what is typically assumed to be a minority of non-compliant HCWs [see, for example, (13-17)], thereby representing such positions as deficits in knowledge, trust, or professional ethics. However, even early in the COVID-19 period, the assumption that the science and ethics of mandatory vaccination could be treated as settled matters was itself subject to ongoing debate prior to, and throughout the first phase of, the vaccine deployment.

Already by September 2020, data on COVID infection fatality rate (IFR) suggested substantial risk stratification by age: Ioannidis estimated a median IFR of approximately 0.27% overall and 0.05% among individuals younger than 70 (18), a pattern later confirmed at scale (19). Other early analyses questioned assumptions about uniform susceptibility and transmission dynamics, pointing instead to variability in immune response, including evidence of pre-existing antibody reactivity in uninfected individuals (20). A large, multicenter cohort study across English hospitals including data largely from the second half of 2020 showed that previous infection with SARS-CoV-2 was associated with an 84% lower risk of infection at seven months in a sample of over 25,000 HCWs, providing further support for the protective effect of natural immunity—as the authors noted, “independent from the vaccine effect” [1467] (21).

By the end of 2020, Doshi, Senior Editor at The BMJ, observed that pivotal vaccine trials were not designed to determine effects on transmission, hospital admission, or mortality (22). In later commentary, he further observed that access to underlying trial data remained limited well after initial publication, raising concerns about transparency and independent verification (23). Subsequent analyses raised further concerns regarding the interpretation of vaccine effectiveness estimates, including the reporting of relative risk reduction without corresponding absolute risk measures (24)—the latter considered by the US Food and Drug Administration the more clinically meaningful metric (25).

In the spring of 2021, following vaccine rollout, reports emerged of substantial transmission in highly vaccinated populations (26), with subsequent reports documenting similar occurrences in medical establishments involving partially and fully vaccinated patients and HCWs (27,28), complicating promising reports of short-window relative efficacy (29). By the summer of 2021, ecological analyses found no clear relationship between vaccination rates and case incidence across multiple jurisdictions (30), underscoring the complexity of interpreting vaccine impact in real-world conditions. Additional studies later suggested increased risk of infection associated with repeated vaccination, with one large cohort study of over 50,000 healthcare employees finding that risk of COVID-19 increased with the number of prior vaccine doses received, counter to general expectations (31).

Safety signals and methodological concerns regarding selected original vaccine trials were likewise documented in the peer-reviewed literature (32). Large pharmacovigilance analyses drawing on adverse event reporting systems in the European Union and the United States identified elevated reporting rates of serious adverse reactions across multiple clinical categories following COVID-19 vaccination (33). Population-based cohort and surveillance analyses identified elevated risks of myocarditis and related cardiac events following mRNA vaccination (34,35), particularly among younger populations (36). Scoping reviews further reported repeated patterns of association between COVID-19 vaccination and autoimmune disorders following broad vaccine uptake in 2022 (37).

Once vaccination became tied to continued employment, these scientific uncertainties intersected with established ethical concerns in healthcare, as documented in the literature. For some HCWs, mandates created tensions between institutional requirements and professional judgment (38), particularly when workers were required to enact policies or practices they experienced as ethically troubling (39,40). The concept of moral injury—originally developed in other domains and later applied to healthcare (41)—captures these experiences as the psychological and ethical burden associated with being required to act in ways perceived to conflict with professional values.

While ethical analyses of vaccine mandates for HCWs have been developed, their framing is often incomplete. For example, bioethical analyses such as those by King et al. and Dubov et al. present the issue as a tension between individual autonomy and collective protection, concluding that mandates are justified—particularly in healthcare settings—to prevent harm to others (42,43). However, these arguments rely on empirical assumptions—such as the necessity of vaccination for protecting others—that are not independently examined within these ethical analyses themselves.

Taken together, this body of literature points to a more complex and contested evidentiary and ethical landscape than is often reflected in policy discourse. This lack of analytic depth in health services research is particularly concerning given that HCWs were not only the subjects of these policies, but also their enforcers and intermediaries, often navigating tensions between institutional requirements and professional judgment, including experiences described in the literature as forms of moral distress and ethical strain. These experiences are likely to remain obscured if dominant framings of the COVID-19 policy response are taken for granted rather than critically examined.

As noted by Carol Bacchi, dominant framings of policy problems are consequential in that they narrow the range of legitimate inquiry (44). In this case, if the problem is assumed to be attitudinal—lack of knowledge, unwarranted distrust, or emotionally driven hesitancy—the policy response becomes one of correcting beliefs, attitudes, or behaviours, while alternative interpretations grounded in the evidentiary, ethical, or contextual foundations of the policies themselves are more readily dismissed. Accordingly, treating dissent as an empirical object of inquiry provides a means of documenting how contested policies were experienced by those required to enact or comply with them, and is essential to evaluating their broader implications for workforce stability, professional autonomy, and the integrity of healthcare systems.

This study examines the views and experiences of mandated COVID-19 vaccination among close to 200 HCWs in Alberta who were subject to such mandates. It is situated within a broader research program examining COVID-19 policy responses across major social institutions, including healthcare systems and academia, as well as the governance of scientific knowledge and dissent. This program includes critical policy analyses of vaccine uptake and hesitancy discourses among HCWs and postsecondary student populations (45,46), investigations of institutional responses to so-called “misinformation” and the role of NGOs and other actors in shaping public discourse (47,48), and ongoing work on the epistemic framing of vaccine safety and risk, particularly in relation to autoimmune disorders (37,49).

Within this broader program, one line of inquiry focuses on COVID-19 vaccination mandates among HCWs. This includes an ongoing examination of mandates across hospital settings in Ontario based on a published protocol (50), as well as earlier survey-based studies conducted in Ontario and British Columbia (51-54), which similarly explored the personal, institutional, and systemic dimensions of COVID-related healthcare workplace policies. Together, these studies form part of an ongoing comparative research program encompassing over 700 HCWs across Canada, designed to enable cross-provincial analysis of convergence and divergence in how such policies were experienced across distinct institutional contexts. As this third study shows, in contrast to Ontario and British Columbia, Alberta exhibited a broader spectrum of responses, including notable support for mandates among a small yet vocal minority of HCWs—patterns examined here through a province-wide survey. We present this article in accordance with the STROBE reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0002/rc).

Methods

An online cross-sectional survey was conducted with a convenience sample of HCWs in Alberta, Canada. The survey instrument was based on a questionnaire previously developed and used in studies conducted in Ontario (54) and British Columbia (52) and was further refined through pilot testing and consultation with members of the target population. Specifically, prior to launch, the survey was reviewed by a physician and an allied health professional, whose feedback informed minor revisions, including the addition and clarification of selected items. The practice of developing survey instruments in consultation with relevant stakeholders is common in the field. For example, a large national survey of Canadian HCWs conducted by Ipsos for the Public Health Agency of Canada was developed in collaboration with public health authorities (55). In contrast, the present instrument was developed in consultation with members of the population under study—namely, HCWs themselves. This approach was intended to enhance the relevance and interpretability of survey items in relation to respondents’ lived experiences, particularly in capturing dimensions of policy implementation that may not be fully reflected in instruments developed through institutional channels alone.

As of 2022, approximately 309,100 people were employed in the healthcare and social assistance sector in the province (56). Respondents were eligible if they had worked in Alberta’s healthcare sector—whether in clinical, administrative, or support roles—during the period in which COVID-19 vaccination was mandated as a condition of employment. Eligibility was independent of current employment status and included individuals who had been laid off, taken early retirement, or otherwise exited the workforce due to mandate-related pressures, as well as individuals of any age, gender, years of experience, socioeconomic background, race/ethnicity, or vaccination status. The sole exclusion criterion was not having worked in a healthcare setting in Alberta under mandated vaccination.

The survey was administered using Google Forms and promoted through social media platforms and the professional networks of the research team using a snowball sampling approach, encouraging respondents to share the invitation with other eligible HCWs (57). Recruitment took place from March 1^st, 2025 through April 30^th, 2025, with invitations redistributed at seven-day intervals. As noted by Alreck and Settle [2003], a minimum sample size of n=100 is generally considered sufficient to generate meaningful data in studies involving large populations (58). For this exploratory survey, the target sample size was between 100 and 400 respondents. This objective was met, with a final sample of n=189 HCWs recruited in Alberta.

Respondents were informed about the purpose of the research and the confidentiality of the data. Participation was voluntary, and consent was obtained at the outset of the survey by clicking “yes” in response to the question “Do you consent to participate?” and confirming that they worked, or had previously worked, in a healthcare setting in Alberta during the mandate period. Upon survey completion, respondents were entered into a raffle for a $100 gift card.

The survey used skip logic, with some questions displayed depending on vaccination status, employment status, or whether respondents had been terminated or laid off due to non-compliance with workplace vaccination policies. Respondents were asked about demographic and employment characteristics; COVID-19 experiences; vaccination decision-making; informed consent; vaccine side effects; accommodations and alternatives to vaccination; personal, professional, and family impacts of vaccination policies; employment consequences; perceived impacts on patient care; and experiences administering COVID-19 vaccines. The instrument consisted primarily of multiple-choice and Likert-style items, with one open-ended question inviting additional comments and one item asking whether respondents consented to be contacted for a follow-up interview. The full survey instrument is provided in Appendix 1.

The survey instrument included both descriptive items documenting respondents’ experiences and circumstances and evaluative statements. Descriptive items captured factual information without evaluative framing, such as changes in employment status or income and reported adverse reactions following vaccination. Self-rated physical and mental health were included as general indicators of respondents’ overall well-being during the COVID-19 period. These measures, along with items on adverse reactions and health changes, captured self-reported experiences and were analyzed descriptively without attribution to specific causes or clinical relationships, consistent with standard population survey practice, including surveys commissioned by the Public Health Agency of Canada.

Unless otherwise specified, percentages in the tables are calculated using the full analytic sample as the denominator to preserve consistency across items. In the Results narrative, conditional percentages are reported where analytically relevant, with denominators stated explicitly. For analyses of adverse events by dose number, denominators were restricted to respondents who reported receiving the corresponding dose, such that rates reflect the population exposed to each dose. Communication of adverse reactions was analyzed using the vaccinated sample as the denominator because a precise adverse-reaction subgroup denominator could not be derived from non-mutually exclusive dose- and severity-specific response categories. Evaluative statements, by contrast, were formulated in positive, neutral, and critical terms and invited respondents to express agreement, disagreement, or neutral responses (e.g., “I felt entirely free to choose whether or not to get vaccinated”; “I felt coerced to get vaccinated”).

This design enabled the systematic documentation of a broad range of experiences and perspectives, including dissenting views, without presuming either consensus or deficit, or treating any particular orientation toward mandates as self-evidently legitimate or illegitimate. Accommodation-related items were especially relevant to the study’s cross-provincial design because formal accommodation frameworks varied by province. For example, Ontario’s Directive 6 permitted alternatives to vaccination, such as testing and education-based compliance mechanisms, whereas Alberta and British Columbia adopted narrower formal accommodation frameworks.

Importantly, the inclusion of items capturing potentially adverse or contested experiences (e.g., perceived coercion, workplace conflict, or health impacts) reflects standard practice in descriptive policy research and does not imply a priori assumptions about their prevalence. Excluding such items would risk introducing bias by constraining the instrument’s capacity to detect experiences that may be underrepresented in institutional or workforce-based samples—particularly in contexts where policy processes themselves have shaped participation, inclusion, or exclusion from the healthcare workforce.

Given the sensitivity and potential legal, professional, and economic implications of employment termination, the survey design anticipated the possibility of partial non-disclosure on direct termination items. Accordingly, analytic decisions distinguished between (I) respondents who explicitly reported termination and (II) respondents who selected “prefer not to answer” to termination questions but nonetheless completed subsequent items referring to the consequences of job loss (e.g., impacts on income, physical health, or mental health). For analyses focused on the impacts of job loss, these respondents were treated as a single analytic subgroup reflecting exposure to mandate-related employment disruption. This approach aligns with established survey methodology in contexts involving stigmatized, legally sensitive, or emotionally burdensome experiences, where non-response to direct status questions may coexist with substantive responses to downstream impact items (59). It is also consistent with the study’s broader epistemic orientation: the study was designed to treat dissent with official COVID-19 vaccination policy as an object of empirical inquiry rather than as a cognitive, behavioural, or normative problem to be corrected.

As with all survey research, particularly in contexts involving employment sanctions and professional risk, potential sources of bias were considered in both study design and interpretation. These include selection bias associated with convenience and snowball sampling; possible differential participation by vaccination status; and self-report, recall, and social desirability biases inherent to survey research. Mitigating features included broad, non-institutional recruitment channels; inclusion of currently employed and terminated HCWs; and survey items framed in positive, neutral, and critical terms to reduce response constraint. Relevant limitations are discussed in the Limitations section.

Statistical analysis

Given the exploratory nature of the study, the analysis was descriptive. Survey data were summarized using counts and percentages, with denominators specific to each survey item. No inferential statistical analyses were conducted, and no adjustment for confounding was undertaken. Predefined subgroup analyses were descriptive and, where conceptually appropriate, included stratification by vaccination status and by mandate-related employment disruption, including a job-loss analytic subgroup as described earlier. Item-level non-response was handled by reporting variable-specific denominators; “prefer not to answer” responses were treated as missing unless analytically relevant, as in analyses focused on employment disruption. The study employed a cross-sectional design with convenience and snowball sampling, so no weighting or adjustment for sampling strategy was applied, nor were sensitivity analyses conducted.

Survey data were organized and analyzed using Microsoft Excel. Results are reported in accordance with APA guidelines for numbers and statistics, which recommend rounding survey data to one decimal place (60). The research team met regularly to review the data, discuss analytic decisions, and interpret findings. The study was conducted following the Declaration of Helsinki and its subsequent amendments, was approved by the York University Office of Research Ethics (No. 2023-389) and informed consent was obtained from all individual participants.

Results

A total of 189 HCWs responded to the survey and were included in the analysis. Recruitment occurred via open dissemination through professional networks, social media, and snowball sampling. As a result, the number of individuals who viewed the survey invitation, initiated but did not complete the survey, or were otherwise exposed to recruitment materials could not be determined. All respondents who met eligibility criteria and submitted survey responses were included in the analysis.

Demographics

Respondents were predominantly mid-career, with just over half aged 35–54 years (102/189, 54.0%), and close to one fifth aged 55–64 years (33/189; 17.5%). The sample was overwhelmingly female (160/189, 84.6%) and largely Canada-born (163/189, 86.2%). Most respondents identified as White (163/189, 86.2%). Most were married or living with a partner (135/189, 71.4%), and many reported caregiving responsibilities, most commonly for children or stepchildren (70/189, 37.0%), followed by both children and elderly relatives (29/189; 15.3%), and elderly relatives only (17/189; 9.0%). With respect to training, many reported nursing credentials, most commonly a Bachelor of Science in Nursing (75/189, 39.7%); the sample also included physicians (18/189, 9.5%) and paramedical/EMT respondents (5/189, 2.6%) (Table 1).

With respect to socioeconomic status, most respondents identified as middle-income (103/189, 54.5%) or high middle-income (59/189, 31.2%), with relatively few identifying as low- or high-income. Most respondents were employed either full time (74/189, 39.2%) or part time (66/189, 34.9%) at the time of the survey. The most commonly reported profession was registered nurse or psychiatric nurse (84/189, 44.4%). Physicians represented a smaller group (18/189, 9.5%), with most of them identifying as general practitioners or family physicians (15/18, 83%). Respondents also reported substantial levels of education and training. Over one quarter reported ten or more years of education or professional training (49/189, 25.9%), while most others reported between five and nine years (70/189, 37.0%). With respect to years of experience in their most recent career, more than half of respondents reported over ten years of professional experience, spanning 11–15 years (38/189, 20.1%), 16–20 years (27/189, 14.3%), 21–25 years (17/189, 9.0%), and 26–30 years (20/189, 10.6%) (Table 1).

Vaccination status

Most respondents had received a COVID-19 vaccine (111/189, 58.7%), and more than one third were unvaccinated (74/189, 39.2%). Among those who had received at least one dose (n=111), a large minority had received two or more boosters (52/111, 46.9%), about one third had completed a full primary series (37/111, 33.3%), slightly over one tenth had been boosted once (15/111, 13.5%), and a small minority were partially vaccinated (7/111, 6.3%). Figure 1 presents the distribution of vaccination statuses across the full sample, whereas the proportions reported above describe the distribution within the subgroup of respondents who had received at least one vaccine dose (Figure 1).

Figure 1 Vaccination status.

Vaccination decision and experiences

Among those who received COVID-19 vaccines, the main reported reason was to protect themselves from severe outcomes (37/111, 33.3%). The second most common reason was because it was mandated at work (33/111, 29.7%). Other frequently cited reasons included to protect the larger community from severe outcomes (18/111, 16.2%), to protect loved ones from severe outcomes (15/111, 13.5%), or because it was mandated by an educational institution (2/111, 1.8%) (Table 2).

Among vaccinated respondents, approximately one third reported no adverse reactions following COVID-19 vaccination (41/111, 36.9%). Among those who reported adverse reactions, mild reactions were most commonly reported after the first dose (32/111, 28.8%) and the second dose (34/104, 32.6%), with no mild reactions reported after the third or later dose. Moderate reactions were reported less frequently and occurred following the first dose (7/111, 6.3%), the second dose (11/104, 10.6%), and the third or later dose (2/67, 2.9%). Severe reactions were reported following the first dose (6/111, 5.4%), the second dose (3/104, 2.9%), and the third or later dose (3/67, 4.5%). For dose-specific analyses, denominators were restricted to respondents who had received the corresponding number of doses (i.e., first dose: n=111; second dose: n=104; third or later dose: n=67), ensuring that adverse events were calculated relative to the population at risk for each exposure (Table 2).

When asked whether they had communicated adverse reactions to a general practitioner, family physician, or other medical staff, only a small proportion of vaccinated respondents reported that their reaction had been communicated and formally reported (6/111, 5.4%). A similar proportion reported communicating a reaction without a report being filed (5/111, 4.5%), or communicating a reaction but not knowing whether a report had been filed (6/111, 5.4%). By contrast, over one third reported never communicating their reaction to a physician (38/111, 34.2%). In addition, more than one tenth of vaccinated respondents reported experiencing an adverse reaction yet being required to receive additional vaccine doses (14/111, 12.6%) (Table 2).

As noted in the Methods section, all proportions were calculated using the vaccinated sample (n=111) as the denominator. A conditional denominator restricted to respondents who experienced an adverse reaction could not be derived precisely from these data because adverse reactions were reported by dose and severity and were not mutually exclusive across doses. While these estimates reflect respondents’ reported communication with medical personnel following adverse reactions rather than clinically adjudicated rates of vaccine-related injury, they should be interpreted as conservative estimates within the vaccinated group. If the denominator were restricted only to respondents who experienced adverse reactions, the corresponding proportions would be higher. Differences between “no reaction ever” and “not applicable” responses likely reflect variation in how respondents interpreted and reported experiences across survey items, as commonly observed in self-reported data (61).

Accommodations & equity considerations

Over three quarters of respondents reported that they had not been offered any alternatives to vaccination, such as testing, remote work, or recognition of natural immunity (145/189, 76.7%). Nevertheless, some respondents reported requesting exemptions, most commonly on religious grounds (40/189, 21.2%), followed by medical (16/189, 8.5%) and conscientious objection (12/189, 6.3%). Among the 49 respondents who reported requesting an exemption, only three reported receiving one (3/49, 6.1%), while 46 reported that their request was denied (46/49, 93.9%). An additional 36 respondents reported not requesting an exemption; the survey item identified intimidation or expected denial as examples of reasons for not doing so (36/189, 19.1%) (Table 3).

Informed consent

When asked whether their employer, professional college, or public health authority had provided written information about COVID-19 vaccines, most respondents reported that no such information had been provided (111/189, 58.7%). Approximately one third reported receiving information from public health agencies or equivalent sources (60/189, 31.8%), while close to one tenth reported receiving a package insert from the vaccine manufacturer (15/189, 7.9%). Among respondents who reported receiving written information and answered the follow-up item, over half indicated that the information enabled them to make an informed decision (46/75, 61.3%), while a large minority indicated that it did not (29/75, 38.7%) (Table 3).

With respect to perceived freedom of choice, most respondents disagreed or strongly disagreed with the statement “I felt entirely free to choose whether or not to get vaccinated” (127/189, 67%), including those reporting strong disagreement (99/189, 52.4%). Safety concerns were also prominent, with a majority of respondents (114/189, 60%) agreeing or strongly agreeing that they had concerns regarding COVID-19 vaccines, including those reporting strong agreement (100/189, 52.9%). One third of respondents agreed or strongly agreed that they had personal medical concerns (61/189, 32.3%), and a similar proportion reported religious concerns (65/189, 34.4%). Over half of respondents disagreed or strongly disagreed with the statement that they felt comfortable expressing safety concerns to their employer (102/189, 54%). A large majority reported having conducted their own research on the safety and efficacy of COVID-19 vaccines (158/189, 83.6%) (Table 4).

Personal impact of vaccination policies

Reported personal impacts of vaccination policies varied substantially by employment outcome, particularly between respondents who remained employed and those who experienced job loss following non-compliance with vaccination requirements. One fourth of respondents explicitly reported having been terminated or laid off due to vaccination mandates (48/189, 25.4%) (Table 5). However, a subset of respondents selected “prefer not to answer” to the termination item yet, as shown in the following section, subsequently responded affirmatively to follow-up questions that explicitly referenced job loss and its consequences. For analyses examining the impacts of job loss, these respondents were assessed alongside those who explicitly reported termination, yielding an analytic subgroup of 61 respondents. This approach reflects the internal logic of the survey instrument, in which follow-up items presupposed employment disruption, and allows for a more complete assessment of the consequences associated with mandate-related job loss.

A small minority of respondents agreed that their income was lower than prior to the introduction of vaccination mandates (32/189, 16.9%), including those reporting strong agreement (18/189, 9.5%). A separate item asked respondents in the job-loss analytic subgroup whether losing their job had significantly reduced their income. Most respondents in this subgroup agreed or strongly agreed (45/61, 73.8%), including those reporting strong agreement (33/61, 54.1%). These two items capture related but distinct constructs: the first reflects respondents’ overall comparison of current income to the pre-mandate period, whereas the second captures the perceived impact of job loss itself. As such, the latter does not require that income remained lower at the time of the survey and may include respondents whose income had subsequently stabilized or recovered following job loss (Table 6).

A small minority of respondents agreed that they had experienced chronic physical ailments due to employer vaccination requirements (20/189, 10.6%), including those reporting strong agreement (12/189, 6.3%). Among respondents in the job-loss analytic subgroup, over half agreed or strongly agreed that losing their job had negatively impacted their physical health (35/61, 57.4%), including those reporting strong agreement (18/61, 29.5%). A small minority also agreed that they had experienced a physical disability as a result of employer vaccination requirements (9/189, 4.7%), with responses distributed relatively evenly between agreement and strong agreement. Negative mental health impacts were more pronounced. Over one third of respondents agreed or strongly agreed that they had experienced anxiety or depression due to employer vaccination requirements (71/189, 37.6%), including those reporting strong agreement (49/189, 25.9%). The impact was greater within the job-loss analytic subgroup, where most respondents agreed or strongly agreed that job loss had negatively affected their mental health (44/61, 72.1%), including those reporting strong agreement (31/61, 50.8%) (Table 6).

Approximately one fifth of respondents agreed that they had sought help from a counsellor due to situations arising from vaccination requirements (41/189, 21.7%), with strong agreement (25/189, 13.2%) exceeding agreement alone. Concerningly, a small but notable minority of respondents agreed or strongly agreed with the statement “I have experienced suicidal thoughts due to employer vaccination requirements” (14/189, 7.4%), including those who strongly agreed (9/189, 4.8%). Broader psychosocial impacts were also reported. Nearly half of respondents agreed or strongly agreed that their personal relationships had suffered due to situations arising from vaccination requirements (89/189, 47.1%), including those who strongly agreed (64/189, 33.9%). Finally, nearly one half of respondents across vaccination statuses agreed or strongly agreed with the statement “I feel I have been unfairly treated by my employer regarding vaccination requirements” (89/189, 47.1%), with strong agreement predominating (74/189, 39.2%) relative to agreement (15/189, 7.9%) (Table 6).

Self-rated health changes

Over one third of respondents (66/189, 34.9%) reported that their physical health was better before the COVID crisis. An even higher proportion of respondents (84/189, 44.4% each) self - rated their mental health as having been the same as, or better, before COVID, reflecting respondents’ self-assessment of overall health rather than attribution to specific causes (Figures 2,3).

Figure 2 Physical and mental health self-rating.

Figure 3 Physical and mental health self-rating before COVID-19. Interpretation: over one third (N=66; 34.9%) of respondents rated their physical health, and nearly half (N=84; 44.4%) of respondents rated their mental health as higher before COVID-19. COVID-19, coronavirus disease 2019.

Vaccination requirements and employment status and conditions

In addition to termination for non-compliance with vaccination, about one fifth of respondents reported disciplinary measures short of termination (37/189, 19.6%), including accusations of professional misconduct, reporting to licensing colleges, temporary suspension of pay, exclusion from pension plans, or withdrawal of professional licensure. A small minority reported being rehired in Alberta after having been terminated in another province for refusing mandated vaccination (10/189, 5.3%) (Table 5).

Workplace conflict following the introduction of vaccination requirements was widely reported. Most respondents agreed or strongly agreed that they had experienced conflict among colleagues (121/189, 64.1%), with strong agreement (78/189, 41.3%) exceeding agreement (43/189, 22.8%). Similarly, most respondents agreed or strongly agreed that they had experienced conflict between employees and management (110/189, 58.2%), with strong agreement (73/189, 38.6%) again exceeding agreement (37/189, 19.6%) (Table 7).

Respondents also reported widespread workforce attrition associated with COVID-19 vaccination policies. Most respondents agreed or strongly agreed that they knew of HCWs who had taken early retirement (123/189, 65.0%), with strong agreement predominating (84/189, 44.4%). Most also agreed or strongly agreed that they knew of HCWs who had been laid off for non-compliance with vaccination requirements (125/189, 66.1%), and an even greater proportion agreed or strongly agreed that they knew of HCWs who had resigned rather than accept vaccination (131/189, 69.3%), including those reporting strong agreement (94/189, 49.7%). In addition, over one third of respondents agreed or strongly agreed that they knew of students in the health professions who had been deregistered due to non-compliance with vaccination policies (66/189, 34.9%) (Table 7).

Among respondents who had been terminated, nearly one third disagreed or strongly disagreed with the statement “I would return to my previous role if possible/if mandates were dropped” (18/61, 29.5%), including those reporting strong disagreement (16/61, 26.2%). Finally, about one fifth of respondents agreed or strongly agreed with the statement “I intend to leave my occupation/the healthcare industry due to my experiences with the COVID-19 policy response” (40/189, 21.2%), including those reporting strong agreement (22/189, 11.6%) (Table 7).

Impact on patient care

Over three quarters of respondents reported having worked with COVID-19-positive or suspected patients prior to the introduction of vaccine mandates (150/189, 79.4%). Most respondents agreed that they had observed concerning changes in patient care or clinical procedures coinciding with the onset of the COVID-19 crisis (124/189, 65.6%), with strong agreement (69/189, 36.5%) exceeding agreement (55/189, 29.1%). A slightly lower proportion agreed that they had observed concerning changes in patient care following the introduction of COVID-19 vaccines (114/189, 60.3%), again with strong agreement (75/189, 39.7%) exceeding agreement alone (39/189, 20.6%) (Tables 8 and 9).

Similarly, most respondents agreed that they had observed differential treatment of patients based on vaccination status (107/189, 56.6%), with strong agreement (78/189, 41.3%) exceeding agreement (29/189, 15.3%). About half of respondents also agreed that they had observed an increase in patient harms associated with COVID-19 vaccines (94/189, 49.7%), with strong agreement (67/189, 35.4%) again exceeding agreement alone (27/189, 14.3%) (Table 9).

Over half of respondents disagreed with the statement “I felt free to express any concerns I had about patient care or potential vaccine harms with my employer” (104/189, 55.0%), including those who strongly disagreed (75/189, 39.7%). Among respondents who provided a substantive response to the conditional item asking whether concerns, if expressed, were documented and acted upon by their employer, a majority disagreed or strongly disagreed (72/118, 61.0%), with strong disagreement predominating (61/118, 51.7%). Most respondents also disagreed with the statement “From the perspective of a potential patient, I am confident that the current healthcare system will provide adequate and quality care while respecting my personal preferences and values” (113/189, 59.8%), with strong disagreement (78/189, 41.3%) exceeding disagreement alone (35/189, 18.5%) (Table 9).

Over one third of respondents agreed or strongly agreed that they had been accused of undermining the COVID-19 public health response or patient care due to their views or decisions about vaccination (71/189, 37.6%), with strong agreement (48/189, 25.4%) exceeding agreement alone (23/189, 12.2%). Just under one quarter also agreed that they had been disciplined for the same reason (43/189, 22.8%), again with strong agreement (26/189, 13.8%) exceeding agreement (17/189, 9.0%) (Table 9).

A smaller but notable minority of respondents reported that they had been coerced into recommending or administering COVID-19 vaccines against their best clinical judgment (31/189, 16.4%). Examples cited included situations in which respondents reported believing that a patient might experience an adverse event, had previously experienced an adverse event following vaccination, was too young or too old to benefit, or had previously experienced COVID-19 and therefore had strong natural immunity (Table 9).

Over half of respondents reported that they had not been encouraged to report adverse events following COVID-19 vaccination if observed (106/189, 56.1%). A similar proportion reported that they had not been trained to report such events (102/189, 54.0%). By contrast, approximately one third of respondents reported being encouraged to tell patients that COVID-19 vaccines were safe and effective (63/189, 33.3%) and to encourage them to trust health officials and official sources of information (63/189, 33.3%). In addition, one quarter of respondents reported being encouraged to dismiss non–officially approved information as “misinformation” (48/189, 25.4%) (Tables 8,9).

For HCWs who administered COVID-19 vaccines

A small minority of respondents reported having administered COVID-19 vaccines (30/189, 15.9%). Among these respondents, one third reported receiving compensation for this work (10/30, 33.3%), with one respondent strongly agreeing that the compensation received was greater than what they would otherwise have received for comparable clinical activities (1/30, 3.3%). Most respondents in this subgroup reported that they believed COVID-19 vaccines could cause serious or life-threatening injuries, including death (21/30, 70.0%), with agreement (10/30, 33.3%) and strong agreement (11/30, 36.7%) reported at similar levels (Table 10).

When asked about their feelings while administering COVID-19 vaccines, the most commonly selected responses were “Energized; I was part of the solution for a serious public health problem” (18/30, 60.0%) and “Uneasy; I did not know what might happen to vaccine recipients” (17/30, 56.7%). Other response options included “Accepting; it was part of my responsibility” (14/30, 46.7%), “Other” (3/30, 10.0%) and “Prefer not to answer”. Finally, over one quarter of respondents who administered vaccines agreed with the statement “I was coerced into recommending or administering COVID-19 vaccines against my best clinical judgment” (8/30, 26.7%), with strong agreement (5/30, 16.7%) exceeding agreement (3/30, 10.0%) (Table 8).

Discussion

The Alberta HCWs surveyed in this study were predominantly mid-career professionals, most of whom identified as women, were Canadian-born, and reported substantial levels of education and work experience within the healthcare system. This profile aligns with the demographic composition of much of the Canadian healthcare workforce (62) and situates the findings within the experiences of workers who are neither early-career nor marginal to clinical and institutional practice. As such, the perspectives documented here reflect the views of HCWs with long-standing professional engagement and familiarity with prevailing clinical, ethical, and organizational norms.

Within this context, most respondents had been vaccinated, with more than one quarter receiving two or more booster doses. However, nearly one third reported workplace mandates as the primary reason for vaccination, indicating that institutional pressure—rather than informed and autonomous decision-making—played a significant role. Most respondents reported never being provided with written information about the vaccines, with many further reporting that if written information was provided, it was not sufficient to support an informed decision. Most also reported not feeling free to choose whether to be vaccinated. Together, these findings suggest a perceived erosion of informed consent—a foundational principle of biomedical ethics in both contemporary Canadian medical practice (63) and its historical articulation (64)—among a subset of HCWs.

Across measures of personal impact, negative outcomes—including reduced income, physical health concerns, and deteriorated mental health—were consistently more pronounced among respondents in the job-loss analytic category. Compared with respondents who remained employed, this group reported substantially higher levels of economic hardship, health-related decline, and psychological distress. The clustering of adverse outcomes within this analytic category indicates that job loss associated with mandate enforcement functioned as a key axis of harm shaping respondents’ lived experiences. This pattern is consistent with a substantial body of research demonstrating that employment disruption and involuntary job loss are associated with elevated risks of psychological distress, depressive symptoms, and adverse physical health outcomes, particularly when job loss occurs under conditions of limited worker agency and institutional constraint (65,66).

Reports of severe adverse reactions among respondents were relatively uncommon; however, nearly two thirds of vaccinated respondents reported some form of adverse event, and some indicated that they were required to receive additional doses despite prior reactions. While the study did not include detailed characterization of reported adverse events—and therefore cannot assess their clinical significance—the findings raise questions about the reporting environment in which these events were observed or communicated. Among vaccinated respondents who communicated an adverse reaction to a healthcare provider, responses varied as to whether a formal report had been filed, had not been filed, or whether respondents were unsure. Formal reporting of adverse events also appeared limited in relation to patient care: most respondents reported not being trained or encouraged to report post-vaccination adverse events if observed among patients.

Taken together, these findings point to reports of institutional arrangements that disincentivize adverse event reporting, including perceived risks of professional or employment consequences, patterns also documented in other jurisdictions (67). Consistent with prior research, the combination of structural barriers to reporting and lack of institutional response weakens accountability mechanisms and undermines the institutional integrity required for effective public health governance, particularly during periods of crisis (68).

Many respondents also described their vaccination decisions as shaped by fear of job loss or by explicit employer coercion. This pattern is consistent with earlier findings from our Ontario and British Columbia surveys, in which HCWs who complied with vaccination mandates frequently reported doing so under duress and while experiencing ethical conflict (52,54). It is also consistent with findings from the Ipsos survey, which reported that for approximately half of respondents the threat of job loss was a primary driver of vaccination decisions (55).

Although mandates have often been justified as a moral imperative—a “duty to care towards patients and an ethical obligation of nonmaleficence to patients” (69)—in our study respondents’ accounts point to a breakdown of ethical norms within healthcare employment practices, including violations of bodily autonomy, professional judgment, and clinical discretion. These findings echo longstanding concerns in the social scientific literature regarding the deployment of coercive or manipulative strategies under the guise of public health rationality (70,71).

The Alberta data also provide insight into the consequences of vaccine mandates for institutional functioning. Respondents described mandate enforcement as exacerbating already fragile staffing conditions, contributing to the exclusion of experienced personnel, and undermining morale among remaining staff. These effects were not peripheral but integral to how the policy was implemented and experienced. While mandates have often been justified as necessary to protect patient safety and ensure healthcare system resilience (72)—frequently resting on claims about the increased occupational exposure of HCWs (73)—our findings do not support this justification. Instead, the data indicate that mandate enforcement intensified the very vulnerabilities it was intended to mitigate, contributing to workforce instability, weakened team cohesion, and diminished institutional legitimacy—patterns also documented in other studies (74,75).

Moreover, even if increased risk of exposure among HCWs were accepted as a relevant consideration, exposure alone is not equivalent to increased risk of severe disease or to posing a transmission threat to patients—particularly within a generally healthy, working-age workforce that, by 2021, had widespread prior infection and broad, strong, and durable naturally acquired immunity (21), at least comparable in strength and duration to vaccine-acquired immunity (76).

In this context, the imposition of vaccine mandates on the healthcare labour force raises serious benefit–risk concerns, particularly given the absence of compelling real-world evidence at the time that vaccination meaningfully prevented infection or transmission in ways that would materially affect healthcare workforce availability or system capacity (26,30,77,78), alongside early and growing evidence of associated harms (79,80). At the same time, the shift in how HCWs were framed—from essential to potentially risky—points to a broader disjunction between evolving empirical evidence and the policy rationales used to justify mandate-based interventions (50).

The mismatch between official rationales and HCWs’ lived experience also contributed to a broader epistemic breakdown, in which respondents reported being censored or silenced when raising clinical or ethical concerns. This pattern is consistent with a growing body of empirical scholarship documenting institutional mechanisms of information control during the COVID era, including the marginalization of heterodox scientific perspectives, professional sanctions against dissenting clinicians, and the progressive narrowing of acceptable debate within medical and academic institutions (81-83). In these contexts, questioning dominant policy assumptions is frequently reframed as misconduct or misinformation, rather than treated as a routine and necessary component of scientific inquiry and ethical deliberation. This pattern reflects a broader and well-documented phenomenon: the suppression of dissent in medical, public health, and other areas of research and practice (84,85).

These patterns also raise fundamental questions about the governance of healthcare and the boundaries of professional autonomy. In many accounts, HCWs described not only personal injury or coercion but a deeper disillusionment with the ethical architecture of their profession. The policy environment, respondents suggested, had transformed core ethical commitments—such as “do no harm”, informed consent, and bodily autonomy—into liabilities rather than guiding principles. Particularly concerning was the sense that dissent, even when grounded in clinical reasoning or observed patient harm, was met not with deliberation but with punitive enforcement. Such an environment not only degrades morale but risks long-term damage to healthcare systems that depend on open dialogue, ethical judgment, and institutional integrity to function effectively (86).

Limitations and strengths of the study

This study has several features that limit the generalizability of the findings. First, it relied on a convenience sample of HCWs. Second, although the survey was promoted through multiple channels and open to HCWs of all vaccination statuses, the proportion of vaccinated respondents was lower than provincial averages. Third, most participants were women—a pattern consistent with the demographic composition of the Canadian healthcare workforce (87)—but one that may reflect gendered perspectives. Fourth, respondents were predominantly mid- to late-career professionals, which may have underrepresented the experiences of younger HCWs or those in more precarious socioeconomic positions who may have been less willing or able to challenge vaccination policies. Additional limitations include the cross-sectional design and the use of descriptive statistics, which precluded examination of temporal change or associations between variables.

However, these features are not unique to our study. The largest national survey of Canadian HCWs, conducted by Ipsos for the Public Health Agency of Canada in 2023 (n=5,372), similarly relied on a convenience sample, included predominantly female, mid-career respondents, employed a cross-sectional design, and limited analyses to descriptive statistics (88).

It could also be argued that, as with all retrospective self-reported data, responses may be subject to recall bias, as participants were asked to reflect on past experiences and perceptions, some of which occurred well before the time of the survey. However, this concern should be interpreted with caution. The survey did not seek to elicit precise recall of routine or low-salience behaviours, which are more susceptible to memory decay, but rather participants’ evaluations and interpretations of policy-related experiences that were often consequential and personally significant.

Further, research in survey methodology and cognitive psychology indicates that variability in self-reports is not solely a function of temporal distance but is also shaped by question interpretation, response formats, and contextual features of the instrument. Retrospective and contemporaneous reports may therefore differ not only because of memory processes, but also because respondents interpret questions differently depending on reference periods and context. In this sense, temporal proximity does not guarantee greater validity (61). Given that the present study aims to capture how participants experienced, interpreted, and evaluated policy impacts, retrospective accounts remain analytically relevant, even when reported after the events in question.

Another possible objection is that our sample included a relatively large proportion of unvaccinated respondents, in contrast to official sources reporting high vaccination rates among HCWs (55). However, this interpretation overlooks the substantive policy processes that shaped who remained within—and who was excluded from—healthcare institutions during this period. It also overlooks limitations in existing data sources, many of which are based on highly vaccinated institutional samples. A recent systematic review, for example, acknowledged that all included studies relied on such samples—a limitation the authors themselves identified as a potential source of bias (89).

By contrast, although more than half of our respondents were vaccinated, the inclusion of a substantial proportion of unvaccinated HCWs allowed us to capture a broader range of perspectives. This was possible because recruitment did not occur through medical institutions—which would have restricted participation to currently employed (and therefore vaccinated) HCWs—but through social media channels, enabling access to voices otherwise excluded from institutional research, including those most directly affected by mandate enforcement. Importantly, the finding that many vaccinated respondents expressed negative views toward mandates challenges the widespread assumption that vaccine uptake necessarily reflects acceptance rather than compliance under constraint. This interpretation is consistent with findings from the Ipsos survey, which reported that for approximately half of respondents the threat of job loss was a primary driver of vaccination decisions (46).

Finally, a key strength of the study lies in its methodological strategy of including survey statements that reflect a range of normative positions regarding COVID-19 vaccination and mandate policies. This approach was designed to capture the diversity of views present among HCWs during a period of intense policy contestation, rather than presuming consensus or treating dissent as analytically irrelevant or normatively suspect. Respondents were able to strongly agree, strongly disagree, or select intermediate responses to each statement, and the resulting patterns demonstrate substantial variation across positions.

In policy environments where certain viewpoints are professionally sensitive or institutionally discouraged, restricting survey instruments to affirming or neutral formulations risks obscuring meaningful disagreement. By contrast, allowing respondents to evaluate statements that may explicitly endorse or reject official policies enables a more accurate representation of how these policies were experienced and interpreted within the workforce. In this sense, the inclusion of evaluative and critical statements constitutes a necessary condition for documenting perspectives that would otherwise remain underrepresented in healthcare research.

Conclusions

Our findings contribute to a growing body of empirical work—now spanning three Canadian provinces—examining the effects of COVID-19 vaccine mandates on the healthcare workforce. While these policies were framed by their proponents as necessary to protect patients and preserve healthcare system capacity, the experiences reported by respondents in this and prior studies do not align with those stated rationales. Instead, the data document consistent and recurring reports of workforce destabilization, constraints on professional judgment, and limitations on informed consent under conditions of mandate enforcement.

Extending this line of inquiry across multiple provinces allows for systematic comparison of HCWs’ experiences of COVID-19 vaccination mandates, highlighting recurrent patterns across jurisdictions that point to common institutional dynamics, alongside important local variations. The consistency of several reported experiences across provinces in our data underscores the value of this comparative approach.

Taken together, these cross-provincial findings raise fundamental questions about the evidentiary and ethical foundations of mandate-based interventions in healthcare settings. Public health governance depends not only on transparent scientific reasoning but also on adherence to core ethical principles, including professional autonomy, voluntary medical decision-making, and informed consent. Policies that override these principles do not merely generate ethical tension; they depart from the conditions under which public health authority can be legitimately exercised and weaken the institutional integrity required for healthcare systems to function effectively.

Acknowledgments

C.C. thanks the 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 continuing support. N.H. thanks her family and friends for their encouragement and support, and Dr. Chaufan for her mentorship. R.M. thanks her friends, family, and Dr. Chaufan 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 STROBE reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0002/rc

Data Sharing Statement: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0002/dss

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0002/prf

Funding: This work was supported by a 2021 Social Sciences and Humanities Research Council (SSHRC) (https://sshrc-crsh.canada.ca/en.aspx) (grant # 435-2022-0959) and by a New Frontiers in Research Fund (NFRF) (https://sshrc-crsh.canada.ca/funding-financement/nfrf-fnfr/index-eng.aspx) 2022 Special Call (NFRFR-2022-00305). The funders played no role in the study design, data collection and analysis, manuscript preparation, or decision to publish.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-2026-1-0002/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 and its subsequent amendments, was approved by the York University Office of Research Ethics (No. 2023-389) and informed consent was obtained from all individual participants.

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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