In July, well before the Covid-19 vaccines were approved by the U.S. Food and Drug Administration, a group of medical professionals at St. Claire Regional Medical Center in Morehead, Kentucky, voted to mandate hospital employees take the vaccine or be terminated.

By the September 15 deadline, the healthcare system had terminated 24 of its 1,200 employees, including six nurses, Don Lloyd, St. Claire’s president and CEO, said. While some medical exemptions were granted, the healthcare system held firm on its decision to mandate vaccines for its employees.

“We tried to accommodate those special needs and requests, but I’m proud to tell you right now that 100% of our employees and medical staff are fully vaccinated,” Lloyd said. “Does it hurt? Yes. Did we want to lose any of our employees? No. But our clinical leadership really feels strongly that we have an obligation to provide a safe environment and so that was the position we took and we’re glad we did.”

The healthcare system has been able to fill most of those positions, he said.

But some rural hospital administrators worry that a new vaccine mandate for healthcare workers could mean fewer staff members.

While most administrators agree that vaccinations are an important step in protecting patients, employees, and other community members, some fear that vaccine mandates could result in staff members quitting rather than getting the shot, leaving hospitals with fewer staff.

On September 9, President Joe Biden announced a series of vaccine mandates, including one that required all hospitals receiving Medicare or Medicaid funds to have their employees vaccinated. The mandate would affect more than 17 million healthcare workers, the White House said, and would create a consistent nationwide standard to “alleviate patient concerns” over whether or not healthcare providers were vaccinated.

With the mandate in place, hospitals should be focusing on how to fill staff openings if they occur, said one rural health advocate.

“Instead of being wrapped around the axle of should we mandate or should we not mandate, the question we should be asking is if we’re going to mandate, how are we going to ensure rural hospitals continue to have adequate staffing,” said Alan Morgan, CEO of the National Rural Health Association (NRHA).

Rural hospitals are already understaffed, Morgan said, and recent surges in Covid patients are putting more strain on limited resources. NRHA members are worried, he said, about having a sufficient workforce to meet the current needs if workers quit over vaccines.

What’s missing, he said, is a plan to address staffing issues once mandates are put into place.

“There will be service disruptions, and there are multiple measures available to respond to them, but it appears that no one has taken the time to think this through yet at the federal level,” he said.

Throughout the pandemic, he said, federal and state officials have used several measures – from deploying FEMA disaster teams or National Guard members, to utilizing nursing or medical school students as clinical help, to using provider relief funds on traveling nurses.

“I’m sure there are other measures available here, but these need to be communicated so that hospitals and clinics can proceed with implementing vaccine mandates with confidence that patient care will not be compromised, and the delivery of care can continue,” he said.

Already, the vaccine mandates are having an impact on hospital staffing in some areas of the country.

In North Carolina, two hospital systems have seen resignations because of vaccine requirements.

At Novant Health in Winston-Salem, North Carolina, 375, or about 1%, of its more than 35,000 employees were placed on suspension for not complying with a vaccine mandate, the hospital system said in a press release.

At UNC Health in Chapel Hill, North Carolina, 60 of its 30,000 employees — about 0.2% of the workforce — had resigned from their jobs, citing the healthcare system’s vaccination requirement. UNC Health announced in July that it would require its employees to get vaccinated by September 21. However, on September 20, the healthcare system pushed the deadline back to November 2. An estimated 95% of its employees have been vaccinated or granted exemptions, the system said, but it is still working to confirm the status of about 1,100 employees.

At Yale New Haven Health, in New Haven, Connecticut, about 700 of its 30,000 employees are unvaccinated and could face termination if they do not comply with the hospital’s vaccine mandate by Oct. 1.

Marna Borgstrom, the system’s CEO, told the Register Citizen that if people were going to resign it would likely be at the end of September, but that she expected that most of the unvaccinated would get the vaccine.

“We’ve done everything possible in my opinion to do this the right way and as humanely as possible, not only for our patients and their loved ones but also for our valued colleagues, and I think the number of people who end up exiting the organization is going to be relatively small,” Borgstrom told the Citizen.

In Rhode Island, Governor Dan McKee and the Rhode Island Department of Health (RIDOH) announced the state would enact a new vaccine enforcement strategy for healthcare workers who aren’t vaccinated to prevent disruptions to care.

Healthcare workers in that state who aren’t vaccinated by October 1 will be given 30 days to come into compliance, during which time the employer can find a fully vaccinated replacement for that position. Healthcare facilities will be required to outline their plan to get workers into compliance while demonstrating that any unvaccinated staff member still working after October 1 is doing so to assure quality of care.

About 87% of the state’s 57,600 healthcare workers have been vaccinated, the health department reported.

But for some rural hospitals, losing even a fraction of those numbers of workers would be devastating, NRHA’s Morgan said.

“For larger systems, losing 24 employees may not be a struggle,” he said. “But for smaller hospitals that could amount to 5 to 10% of their staff which would be devastating.”

Morgan said the organization has reached out to the White House to see if there is a plan to help rural hospitals with staffing, but as of September 21 it had not responded.To combat vaccine hesitancy, the NRHA launched the Rural Vaccine Confidence Initiative on September 21 that provides rural hospitals with action items and talking points that are rural specific and promote vaccine confidence to healthcare workers and rural community members.