Introduction

The planned study outlined in this protocol is motivated by a paradox that began to unfold in the early months of the Covid-19 policy response: healthcare workers (HCWs), unvaccinated by necessity, were celebrated as heroes for their willingness to serve under crisis conditions (see for example [1,2]). Yet many of these same workers would be later reframed as threats to public health – regardless of their protective behaviours, workplace settings, or evidence of their harmfulness (see for example [3,4]).

Notably, policies mandating influenza vaccination for healthcare workers in Canada have historically operated with alternatives—“vaccinate‑or‑mask,” temporary work restrictions during outbreaks, or encouragement rather than compulsion—and have been adjudicated through labour arbitration that stresses least‑intrusive means and a balancing of employee rights with patient safety [5]. In parallel, scholarly and professional debate has long been divided on whether influenza mandates are warranted [6], with critics noting their limited high‑level evidence for patient benefit and warning against employment‑threatening policies, and supporters arguing that mandates can raise staff vaccination and are ethically justified; even popular polls in clinical forums have reflected this split [7].

A similar flexibility appeared to characterize early Covid-era policy—at least on paper. In Canada, for example, Directive 6, issued by the Chief Medical Officer of Health for the province of Ontario, required every covered organization to implement a Covid‑19 immunization policy, but preserved institutional discretion in how to operationalize it. The Directive allowed for compliance via vaccination, documented medical exemption, or participation in an educational program with regular antigen testing for those not fully vaccinated [8].

Against this backdrop, the shift from “hero” to “threat” and employer’s policy choices raise critical scientific, policy, and ethical questions. Why were vaccine mandates implemented as condition of employment on HCWs who had already faced sustained exposure to Covid-19, continued to care for patients without interruption, and were not shown to pose a demonstrable risk—well before vaccines were even available? What evidence and arguments were presented to support the contention that vaccination would prevent viral transmission in healthcare settings, the key rationale for their implementation? Why was the most extreme vaccination policy chosen by most establishments? How did political and institutional dynamics shape the justifications and enforcement of mandates? And how were dissent, resistance, or requests for accommodation framed within policy discourse?

To address these and related questions, this qualitative multi-method study planned study will investigate the implementation of Covid-19 vaccine mandates in medical establishments in Ontario, Canada. While many studies have focused on what has been framed as “vaccine hesitancy”, we focus instead on mandate legitimation and dissent suppression as institutional processes. This examination will document the timeline of mandate introductions, appraise how institutions interpreted and operationalized provincial directives, and identify what scientific, administrative, or rhetorical justifications were used to support their adoption. The work will be grounded in a critical analysis of the social and institutional narratives that shaped HCWs’ changing roles throughout the Covid policy response. Instances of such narratives appeared following the policy rollout, when the “hero” label was deployed as a technique of governance and a tool to enforce professional compliance. As Mohammed et al have argued, the language of heroism – replete with militaristic and sacrificial imagery – elevated frontline HCWs while masking serious lapses in workplace safety, labour protections, and staffing shortages [9]. Similarly, Boulton et al. have suggested that public rituals such as balcony clapping and military flyovers further served as forms of “performative allyship” that, while seemingly supportive, helped to normalize institutional neglect by recasting structural vulnerability as moral duty [10]. These worthy critiques notwithstanding, to our knowledge no research has been conducted on the rhetorical and institutional reframing of dissenting HCWs from lauded protectors of public health to perceived threats to it.

We observe that since the launch of the global vaccination campaign, much of the literature that addresses HCWs’ concerns with or refusal of vaccination has tended to pathologize dissent, focusing on behavioural correction through education or coercion rather than engaging with the scientific, political, or ethical dimensions of resistance (see for example [11,12]). Rarely considered are the moral and psychological tolls that these policies have imposed – particularly on women, who already face higher rates of burnout, moral distress, and suicide [13,14] nor are their empirical grounds scrutinized. Finally, even less explored is the institutional silence surrounding the demonization of dissenting HCWs, some of whom have faced termination, ridiculing, or blacklisting – or have even witnessed hostility towards unvaccinated patients [15]. These gaps in the literature suggest not only a lack of scholarly curiosity but also a tendency to frame resistance as pathology rather than as a potentially legitimate professional – scientific and ethical – stance, thus our study.

To investigate these issues, we have adopted a qualitative multi-method study design structured in two complementary phases. In Phase 1, we will conduct an environmental scan that involves the systematic collection and document analysis of a broad range of publicly accessible materials - including hospital policies and internal documents, press releases, media coverage, and legal materials such as grievances and arbitration rulings retrieved from the Canadian Legal Information Institute (CanLII). This phase aims to document how individual Ontario healthcare institutions implemented Covid19 vaccine mandates, what options they selected under Directive 6, how choices were justified, and how variation in implementation may reflect broader institutional logics. In Phase 2, we will conduct a critical interpretive document analysis of the materials collected in Phase 1 to examine how dissenting healthcare workers were framed within institutional discourse. Drawing on Max Weber’s theory of bureaucracy and legitimacy, Carol Bacchi’s WPR framework, and Brian Martin’s typology of dissent suppression, this phase explores how institutional actors framed noncompliance, justified their policies, and responded to internal or public contestation. Taken together, the two phases will generate both descriptive and interpretive insights into the bureaucratic, rhetorical, and ethical dimensions of mandate enforcement and dissent suppression in Ontario’s healthcare sector.

The planned study builds on a body of work by the lead author and collaborators, including critical analyses in the academic literature of problem representations of HCWs’ dissent [16], surveys on the impacts of Covid-19 policy on HCWs’ well-being and patient care [17,18], thematic analyses of HCWs lived experience [15], and the medicalization of dissent with official Covid policies [19,20]. It is part of two larger projects registered in the Open Science Framework that examine the impact of Covid-19 policies on healthcare work and governance more broadly (https://osf.io/z5tkp; https://osf.io/84kbr/). By examining the tensions in the healthcare workplace through the lens of policy implementation, institutional authority, and discourse, the study aims to illuminate a neglected dimension of the Covid-19 policy response: how policies framed as protective may have functioned as instruments of exclusion, control, or compliance enforcement – especially against those within the healthcare system who raised difficult, but necessary, questions.

Theoretical framework

The interpretive phase of this planned study is grounded in the sociology of Max Weber, particularly his conceptualizations of bureaucracy, rational-legal authority, and ideal types. These concepts will help to illuminate how healthcare institutions implemented Covid-19 vaccine mandates, legitimized those decisions, and framed or managed internal dissent within their bureaucratic structures. Weber’s model of bureaucracy emphasizes rule-governed conduct, hierarchical organization, and a clear distinction between personal and official roles. These features were especially pronounced at the launch of the global vaccination campaign, as healthcare institutions invoked procedural authority to justify exclusionary mandates. That said, and as Byrkjeflot has argued [21], Weber’s model has often been misinterpreted as primarily about efficiency and rule-governed behaviour in the context of hierarchical institutions, when it could be as much or better understood as a theory of legitimacy – an insight central to this study’s analysis of institutional behaviour.

To organize institutional variation in mandate implementation against the range of possible policy options afforded by Directive 6, the planned study will also apply Weber’s concept of “ideal type” [22], an analytical construct that emphasizes certain features of a phenomenon in order to enable comparison. Ideal types will be used to develop heuristic categories of institutional response, ranging from minimalist compliance with provincial guidance to maximalist exclusion of unvaccinated staff. These categories are not meant to capture reality perfectly, but to provide clarity in identifying patterns. As well, this analysis draws on Weber’s notion of “verstehen,” or “interpretive understanding”. As Gann explains [23], verstehen is about grasping the subjective meaning of social action. Our project will apply this interpretive lens to institutional texts – mandate statements, internal memos, media releases – in order to identify not only what was said, but also what was meant – therefore supplementing the environmental scan with a richer understanding of how mandates were discursively justified to render dissent invisible or illegitimate.

Finally, the application of Weberian concepts – bureaucracy, ideal types, and verstehen – framing the second phase of the project will be informed by Brian Martin’s typology of dissent suppression [24], which will help to document how dissenting HCWs were not only excluded in practice, but also delegitimized through tactics such as devaluation, reinterpretation, and institutional silence. This typology will allow the study to go beyond documenting policy timelines and examine how authority, legitimacy, and exclusion were constructed in real time. By analyzing the treatment of dissenting HCWs through the lens of this typology, the project aims to document whether and how such forms of suppression operated in institutional settings during Covid.

Mapping theoretical frameworks to study phases

The table below presents the alignment between the study’s theoretical frameworks and the two main phases of research. Each framework will contribute a distinct analytical perspective to guide data collection, categorization, and interpretation.

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https://doi.org/10.1371/journal.pone.0332589.t001

Aim and objectives

The overall aim of this planned study is to document the implementation of Covid-19 vaccine mandates in medical establishments in the province of Ontario, Canada, understand how authority, legitimacy, and exclusion were constructed in real time, and elaborate on the scientific, political and ethical implications of these processes. The following research questions will guide the study:

1. 1) How and when were Covid-19 vaccine mandates implemented across medical institutions in Ontario?
2. 2) What were the institutional rationales for vaccine mandates, and how were alternatives to these mandates framed, promoted, tolerated, or suppressed?

Methods

Timeline

The planned study is expected to be conducted according to the following timeline:

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https://doi.org/10.1371/journal.pone.0332589.t002

Expected outcomes

This planned study will yield descriptive and interpretive insights into how bureaucratic structures shaped mandate enforcement and dissent suppression. Results should inform academic debates on institutional legitimacy, governance, and public health ethics through a variety of strategies of dissemination. In practice, they will culminate in 4 publications:

1. A descriptive report that maps mandate implementation and variation across institutions using environmental scan methodology.
2. A critical analysis of the rationale and discourse surrounding the mandates, drawing on Carol Bacchi’s “What is the Problem Represented to Be?” (WPR) framework [30], Martin’s typology, critical discourse analysis [31], thematic analysis [32] and document analysis [33].
3. A policy brief that integrates and translates the results of the study for a policy audience.
4. A lay article that integrates and translates the results of the study for the public.

Statement on reflexivity

This study is informed by the lead investigator’s long-standing professional interest in the intersection of policy, governance, and the ethics of healthcare delivery. While the author holds well-developed views about the political and institutional dynamics surrounding Covid-19 mandates, the research design is grounded in a commitment to methodological rigour and epistemic integrity. The aim is not to confirm predetermined assumptions but to systematically document and interpret the evidentiary and discursive basis of institutional decision-making.

Following Finlay [34], reflexivity is approached here not as a means of personal disclosure but as a discipline of methodological transparency and interpretive accountability – meaning not foregrounding the researchers’ biographies but rather as reflexive practice deployed to clarify how judgments were made about source selection, interpretive framing, and categorization of mandates. This reflexive orientation allows research like this study to maintain a dual commitment, both to rigorous analysis of institutional policy and to critical self-awareness about how the researcher’s position may shape – not predetermine – interpretation.

Limitations

It may be argued that this project has a built-in bias due to its negative framing of mandated vaccination and is therefore incapable of informing policy. To this we reply that while we have a position on the policy of mandates, the study will not presume their legitimacy or lack thereof, but rather document and explain how they were implemented, justified and contested, and what the tensions identified may reveal about institutional decision-making and professional agency. Critics may also question whether we can expect to gather enough data to support our theoretically informed analysis; they may also question whether the CBC ranking, while offering a consistent starting point for institutional sampling, can truly capture policy diversity or institutional discretion, given the shortcomings of its evaluation criteria, as acknowledged by the CBC itself. We believe that despite these shortcomings – shared by comparable studies, as authors acknowledge [35] – the interpretive phase will be grounded in a diverse and robust corpus of texts – institutional documents and media reports – that should ensure that theoretical insights are empirically anchored, enough to make this study valuable and transferable to other settings and jurisdictions [36].

Significance

This study should offer timely and broadly relevant insights into how healthcare institutions implemented and justified Covid-19 vaccine mandates, while offering a novel perspective, by treating vaccine mandates not merely as clinical interventions, but as institutional policies subject to political, rhetorical, and ethical contestation. By focusing on Ontario - Canada’s largest province and a leader in healthcare policy – the study will provide a detailed case that can serve as a framework for similar investigations across other provinces. Given that healthcare in Canada is primarily administered and delivered at the provincial level – with federal guidance providing general standards but not operational control [37] – understanding institutional decision-making at the provincial level is essential for evaluating the health system under contested conditions.

The project is also significant for what it can reveal about institutional behaviour in the face of political pressures. While prevailing narratives framed the moment as an emergency [38], responses to vaccine mandates varied widely – not only across jurisdictions, but also between institutions operating under the same provincial directives. These variations raise important questions about how formal organizations enact authority, interpret policy, and manage internal dissent. Max Weber’s analytical lens – particularly his insights into bureaucratic rationality and the interpretive meaning of social action – will help to examine how institutions balanced the tensions between competing perceived needs and goals – providing high quality patient care, complying with public health directives, managing internal / sectoral politics, and maintaining internal and external legitimacy. It will also help to understand the tension between structure and agency, i.e., the discretionary space available to decision-makers within bureaucratic systems and the details of the use of this space by medical institutions under the perceived weight of provincial orders.

In addition to these institutional and professional implications, the study may also have relevance for patient outcomes and health care quality. By exploring how healthcare institutions implemented and justified mandates, the research can help illuminate how administrative decisions – shaped by legal authority, rhetorical framing, and organizational discretion – may influence staffing levels, workplace morale, and institutional trust, which in turn can affect the quality, continuity, and equity of care delivered within healthcare systems [39,40], especially under conditions of institutional uncertainty and operational strain.

Further, the project should also contribute to broader debates about how legitimacy is constructed and enforced in public health governance, by documenting not just policy timelines but also rhetorical strategies, decision-making logics, and institutional responses to dissent. In doing so, it should shed light on questions of professional autonomy, evidence-based policy, and the ethics of labour practices in the health sector. Moreover, findings can shed light beyond Canada. For example, in the United Kingdom, with a more centralized health care policy, the government initially announced plans to mandate Covid-19 vaccination for National Health Service workers [41], but in contrast to Canada, it reversed the policy partly due to organized resistance from within the profession [42]. In the United States, where health policy is more decentralized than in Canada, some states – for instance, California – enforced healthcare mandates [43], while others – Texas and Florida – banned them altogether [44]. These divergent approaches highlight the need for grounded, context-sensitive analysis. By documenting the Ontario case in detail, this project should offer conceptual and empirical tools to examine how institutions across jurisdictions justify policies involving coercion, manage opposition, and maintain legitimacy in the name of public health.