Abstract
BACKGROUND:
Certified Nursing Assistants (CNAs) experience a high risk of work-related musculoskeletal disorders (WMSDs) and are further made vulnerable by their situation in low levels of workplace and societal hierarchies of power and privilege.
OBJECTIVE:
This study applies structural vulnerability theory to CNA WMSD experiences in order to identify structural factors that may influence such injuries.
METHODS:
A sample of CNAs (n = 26) working in Nursing and Residential Care Facilities (NRCFs) was selected from workers who filed a claim during 2011–2014 for a WMSD of the back, shoulder, knee, or hand/wrist in the Washington State Department of Labor & Industries workers’ compensation system. Interviews included questions about workers’ injury experiences and work contexts. Qualitative data was analyzed for themes related to structural vulnerability theory and occupational safety and health (OSH) models.
RESULTS:
Themes illustrate a work environment in NRCFs with major organizational deficiencies for CNA safety and a broader structural environment that appears to mediate them. CNAs described policies and practices that result from management priorities being diverted away from worker safety. These difficulties are compounded by several aspects of CNAs’ socio-economic vulnerability.
CONCLUSIONS:
This study demonstrates the utility of a structural perspective for OSH disparities research and points to the need for occupational health intervention on a structural level.
Introduction
The nursing and residential care industry has long been known as a high-risk industry for work-related musculoskeletal disorders (WMSDs) [1–4]. Certified nursing assistants (CNAs) are at particular risk for such injuries as their work often requires transferring heavy, unresponsive, or combative patients with limited access to lifting equipment [1, 2]. CNAs have been described as a vulnerable population, both in terms of work-related exposures and social factors that act as barriers to life and health stability [5]. It can also be said that this group’s worse health outcomes represent an occupational safety and health disparity, one of many differential outcomes found in occupational health based on social stratification or hierarchy of the value given to different occupations. However, most research and interventions aimed at preventing WMSDs for CNAs have maintained individual-level or workplace-level approaches, ignoring the structural factors that mediate these proximal variables. This study uses structural vulnerability theory to frame the WMSD experiences of a sample of CNAs working at nursing and residential care facilities (NRCFs) in Washington State in order to begin to inform an understanding of the structural factors affecting this vulnerable worker population, as well as to provide an example of the theory’s utility for occupational safety and health research more broadly.
Background
Work-related musculoskeletal disorders for certified nursing assistants
Work-related musculoskeletal disorders (WMSDs) are occupational injuries that affect the muscles, nerves, tendons, and joints of the body, such as carpal tunnel syndrome, epicondylitis, rotator cuff syndrome, and sciatica. In Washington State during 2002 to 2010, WMSDs accounted for 27% of all compensable workers’ compensation (WC) claims and 44% of all costs [6]. Fifty years ago, the health care industry was identified as a high-risk industry sector for WMSDs [7], and the problem has persisted today both in the US and internationally as a major occupational health concern [1, 8]. For example, in 2014, the national incidence rate of musculoskeletal disorders in the Health Care and Social Assistance sector was 46.9 cases per 10,000 workers, compared with the rate in all industries, 31.9 per 10,000 1 [9]. Nursing Care Facilities as a group have a notably high WMSD incidence rate, with 104.1 cases per 10,000 workers [9].
WMSDs in health care are largely a result of heavy and awkward patient lifting and transferring tasks [8, 10]. These tasks are performed often by nursing support staff, including CNAs, aides, and orderlies, putting these worker groups at a particularly high risk for back sprains and strains [1, 2]. In 2014, CNAs had 191.1 musculoskeletal disorder WC claims per 10,000 workers, six times the rate of all occupational groups combined (31.9) [9]. CNAs and aides who work at NRCFs are subject to a number of additional setbacks related to work. Both in the US and internationally, this group often receives low-income level wages [2, 5], with 45% below or near the poverty level in the US (16% below the poverty level, compared to the national rate of 12–13%) [11]. CNAs often receive limited or no health insurance and pension benefits [5, 11], experience high levels of work-related stress due to the high-demand/low-control nature of the occupation [2], must often adjust their lives around odd schedules and lack of paid sick leave, are rarely given opportunities for reward or advancement [5], and work in an occupation that is devalued and under-rewarded by society [12, 13]. Several demographic characteristics of this population further increase the vulnerability of CNAs to experiencing hardship. As a group, they are disproportionately ethnic and racial minorities [5], are more than 25% immigrants [13], are overwhelmingly women (90%), have low educational levels (73% high school completion or less as highest level of education) [11], are disproportionately single mothers, and many have in the past or currently utilize public assistance programs [5].
A considerable amount of research and interventions have been conducted to address the high risk of WMSDs for nursing staff in the health care sector [8]. Research has focused largely on the importance of mechanical patient handling equipment and “zero-lift” policies that prohibit manually lifting patients [8, 14]. Other interventions have included worker education, physical conditioning, disability management, and workplace-level policy change. While some of these interventions have been shown to be effective in reducing injuries [8], the high rate of WMSDs in health care remains a persistent reality that is not yet fully understood. Existing research and intervention approaches have largely focused on the proximate realm of the risk environment, including individual-level factors (e.g. worker knowledge and abilities) and workplace-level factors (e.g. workplace social and physical environment; workplace policies). Applying a structural lens to this problem may yield a broader understanding of the underlying forces driving this trend.
The nursing and residential care facilities industry
The NRCF industry has long been plagued by systemic financial and quality of care problems that form a challenging environment for both its patients and workforce. The industry received little substantial regulatory attention in the U.S. until the late 1980s after multiple cases of fraud and patient mistreatment raised public alarm throughout the 1970s. The U.S. Congress passed the Omnibus Budget Reconciliation Act of 1987 that attempted to reign in these problems by initiating more thorough annual inspections and increasing penalties for deficiencies. However, subsequent analyses of the state of NRCF quality of care have repeatedly brought the effectiveness of these regulations into question, as quality remains low across the industry [15–17]. One major critique of existing regulations is their failure to set and enforce requirements for minimum staff-to-patient ratios as a means of ensuring quality of care [17].
The NRCF industry is unique within the health care sector for being dominated by for-profit institutions, with about two thirds of nursing homes in this category, in contrast to a majority of non-profits in other health care industries [15, 17]. When comparing for-profit nursing homes with non-profit ones, multiple studies have shown an association between for-profit status and lower quality of care measures [18, 19]. This result brings into question the motives and practices of the for-profit nursing home industry, particularly when the industry receives the majority of its payments from the federal Medicaid and Medicare systems [20]. With a strong corporate nursing home lobby as well as a reluctance from government to mandate its own increase in spending (through Medicaid/Medicare payments for higher quality care), the NRCF industry has faced little pressure to put quality care above profit goals [17].
Meanwhile, nursing home administrators on the ground must manage the competing priorities of generating profit for owners and shareholders while also complying with regulations enforced by the states. When a facility is found deficient by surveyors, the administrator may face fines or denial of Medicaid/Medicare payments [15], an already dwindling source of payment due to government spending cutbacks [20]. In this way, administrators are squeezed by financial constraints on two ends—profit margins and payment losses, with little room for investing in quality, or in worker safety. Thus, the NRCF industry has the potential to devalue protections for the most vulnerable parties (patients and workers) while supporting the financial interests of the privileged (owners and shareholders).
Addressing structural factors in occupational safety and health
Established occupational safety and health models
Within occupational safety and health (OSH) research literature, there are several commonly used models with many overlapping concepts. Carayon et al. [21] presented the balance model of the work system in which the worker is surrounded by multiple influencing realms: technology, organization, environment, and tasks. Subsequent models have further re-worked nuances of how these realms operate and interact, as well as included additional spheres of influence, such as “economic, political, and cultural external environment” [22], “community environment,” and “health policy environment” [23, 24]. These additional areas draw attention to the ways that factors external to the work environment/organization can also influence worker health and safety outcomes. Despite the inclusion of external factors in OSH models, however, these social, political, and economic realms are rarely given attention in analysis, as the studies using these models remain primarily focused on individual-level and workplace-level factors. This is problematic for two reasons: 1) research that fails to capture data regarding external factors fails to acknowledge, and therefore seek to change them; and 2) research that attempts to illustrate health disparities cannot present a full picture without capturing information about the societal-level factors often at the root of such inequities. Both of these concerns are further discussed below to demonstrate the need for a structural perspective in OSH research.
OSH disparities
There is a scarcity of occupational safety and health research addressing health disparities in worker populations. In discussions of “health disparities”, public health research often also refers to the “social determinants of health”; both concepts work to identify the ways that social structures unevenly distribute illness and injury across populations such that certain groups experience higher risk. Disparities can exist both among members of a defined group (e.g. women compared to men in one occupation) as well as between different groups (e.g. occupations commonly held by women compared to those commonly held by men). In 2006, Lipscomb and partners laid out a model for work-related health disparities, making the case that the workplace, other work-related factors (income, benefits, vacation/sick leave), and external factors that influence the workplace (government policy, work availability/economic development, racism, sexism, classism) all have the potential to operate as impediments to health for some groups more than others [25]. That publication served as a call to action for OSH researchers to include the broader social and policy environment external to the organization-level when conceptualizing worker health and associated research.
In the ten years since that publication, increasing attention has moved in the direction of OSH disparities based on categories such as: language preference [26, 27], racial categorization [28–33], ethnicity [34–36], gender [37], native/non-native place of birth [38–41], immigration status [42, 43], and socioeconomic status [44–46]. However, the subject of health disparities remains under-studied in the field of occupational safety and health, and applications of such research to policy and intervention are notably deficient [44, 47] and sometimes produce limited effect [48].
In the last two years, some OSH research has addressed issues of health disparities using the concept of “vulnerability,” demonstrating again how some groups of people (“vulnerable” groups) are at higher risk for work-related injury/illness than others. A recent report from the National Institute for Occupational Safety and Health (NIOSH) presents a framework for understanding the ways in which multiple types of worker vulnerabilities (Hispanic immigrants, small business workers, and young workers) can overlap to further increase and complicate health risk [49]. Another group of researchers from the Institute for Work and Health (IWH) have developed a measure for “occupational health and safety vulnerability,” in an effort to capture the distribution of worker vulnerability across populations without relying on pre-determined categories such as “young workers,” “new immigrants,” or other known vulnerable groups [50, 51]. They define OSH vulnerability as a combination of increased exposure to hazards, in addition to inadequate workplace policies/procedures, low worker safety awareness, and/or diminished worker safety empowerment with which to buffer those hazards.
Both of these projects represent important work in moving research forward to address OSH disparities, and they provide helpful information to guide individual-level and workplace-level interventions. However, as Lipscomb et al. made clear [25], work-related health disparities remain rooted in historical and institutionalized systems of inequality that lie beyond the walls of individual businesses. Losing sight of these structural barriers can lead to placing responsibility on individual workers when structural protections (government policies) could better address larger forces operating against them. Flynn et al. present OSH research that begins to more directly address the role of structural factors in the workplace, applying the concept of “structural violence” from the field of medical anthropology [42]. The study identifies undocumented immigration status in the US as a social determinant of OSH, thus pointing to the role that federal policies, such as immigration policy, can play in generating worker health disparities. The medical anthropology literature defines structural violence as the imbalanced, detrimental effects of not only government policy but also of other broadly accepted practices that result from socially engrained biases and historically rooted economic inequities [52]. This perspective proves helpful in answering the call set forth by Lipscomb et al. for OSH researchers to uncover, analyze, and confront the roles of structural forces in the study of work-related health disparities. Lipscomb et al. identified the same structural forces, in different terms—“government policy, historical segregation (by race, gender, ethnicity, or class), geographic variation, unrecognized social norms, economic opportunity, and long-standing patterns of exploitation” [25].
Structural vulnerability theory
Recent work in medical anthropology has further developed the nuances of structural violence theory, defining “structural vulnerability” as the individual experience of the forces of structural violence [52]. This concept lends well to OSH research, in which the term “vulnerability” has already been used to define worker groups that are subject to health disparities, and it also brings awareness of structural factors to OSH disparities work. Established structural vulnerability theory is especially noteworthy for two reasons. First, where “structural violence” implies a dichotomy between structural factors and the subject of that violence, theorists of structural vulnerability illustrate how the phenomenon is experienced at multiple levels of work and societal hierarchies; mid-level individuals, while experiencing less intense vulnerability, are nonetheless constrained in exercising agency to solve problems [53]. Second, structural vulnerability theory helps to identify not only the external forces at play, but also how “individuals and collectivities often internalize [emphasis added] their externally generated depreciated status…as natural and deserved” and therefore become blind to the structural factors that harm them, instead blaming themselves [52].
Structural vulnerability theory has been used largely to describe undocumented Latino populations in the US, particularly those in farm work, who are rendered structurally vulnerable by their poverty, citizenship status, and ethnicity, and are suffering worse health outcomes as a consequence [52, 53]. However, these authors make clear that “structural vulnerability is not unique to Latino migrants in the United States,” stating, “It applies to the poor, the medically uninsured, the sexually stigmatized, people of color, the disabled, the incarcerated, and those with drug and alcohol problems... [and is further] shaped unevenly by specific status attributes (i.e., gender, age, ethnicity, etc.), [and] conditions (i.e., legal status, economic and living conditions, etc.)” [52]. CNAs working in NRCFs are notably structurally vulnerable due to their socio-economic status, workplace gender imbalance, racial and ethnic make-up, position in a devalued, low-paying occupation, and other demographic characteristics described earlier. Therefore, the present study utilizes a structural vulnerability framework to more broadly define the hazards influencing high WMSD rates among CNAs. An additional purpose of this paper is to demonstrate the utility of structural vulnerability theory in OSH research more broadly as a helpful framework that makes more explicit the role of structural factors in OSH disparities.
Methods
The current study is part of a larger, multi-dimensional research project that collected multiple types of data from different sources to describe and identify patterns in WMSD workers’ compensation claims across six major industry sectors in the state of Washington, details previously published [54–57]. The project’s methods were approved by the Washington State Institutional Review Board. Within the six industry sectors, 23 specific industry groups were selected using North American Industrial Classification System (NAICS) 4-digit codes. Within the health care sector, the following two 4-digit NAICS industry groups were selected: Continuing Care Retirement Communities & Assisted Living Facilities for the Elderly; and Nursing Care Facilities (Skilled Nursing Facilities).
One part of this larger study included interviewing workers with injuries from each industry sector about their injury experiences and work contexts as related to injury prevention. Workers were selected for recruitment based on having filed a claim during 2011–2014 for a WMSD of the back, shoulder, knee, or hand/wrist in the Washington State Department of Labor & Industries workers’ compensation system that resulted in 4 or more days of paid time loss. Individuals with missing or invalid contact information were excluded. Interviews included both open-ended and discrete questions in the following two major areas: 1) the worker’s injury experience and work context; and 2) WMSD risk factor exposures. A list of all interview items has been published in a previous article from the same project [54]. The present study used only the open-ended question responses relating to workers’ injury experiences and work contexts (see Table 1). Interviews lasted about one hour each, varying in length to allow the worker to fully answer each question. Interviews were conducted over the phone by a trained qualitative researcher (D.H.), audio recorded with permission from participants, and later transcribed verbatim into a database (Microsoft Access 2010). Within the two health care industry groups specified above, 42 workers were interviewed.
Interview items used for analyses
Interview items used for analyses
In order to better understand the structural factors influencing CNAs, the present study conducted exploratory, qualitative analysis on all interviews conducted with CNAs, n = 26. Open-ended question responses were extracted from the database and imported into QSR NVivo 10 to be coded for themes. A codebook was generated first with a priori codes based on occupational health and medical anthropology literature to answer the question “What factors do CNAs explicitly cite as causes of their WMSDs, and what factors appear to be at play considering CNAs’ descriptions of their injuries’ contexts?” The codebook formed a framework made up of three broad categories: “individual factors,” “workplace factors,” and “structural factors”. One researcher (A.H.) coded sections of text for a priori codes as well as codes that emerged from the textual data set itself, which were then added to the codebook. Coding was checked for consistency through an additional pass of coding. This initial coding process used mid-level categories to capture general areas of concern within the three broad categories (individual, workplace, and structural). A second coding process was conducted to focus on evidence for structural vulnerability experienced by CNAs. Several of the mid-level categories were chosen for more in-depth analysis (based on their relationship to structural vulnerability theory), and each category was coded again using more granular codes. This process was also duplicated, to check for consistency.
The demographic characteristics of the group of CNA participants are shown in Table 2. Notably, the sample is 96% (n = 25) female; is primarily categorized racially as “White” (73%; n = 19) (the second largest racial category is “Other,” made up of 3 participants who also identified themselves as having Hispanic ethnicity); and is roughly two-thirds married. The average age among participants was 45 years (±13), ranging from 20 to 63. Several participants either were not sure of or refused to provide an estimate of their annual household income (23%; n = 6); however, of those who provided an estimate, more than half (55%; n = 11) reported a figure less than $35,000, the equivalent of 1.4% of the poverty threshold for a family of four in 2015 [58]. Most participants identified their highest educational attainment as either a high school diploma/GED or some college/technical school education (85%; n = 22), with a minority of participants (12%; n = 3) having graduated from college. Almost half (46%; n = 12) of the sample had been working at their current place of employment for less than one year. Each participant was employed by an employer unique from the others’ employers, except for 4 of the participants (2 shared one employer and 2 shared another employer). Most CNAs were employed at nursing care facilities/skilled nursing facilities (62%; n = 16), and the remainder were employed at either continuing care retirement communities or assisted living facilities for the elderly. Back and shoulder injuries were the most common (38%; n = 10; and 31%; n = 8, respectively), with fewer knee and hand/wrist injuries.
Self-reported CNA participant demographics (n = 26)
Self-reported CNA participant demographics (n = 26)
*as per North American Industry Classification System (NAICS) 6-digit groups.
Themes that resulted from analysis of the interview data are displayed in Table 3. The following description presents those themes that are particularly relevant to forming a structural understanding of CNA WMSD experiences. Themes fall into three broad categories: 1) individual factors (characteristics and behaviors of individual CNAs and patients); 2) workplace factors (elements of the sphere of the employment organization); and 3) structural factors (elements originating from beyond the workplace that operate through a broader sphere of influence). We begin by describing the workplace and structural spheres, then follow with description of individual factors to illustrate how individual behaviors may be mediated by workplace- and structural-level influences.
Structure of themes addressing individual, workplace, and structural factors for CNA WMSDs* (Count of participants who described each theme)
*Items in brackets are not described in the present manuscript, but are provided here as part of a code/theme structure that can be used as a template in future studies.
The most immediate structure of human policies, practices, assumptions, and power differentials that the worker encounters is the structure of the organization—the workings of the workplace. While factors of the “organizational design” [22], or the “social environment” [24] have been well-covered previously in occupational health research, we include some of them here to demonstrate how these organization-level factors may be influenced by larger, external structural factors.
Internal work policies and practices
More than half of the CNAs discussed the problem of understaffing, stating this as a contributor to worker WMSDs. Several aides described high patient-to-CNA ratios, from 12-to-1 to 20-to-1. One CNA explained the problem is even worse during worker breaks, when the burden of care is shifted to the remaining coworkers. Another CNA explained that a 6-to-1 ratio during day shifts would be manageable, and 8-to-1 at the most during nocturnal shifts.
That’s how most nursing homes are. Why do people get injured? It’s because they don’t have enough staffing in most of these nursing homes. On the day that I injured myself, there were only five of us for sixty-six people.
Many CNAs pointed to problems with the evaluation of patient transfer needs as related to worker WMSDs. Patient evaluation is the process of assessing an individual’s state of mental and physical health, and documenting this information in patient charts that guide all staff interactions with patients. Some CNAs explained that evaluations, performed by higher level staff, were not being done often enough, well enough, or simply were not done, either because of a lack of staff or lack of action from higher level staff (even after CNAs brought the need for further evaluation to their attention).
I was transferring a resident that, honestly, they should have put her down for a Hoyer or a sit-to-stand because she could not bear her weight herself. And they refused to do an evaluation on her. Numerous CNAs were reporting the same, that the lady could not bear weight anymore, that she needed a sit-to-stand or a Hoyer... A lack of equipment, a lack of, honestly…the physical therapists there—the rehab people—doing their job. I mean, if they were actually doing their job like they were supposed to and re-evaluating the residents like they’re supposed to every three to six months there wouldn’t be such an issue with the CNAs getting hurt as much as they do…
Other sub-themes on internal work policies and practices include a lack of on-the-job training, difficulties with complicated work schedules and odd or multiple shifts, and requiring “light duty” tasks that are not truly “light,” such as 1-to-1 care for an unstable patient.
Together, these themes illustrate a work environment with limited resources, putting strain on CNAs’ day-to-day work experience. One CNA described the connection between these internal policies/practices and work stress, explaining that she had learned that work stress can lead to increased injury, and described the sources of her stress as low staffing levels and the resulting fast pace of work.
But, if they could get us another helping hand or two, you know, for each hall...we wouldn’t be so stressed out. Because I found out the more stressed you are and the faster you have to work, that that has the tendency of you getting hurt.
Management priorities
Many CNAs described how managers ignored their reports of recurring safety hazards. They explained that sometimes managers said they would fix a problem but then never follow up to do it, while others simply did not listen seriously to input.
You can report as much as you want and they ignore you. You can go write it down, and then the next day, go look to see if somebody’s actually checked it. And what you wrote down is not there anymore. Stuff comes up missing there quite a bit.
The nurses, they say they’ll write it down, or whatever, but they’re so busy passing medications and vitals and that stuff that they probably just forget. Nobody ever follows up with anything.
With this specific resident, she had been punching us, biting us. When I was pregnant, she kicked me in the stomach, she hit me, she cursed at us, she told us we were pretty much like going to hell and stuff. And we reported it and reported it and reported it, and until after the resident had bruises on her from, I guess, somebody who was working that hall during the day time, they moved her downstairs, and that’s all they ever did.
Some CNAs pointed to employers’ prioritization of profit over worker and/or patient safety as contributing to an unsafe work environment.
[Q: What would be the best way to implement this change to reduce the chances of injury?] Get rid of management that’s in there now, and get people in there who aren’t money hungry and who have the workers’ and the residents’ best interests in mind, instead of just money.
A few CNAs explained that managers and owners were resistant to spending money on WMSD prevention measures, including increasing staff levels.
But our administration, their budget, which is one of the reasons I got laid off, they can’t hire anymore people–quote, unquote–they can’t hire anymore people.
They’re just ancient equipment that the facility has and the owner doesn’t seem to want to replace with anything newer... But, the employer could make it much better if he used special—like for the residents’ beds, some facilities have beds that go up and down and you can put it at the level that you need to be to roll the person correctly and not hurt your back. The facility that I am at, he, the owner, is too cheap to buy these new beds.
Two CNAs also described a pattern of increased resources for additional administrative staff but a decreased focus on safety, in terms of cutting frontline staff and negligence to safety concerns.
Several CNA descriptions specifically draw a link between the priorities of management and the issue of limited staffing defined earlier. A few CNAs explained that insufficient staffing is a result of administration’s intensive cutting of staff, either during times when State Inspectors were not scheduled to visit, or generally as a means of making profit and/or managing budgetary constraints.
The facility runs great when State’s there. To be honest, if State is there the place is clean, the residents are getting taken care of, everybody works together, the equipment’s being used. When State is not there, they pull the equipment, there is no more help, they cut down–they don’t have enough aides on the halls.
Some CNAs pointed out the difficulty of retaining workers. They described this as a result of either remote geography (in one case) or, more often, worker dissatisfaction with the way facilities are managed.
Either people would quit, walk out, not come back, because they were tired of the crap, or they just didn’t have enough people working there. …There was such a huge turnover there. It was unreal. I’ve never seen any place, not even a fast food place. …I never even saw a huge turnover like that when I was waitressing. You would see somebody’s face, and then all of a sudden that person was gone like two days later. And then all of a sudden you’d see a brand new face, going, ‘Who are you?’
Structural factors
These organizational factors illustrate an extreme lack of both resources and managerial support for the safety of CNAs, who exist at the lower level of the organizational hierarchy. A structural vulnerability perspective suggests expanding our scope beyond the organization, to consider how external policies, organizational systems, and broader systems of power influence these organizational factors, and in turn, play a role in contributing to worker WMSDs.
External policy
Some CNAs talked directly about or illustrated the lack of external policies that could control the problematic organizational factors described above to create a safer work environment.
4.2.1.1 Direct policy. One CNA pointed specifically to a lack of regulations on staff-to-patient ratio as a risk factor for worker WMSDs. She explained that while there are mandated ratio caps in other states, there is not always one in Washington State.
I’ve been there when there have only been three of us, and that meant that we each had about twenty some people per aide, and that’s really hairy... For their safety, as well as ours, there should be a mandated—you don’t go beyond ten per aide. Eight would be the best number.
One CNA pointed out the lack of regulations on equipment quality, describing how some outdated or broken equipment poses physical hazards and suggested that regulations should govern the quality of equipment. Another CNA felt that her injury might have been prevented if her CNA training had been of higher quality, explaining that she did not learn the proper techniques, even from certified instructors. This suggests the need for improved oversight of CNA education courses.
Well, I think that if I had had the proper training to begin with, that maybe... Part of the reason they offer the class is because they hire you on at the end of the class. …And I needed a job, so I took part in that. Then I realized that I really didn’t learn anything... They were certified to teach it, yes, but they - one of them goofed off the whole time and one of them wasn’t there half the time, so, you kind of got shafted. …We only had three weeks in the class, too. The college offers two months, but when you’re doing a free training from the facility itself, it’s only like three or four weeks.
Two CNAs discussed the lack of resources in assisted living homes versus nursing homes, explaining that assisted living homes lack: 1) patient lift equipment; and 2) training for workers on patients with Alzheimer’s disease and dementia. They explained, however, that both nursing homes and assisted living homes house patients with needs for these resources, and that without them, workers are not safe. This suggests the need for policies that protect worker safety at all types of facilities where dependent patients reside, not just nursing homes.
Several CNAs mentioned required practices that put patient safety first but lead to an unsafe environment for workers. These descriptions imply the need for consideration of both internal and external policies that address patient and worker safety at the same time, rather than siloing regulation for each risk population. A CNA describes one example:
So you’re moving the weight of the lift and the person in the lift and there’s carpet so it’s really hard to move the tires so it’s really heavy. ... [The carpet] helps the residents so they don’t slip and fall as easily... It’s in a skilled facility area of the building, so most residents there need complete care. They have really bad dementia already or Alzheimer’s or they don’t know what’s going on. So you want to keep it as safe as possible.
4.2.1.2 Indirect policy. CNAs also described problems with external policies/practices that govern how organizations outside NRCFs run that end up indirectly affecting worker safety in the work environment. One CNA explained that recently patients with acute health care needs have been admitted to the facility, such that CNAs are now performing acute care without related training or support. She said this change is because of the recent closure of a nearby hospital’s rehabilitation section. This CNA also said that younger patients with mental illness have been recently admitted, sometimes exhibiting erratic behavior that the facility is not equipped to contain.
A few CNAs described difficulties with the process of seeking care for their WMSDs when dealing with multiple, concurrent work-related injuries. They explained that injuries were treated individually, rather than all together. One of these CNAs explicitly pointed to the lack of whole person treatment as a cause of subsequent work-related injury. This highlights the harm that may result from the administrative complexity of the workers’ compensation system, where separate claim management of each injury or “injury event” can potentially lead to multiple health care providers providing treatment absent a structured approach to coordinated care.
CNA socio-economic vulnerability
CNAs in NRCFs are situated within the structural violence of a socio-political system that generates extreme income inequality, often supporting families with minimum wage jobs and/or multiple jobs, and barely getting by financially. The following themes demonstrate this reality and show how low income may affect work and health.
One CNA pointed out the very low income she and other CNAs are paid, and the desperate situation this puts them in when injured. She also explained that for low-wage workers in her field, becoming injured can be financially unmanageable, requiring dependence on limited welfare payments. It is important to note that workers’ financial inability to make ends meet while injured could also pose as a deterrent to reporting injury.
A few CNAs described taking work in this field out of financial desperation, despite known safety hazards or other risks.
Most of the girls make minimum wage, which—they’re mothers with young children, most of them. It’s a desperate situation for them to take this job, and they’re not getting paid enough to hardly pay for their gas to come in to work. So most of the people who do do this job, when they stick with it, like I’ve stuck with it—I was hoping to get into a nursing program; that’s why I stuck with it—but also because there’s no other jobs around here.
One CNA mentioned that she has a second full-time job in addition to her work as a CNA. Several areas need to be considered with this issue: 1) increased work-related hazards for injury; 2) increased stress level; and 3) an indication of poverty.
The structural situation of employers/managers
CNAs shared many complaints about supervisors, managers and employers, most of which have been addressed earlier as issues with managers’ priorities. Within CNAs’ complaints, a handful of themes emerged that also hint at the structural constraints confronted by managers. For, while managers may often be perceived as holding a large amount of power in their work setting, in reality they must answer to facility owners above them and carry out owner directives and demands. By the same token, facility owners are beholden to policy and economic factors beyond their control. Thus, each individual is situated within hierarchical and societal structures that constrain their actions. By exploring these themes, we can begin to understand the structural situation of managers, and that this can in turn influence their decisions at the organizational level, including their treatment of workers.
Two CNAs described difficulties getting management to hear and deal with their safety hazard reports. They explained that the chain of command requires that they report problems to their supervising nurses, whom workers said are consistently “too busy” to do anything about them. This brings up the issue that supervisors in the chain of command may themselves be constrained by limited resources, and may truly struggle to find time to respond to worker needs.
One CNA explained that managers and administrators have high turnover rates, making it hard for CNAs to manage day-to-day because of constantly shifting directives. However, within this explanation, one can see that high turnover of managers and administrators may create an environment that is not only stressful for employees but also for the managers themselves.
Two CNAs explained that administrators often point to their limited budgets as the reason for their inability to respond to resource needs. While one CNA painted this approach as an excuse for profit-driven decision-making, it is important to note the possibility of very real financial constraints restricting administrators’ decisions.
To this very point, two CNAs talked about their employers’ relationships with the Medicaid and Medicare systems. One CNA explained that her employer complains that Medicare doesn’t pay enough and uses this as a reason for understaffing.
So you have an owner, basically, who’s trying to make a profit off of an elderly person that’s a commodity. And then you have, like, Medicare doesn’t want to pay what he wants them to pay. So in order to make the profit that he wants to make he’s cutting the backbone of this facility—the staff—that is the immediate care of these people. …Well, the facility says that they need to be paid better from Medicare/Medicaid, that they’re not receiving enough from them. …But the facility is constantly using that the state is giving them a lack of funds as a reason for why we don’t get new equipment and we don’t get enough staff…and why they can’t give us a pay raise.
Interestingly, however, another CNA described her employer as being interested in admitting Medicare patients because Medicare “pays more.” The incongruence of these two explanations, and their linkage to funding and how it affects employers’ priorities (in relation to worker safety), makes this an important issue to explore further.
Employer/manager mistreatment of CNAs
Several themes demonstrate managers’ direct mistreatment of CNAs, in addition to the more passive negligence described earlier in Management Priorities. Two CNAs described instances in which administrative staff placed primary responsibility on the worker for safety problems or injury, despite other factors outside of the worker’s control being at play.
Well, first we go to our nurse in charge, and then we have to fill out an employee incident report, and it gives us basically what happened, who was there, were there any witnesses, what were you doing as your normal routine, blah, blah, blah. …All that happened was I got called into his office, along with the registered nurse, and I was told, “You seem to get hurt a lot, and I’m going to send you to a body mechanics—proper body mechanics—course or class.”
…They’re like, “Well, our budget only allows for,” and, “you should be able to,” you know? “We have to make budget cuts...
Within this second explanation, the CNA describes management’s focus on budgets, but between the lines implies that there is an expectation of individual responsibility—“you should be able to”—that places blame on the worker.
A few themes emerged about ways that managers discriminate against certain workers. Unlike common concepts of discrimination, CNAs in this study did not bring up issues of race, ethnicity, gender, or other identity discrimination. However, CNAs discussed other forms of discrimination pertaining to workers’ relationships with safety problems. Some CNAs explained that administration treated them poorly after they had filed WC claims. For most of these workers, this resulted in dismissal.
It’s affected me quite a bit. Not to mention I got fired over the whole incident... I believe I was fired because I filed a claim. It seems kind of weird to me that like a week after I had filed the claim they pulled me into the office and told me that I had poor performance. I had never been told anything prior to that.
A few CNAs described ways that they and other workers had been discriminated against at work because of speaking up about worker or patient safety issues.
Last time I talked to the State I wound up being black balled by my employer and he won’t promote me to any position other than CNA. I got promoted and he demoted me as soon as he found out that they promoted me to that position. And then the scuttlebutt around was, “Well you made too many mandatory reports to the State, that’s why he won’t let you have the job.” …But they do discriminate if they find you have talked to the State. And this isn’t the only nursing home I’ve seen that happen. The other nursing homes I’ve worked at I’ve seen that happen to other aides. They’d talk to the State and suddenly the forty hours disappeared and you’re down to twenty, fifteen hours a week, and, yeah, they find a way to get around it and make your life miserable.
It is also important to note that patterns of safety-related discrimination may lead to workers ceasing to report safety concerns or file WC claims, setting up a scenario prone to more severe injuries across the organization.
By examining related themes from multiple levels of analysis above, one can see how these factors may be related and that the structural situation of managers may be translated into organizational-level factors and individual experiences. For example, consider the possible relationship of the following themes:
management’s prioritization of profit over safety (Organization-level)
budgetary constraints acting on managers (including influence from Medicaid/Medicare reimbursement rates) (Structural-level)
management’s mistreatment of workers based on safety issues (Individual experience/Structural outcome)
Organizational and structural context of individual factors
It is important to note that the number of CNAs who described or alluded to structural factors in this study is small. More commonly, when asked what contributed to their injuries, CNAs pointed to either organization-level factors (described earlier), or individual-level factors—either patient factors or worker factors. Patient factors were largely described as behaviors brought on by ill health (e.g. physical instability; cognitive problems), and therefore may be best left as fixed variables in the present analysis.
When it comes to worker factors, CNAs described a few problems that played a role in their injuries, including a lack of knowledge about best practices as well as physical problems (previous injuries; old age; and family history of WMSDs). However, many CNAs (and, interestingly, often these same CNAs) also explained in various ways that they felt it wasn’t their fault they got injured. They said that they had done everything the “right way” (such as using proper body mechanics) and often concluded therefore that there simply was no cause of their injury—it was merely a “fluke,” or “just an accident.” Or, they explained that they “didn’t know” the cause, that they couldn’t think of one.
There’s really no other easy way to move a resident up in bed other than that. And like I said, I’ve done it a bazillion times. I don’t know why, all of a sudden, my shoulder decided to be a butt. …I think it was just a fluke-y thing that happened. Like I said, it’s part of the job. It’s a normal thing. You have to be able to lift a certain amount as a CNA. You know, helping someone get out of bed, get in bed, from the toilet, to the wheelchair, vice versa. It was just a common practice. …I think it was just a fluke thing that happened and that’s it.
It is a regular part of the job, but you know sometimes accidents happen that you don’t know.
I honestly don’t, I don’t know what happened. But I really, I have a feeling maybe it was I just bent wrong, or my—I don’t know. The doctor says that my body shouldn’t have reacted the way it did.
Considering these CNAs’ place in the work hierarchy and socio-economic hierarchy, it is not surprising that they may be less apt to construct a structural perspective of their injury [52], and without such a perspective, be left at a loss for words when it comes to trying to answer the question “Why did this happen?”
Sadly, we can also see from the interview data the lengths to which CNAs go to explain their innocence, to underscore the fact that they chose correct behaviors, that they were really trying to do things right and also that they had not felt any previous warning signs of pain. It seems that without an understanding of how organizational and structural factors can influence injury, many CNAs presume that they themselves are the only possible cause of the injury, ready to blame themselves. However, the feeling of conflict that comes from knowing they were not at fault is palpably unsettling for them:
Because I was dealing with a dementia patient and he wasn’t really feeling good, so I don’t know how else I could have—I mean, I got help. I thought he was not doing that great the first transfer, so I got help. And it should have been okay. Apparently, it wasn’t, but it should have been. You know what I mean? So I don’t know what else I could have done to make it easier or better or to prevent it. Get a more alert patient I guess, but that’s not the field that I work in. That’s not the type of people I work with.
I just didn’t notice anything up until that point. Yeah, I don’t know, maybe I just bent wrong or something, I don’t know. It just kind of happened.
Our analyses of other individual-level factors also found that CNAs described beliefs they hold about their work that seem to influence injury occurrence. For example, some explained their belief that injury risk is simply part of the nature of this type of work.
I don’t really know what would be suggested to prevent that kind of injury. It’s kind of the nature of the job. When you’re lifting, and you’re lifting body weight, either you can bear it or you can’t. Typically you don’t find out until you do, other than using common sense.
To be quite frank, I don’t know that it can be addressed or corrected. I think it just comes with the territory of doing what we do.
More than individual beliefs, these descriptions suggest a culture in NRCFs that engenders a belief in the necessary difficulty of the profession and the normalization of injury as an acceptable and expected characteristic of one’s job. This links to earlier descriptions of the pressure managers place on their workers and a work culture that expects CNAs “should be able to” do what is asked of them regardless of safety concerns, leaving an overall impression that worker safety is not only not important but also not expected.
In a related theme, several CNAs described their belief in the importance of putting patient safety first, even before their own safety. These CNAs’ words convey a sense of duty to keeping patients safe above all else.
We almost fell, but I told myself I wasn’t going to let that happen. So I positioned myself again to a point where I lift and twist or pivot and put him on the chair. And that’s—when I was lifting—that’s when I felt my back.
These CNAs’ patient-focused values mirror the theme described earlier regarding practices and policies that favor patient safety without consideration of worker safety. CNAs’ values on this subject may have been influenced by norms and policies that dictate their everyday habits.
Through a detailed-reading of participants’ descriptions, we can see how individual-level factors related to CNA characteristics and beliefs can have roots in organizational and structural circumstances. By seeing CNAs as operating within these larger contexts, it becomes difficult to see these workers as independently choosing unsafe behaviors, despite the blame they so often assume simply because the systems at fault are invisible to them.
Discussion
Overall, CNAs’ descriptions of their WMSDs paint a picture of a work environment with significant organizational deficiencies and a broader structural environment that appears to produce barriers to worker health and safety. As one of the lowest status and lowest paid occupations in NRCFs (and in the broader health care industry sector) CNAs are structurally situated at the bottom of a hierarchical system that affords them little power to control the outcomes in their lives and personal health. This is reflected in participants’ descriptions of the organizational aspects of their workplaces, including policies and practices that result from management priorities being diverted away from worker safety, and ultimately resulting in a high-stress, high-WMSD-risk reality for CNAs. These difficulties are compounded by several aspects of CNAs’ socio-economic vulnerability, which participants described in terms of low income, choosing/maintaining a high-risk job due to financial desperation, the need to work multiple jobs to make ends meet, and the need to rely on welfare when experiencing an injury-related pay reduction. With limited resources both at work and at home, CNAs experience a “double-whammy” of vulnerability in which they are intensely restricted from exercising control over their lives and experiencing stability.
In considering the individual-level worker behaviors/beliefs more commonly studied in OSH, our analyses of CNA descriptions found not only physical- and knowledge-based factors but also uncovered several themes that link the individual level to the organizational and structural. Some of these themes, including the belief that injuries are “just part of the job” as well as descriptions of injuries as cause-less “flukes,” have been explored more at length in a previous paper that analyzed data across multiple industries from the larger research project [54]. Particularly noteworthy for NRCFs is the theme of CNAs’ beliefs in the value of putting patient safety before their own. By considering this in the context of an earlier theme about organizational policies that favor patient safety, we see an example of the way that the addition of organizational and structural lenses can demonstrate how individual-level factors may be mediated by factors outside an individual’s control.
Several themes in the present study reflect the findings of previous studies, including high work-related stress levels [2], difficult work schedules, and reliance on public assistance programs [5]. There is also one particular parallel between this study’s results and those found in a qualitative study of immigrant workers from a variety of industries [40]. Both demonstrate a connection between workers speaking up about safety issues and/or filing WC claims and the responses of employers: 1) indifference (negligence); and/or 2) retaliation, including dismissal.
Several other known aspects of the structural vulnerability of the CNA worker population notably did not emerge as themes in the present analysis. In particular, CNAs did not bring up gender, race/ethnicity, education level, or marriage status when describing their WMSD experiences. This is not surprising for two reasons: 1) the interview guide was not originally designed to obtain structural-level information from CNAs; and 2) individuals near the bottom of the societal hierarchy are more likely to internalize justification of their lower status, or at least perceive it as an unchangeable reality, and therefore may be less apt to identify characteristics of their social status as problematic [52]. Also, the sampling strategy yielded only a small number of racial and ethnic minorities (7 CNAs), making it less likely to capture information about racial/ethnic discrimination that may be experienced in those populations.
All participants except one were women, which reflects the highly feminized CNA workforce described earlier. While no participants discussed gender in their injury stories (which, again, is not surprising coming from any type of lower-status group, including women), it is important to note the potential for sexism (both personally-mediated and institutional) as a contributor to increased risk for this worker population. Some sociologists have demonstrated how not only do women and men differ in pay rates within one occupation, but also the occupations associated with “women’s work,” such as nursing and nursing assistance, are often undervalued and undercompensated [13, 59]. Thus, feminist perspectives will be valuable in future research on CNAs to illuminate how this additional layer of structural vulnerability may be at the root of some of the challenges described in this study, such as low income, reliance on social services, and difficult schedules [13]. Additionally, research has shown that division of labor in society is often further cut along lines of race and ethnicity, with minority women disproportionately performing “dirty work” (i.e. jobs such as housekeeping and food preparation, vs. “professional” caring labor jobs like teaching and counseling) compared to white women. Given the representation of racial and ethnic minorities making up the CNA profession, it will also be vital to incorporate critical race theory and analyses of intersectionality in future research [12, 13].
CNAs are situated near the bottom of a socio-economic stratification that puts them at many disadvantages. At the same time, they also exist at the lower level of the workplace hierarchy, where workplace policies and practices often work against them. Understanding that organizations do not exist in a vacuum, we can take a structural perspective and ask, What external factors may be influencing these internal policies and practices? Themes from the present analysis point to several ways in which current government regulation of NRCFs is limited, highlighting the need for improved oversight of: 1) staff-to-patient ratios; 2) lifting equipment quality and availability; and 3) CNA training standards, as well as other policies, including parity between worker protections at nursing homes and assisted living homes, and regulations that work in tandem (rather than at odds) with patient safety regulations and practices. Similarly, in another qualitative study with nursing assistants and nurses in the home health care setting, the need for federal standardization of medical devices and for improved quality of worker training on proper use of those devices were identified as important ways to decrease injury risk [24].
In the present study, indirect policy impacts were also identified from institutions outside the realm of NRCFs, including the admittance of acute and mentally ill patients in nursing homes as a result of lacking beds in outside institutions traditionally available for these populations, and uncoordinated treatment of CNAs’ multiple, concurrent, work-related injuries. Such problems call for policy changes that reach beyond regulation of NRCFs alone to cover an even broader reach of society’s structures.
Another important aspect of how internal policies and practices are produced and maintained is the role of administrators and managers. Certainly, compared to CNAs, they are afforded a significantly greater amount of power to make decisions that affect the work environment. However, structural vulnerability theory suggests also conducting analyses of the structural situation of administrators and managers themselves, to understand the forces that constrain them and limit their assumed power to make human-centered decisions, as has been demonstrated in both U.S. farm work [53] and health care [60].
Themes from participant responses point to several constraints for administrators and managers in NRCFs, including: 1) time constraints (always being “too busy”); 2) high management turnover (implying work stress); 3) budgetary constraints; and 4) financial and other challenges of reimbursement through the Medicaid/Medicare system. These constraints may influence management priorities, which some participants described as being profit-driven and negligent to safety. These priorities may in turn lead to the workplace-level policies and practices that CNAs identified as contributing to WMSDs (deficient staffing levels, insufficient frequency of patient evaluations, ineffective training, as well as risky light-duty assignments and difficult schedules and shifts). Such a link has been indicated in a previous study with regard to one of these factors: management turnover; an analysis of Washington nursing home back injury WC claims found management turnover to be a predictor of increased risk of CNA injury [4]. Future analysts may find use in considering the other administrator/manager constraints identified above as potential risk factors.
The identification of difficulties with limited time and finances (especially reimbursement) echoes medical anthropology analyses of the entry of privatized managed care into the Medicaid system. These assessments have demonstrated how this change has brought about reduced reimbursement rates and increased performance measure demands that in turn lead to time constraints for primary and mental health care providers when treating patients [61, 62]. Elsewhere, the limitations of Medicaid/Medicare reimbursements have been identified as barriers for nursing home employers to increase wages and benefits [63], especially since they receive a majority (60%) of payments from Medicaid/Medicare [11]. How the nature of reimbursement may or may not interact with administrator/manager priorities and safety decisions in NRCFs is not yet clear, but due to the intimate relationship they have with the Medicaid/Medicare system, the question should be considered in future research.
Themes from CNAs’ experiences point to a tendency for administrators/managers to place blame on workers with injuries, even if they are aware of other constraints (e.g. budgetary). Similarly, administrators/managers were said to discriminate against workers who filed WC claims or spoke up about safety concerns. It is important to point out that administrators/managers are situated in the middle of a hierarchy (rather than at the top, as is easy to assume), since in reality they experience pressure and manage expectations from both employees below them as well as facility owners who operate above them in the workplace hierarchy. Previous research has also uncovered the ways that constraints on mid-level individuals can translate into victim-blaming of those below them in the hierarchy. For example, time-strapped physicians have been shown to place blame on patients with complex cases as a coping mechanism for the powerlessness they experience in trying to address patients’ needs when given insufficient time resources due to managed care requirements [61, 64]. Considering the evidence in other hierarchical systems in health care for victim-blaming as a coping mechanism for structural constraints, it is possible that a parallel process occurs with NRCF administrators/managers constrained by time and financial limits when confronted by workers they feel unable to help. This structural vulnerability may then be passed down as patterns of blame and discrimination. In this way, the vulnerability at upper levels is transferred downward where it becomes most saturated.
Thus, we can see how NRCF administrators/managers can be viewed as structurally vulnerable themselves. While experiencing many fewer barriers to exercising control, they are limited in being able to make decisions that are in the best interest of the organization and its employees. This perspective adds an important lens to existing research on leadership styles of administrators/managers in NRCFs. One study demonstrated that “consensus manager” leadership styles are associated with the least employee turnover while a “shareholder manager” style is associated with the highest turnover [65]. However a structural vulnerability approach adds the question, What external constraints are acting upon “shareholder managers” that may keep them from engaging with their staff in the first place? To gain a clearer understanding of the constraints administrators/managers experience in NRCFs, and how they may be related to worker WMSDs and other injuries, research is needed that conducts data collection along the spectrum of hierarchy in each organization, from janitors and CNAs to nurses, administrators, and owners.
Overall, themes from the present study demonstrate clear examples in support of the applicability of structural vulnerability theory to CNA work, and to OSH in general. It may be helpful to note that structural vulnerability theory from the field of medical anthropology aligns well with an important public health disparities model, the fundamental cause model [66], which may prove useful for OSH researchers moving forward. The fundamental cause model focuses on describing the structural-level causes of health disparities, such as socioeconomic differences, racism, and other culturally, politically, and historically rooted forces behind inequity. Similar to structural vulnerability theory, the fundamental cause model distinguishes between multiple spheres of influence, from the proximal “surface causes” to the distal “metamechanism” that sets up the environment in which those surface causes form. This perspective has been used broadly in the field of public health, particularly in consideration of institutional racism, but has not been widely applied in OSH specifically. OSH researchers interested in exploring a structural approach may find the fundamental cause model to be particularly transferrable to their field, in addition to considering structural vulnerability theory.
Many recent studies on CNA WMSDs point to the need for interventions at the individual and workplace levels, such as ergonomic assessments, staff training, addition of specific lift equipment, no-lift policies, and other organizational policies [10]. The results of the present study, however, suggest the need for interventions at the structural level through government policy implementation and change. As described earlier, the NRCF industry has long struggled to meet quality of patient care standards, and government regulations have continually failed to significantly improve the situation. From the present exploratory analyses, it appears that the NRCF industry is suffering similarly in regard to worker safety. While some government regulations are in place, CNAs here have described that negligence and problematic organizational practices are allowed to slip through the cracks. It is time for the reconsideration of the instruments used to regulate worker safety in NRCFs. Furthermore, the siloing of NRCF worker safety and patient quality of care is problematic. As described by participants, too many worker safety hazards directly result from practices aimed at improving patient quality of care. Rather than working at odds, regulatory bodies from the labor and the health care camps need to work together, since the health of workers and patients will continue to be intimately tied.
CNA safety also appears to be negatively influenced indirectly through government funding cuts. Whether through the closure of acute care and mental health institutions or the limits of Medicaid and Medicare reimbursements, participants’ descriptions illustrate how funding cuts can have unforeseen detrimental effects down the line, like overloading nursing home staff workloads and squeezing staffing levels. Meanwhile, government has been faced with decades of high rates of WMSDs at NRCFs that drain public funds through workers’ compensation payments, effectively nullifying the initial spending cuts.
Participants also described NRCF managers as focused on financial concerns over safety concerns. As explained earlier, the majority of nursing homes in the U.S. operate as for-profit institutions, in contrast to a minority of non-profits. This raises the question of priorities in this industry, as well as those of the government entities that continue to allow such profit-making in the health care sector. As seen earlier, it has been shown that for-profit nursing homes have lower patient quality of care outcomes. Along the same lines, research is needed that questions a link between for-profit nursing homes and worker injuries. According to participants here, it seems that managers are so constrained by financial goals that worker safety is often left to chance.
Limitations
This study was meant as an exploratory analysis to begin to characterize the structural factors at play in the WMSD risk of CNAs at NRCFs. Notable limitations of this study include the absence of specific interview questions regarding structural factors, a severe under-sampling of racial and ethnic minorities, and the lack of data collection from administrators/managers and other mid-level individuals in the NRCF hierarchy.
Conclusion
Using a structural vulnerability approach, this study suggests ways in which the high WMSD rates of the CNA population may be mediated by structural forces, such as government policy and class inequalities. This analysis demonstrates how these societal-level structures may influence administrator/manager decisions and related workplace-level risk factors that put low-level workers like CNAs at greater risk of harm. Applying a structural perspective to OSH in this way will be intensely useful as the field continues developing its work on disparities. Without a structural perspective, research will continue to yield limited knowledge about all variables and interventions focused heavily on proximal risk factors. An example demonstrates the danger of a narrow approach: one research group provided assertiveness training to Hispanic construction workers to increase their reporting of safety concerns to superiors. However, as these researchers later described, Hispanic workers experience highly precarious jobs and may be more likely to prioritize job security over speaking up [48]. Thus, interventions that focus on worker behavior change may not only be less successful, but also lead to further “victim blaming,” whereas a structural approach acknowledges vulnerable populations’ powerlessness and addresses higher-level influencing factors [67].
A structural understanding of OSH disparities is in its beginning stages. Continued exploratory, qualitative analysis will be necessary as a means to gather and organize a framework of various structural forces and respective mediators working through multiple systems to influence differential health outcomes in a variety of industries and occupations. While qualitative research is often perceived as restrictive due to being time-intensive, it is a necessary first step in early research aiming to address occupational safety and health disparities [68]. Incorporating existing structural vulnerability and public health disparities theories into such analysis will set the groundwork for more detailed models of the ways certain worker populations are left with unequal burdens of WMSDs and other work-related injuries, illness, and fatalities.
Conflict of interest
None to report.
Footnotes
All BLS figures are for private industry in the US for 2014, using the BLS definition of musculoskeletal disorders (MSDs).
Acknowledgments
This research was supported by the Washington State Department of Labor and Industries and by grant number 5U60 OH008487-10 from the Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health (NIOSH). The contents are solely the responsibility of the authors and do not necessarily reflect the official views of the Washington State Department of Labor and Industries or NIOSH. The authors wish to acknowledge the following individuals for their contributions and support: Stephen Bao, David Bonauto, Paul Karolczyk, Han Kim, Renae Knowles, Jennifer Marcum, Shalene Petrich, Steven Russell, Barbara Silverstein, Caroline Smith, and Sara Wuellner.