CNA Injury Rates Linked to Low Pay, Lack of Respect

A recent report from RTI press analyzed the sky-high injury rate–the highest for any occupational setting–among CNAs in nursing and residential care facilities. Lead researcher Galina Khatutsky talked to us this week about her team’s findings, including the fact that injury rates are lower among workers who are better paid and who feel respected and valued by their employers.

Galina Khatutsky

One of your most interesting findings was that CNAs who have better working conditions—those who are higher paid, feel respected and rewarded for their work, and work for facilities they perceive as valuing CNA work—are less likely to get injured on the job. How strong are those correlations and what do you think causes them?
It was a pretty big effect. We don’t know why, but we thought that maybe if CNAs perceive that their organizational cultures were welcoming that would promote a safer working environment because, for instance, it might be easier for them to collaborate and obtain additional help when they need it. We thought they might be less likely to feel that they have to rush and more likely to help each other. As for pay, we thought it may be a proxy for other CNA characteristics that we could not measure. For instance, staff who are higher paid might tend to have more motivation or to provide better care. Maybe they’re just more experienced and know what they’re doing. 

Because you also found that new CNAs get injured more, right?
Yes, absolutely. We created this measure to flag CNAs who are either new to the facility or new to the work, so I call them new workers. We suspect this is because if you’re new to the work you don’t know how to do it, and if you’re new to the facility you don’t know how the facility works. Maybe you don’t know where the lifts are. Maybe you are not yet comfortable to ask for help. Maybe you’re just too insecure to follow through all the steps you need to take to be safe that you learned in your training. It’s very stressful work, so it takes a while to gain confidence.

How bad is the problem of injury rates among CNAs in nursing homes?
Injuries are really prevalent. Nationally, 60.2% of all CNAs reported some sort of work-related injury in the year prior to the survey. The most common injuries among CNAs were scratches, open wounds, cuts and back injuries. There was a similar survey of home health aides. The questions were asked differently, so the injury prevalence data are not directly comparable. The most common injuries among home health aides were needlestick injuries and abuse/assault by their clients.

The scratches and cuts and some of the open wounds reported by the CNAs could also be a result of abuse by clients, couldn’t they?
Our survey asked how they got the injuries. The answers they gave were not mutually exclusive – there could have been more than one cause for a single injury. The highest response was for was aggression by residents, which 59.4% reported as a cause of their injuries. We thought that number was really high. In fact, we found it difficult to believe, so I didn’t report it in our paper.

The other reasons given were were “lifting, bathing, and helping people” (51.4%); bumping or hitting equipment (11%); slips, trips, and falls (4.8%); and other (5.2%).

Which of your findings did you find most surprising?
The most surprising for me was that the effect of lifting equipment on reducing injuries was not significant, once you controlled for other variables. Our main goal was to examine the relationship between assistive equipment and injury rates, and we expected to find it was the main variable in keeping them down. Instead, we found that a lot of CNAs use lifts and they’re widely available, but the use of lifts does not affect injury rates once you take into consideration other factors.

So there are a lot of other important issues that do affect injury rates, including organizational culture. Before we added organizational factors and other work characteristics into the model, the lifting equipment use was significant, actually.

That must have been surprising too, but in a good way, since it points to things people can do to lower injury rates.
Yes. It is obviously important to have a good organizational culture, because CNAs work better and get injured less in facilities where they feel respected and supported. And people who work a lot of mandatory overtime get injured at higher rates. This is intuitively much more understandable than the lifting equipment finding: you would expect long hours and night shifts to lead to more injuries. And CNAs who report they don’t have enough time to deliver personal care get injured more, which also feels completely understandable.

Your study found that more than a third of all CNAs don’t always use mechanical lifts even though they are widely available. Why do you think that is?
I’m just speculating here, but I think sometimes a lift requires a two-person assist and they just don’t have time to wait for another CNA because they’re rushing. I’ve also observed personally that people—especially those with cognitive impairment—can get really scared and nervous around large equipment , so maybe it’s just easier sometimes to move the resident without a lift. We also thought that some facilities may have these old style manual crank beds and they may be more difficult to use. But my gut sense is that it’s mostly time pressure and inexperience.

Another thing we found in a different study was that language and communication is a very big issue in nursing homes. Maybe using a lift—explaining what you’re going to do and why it is needed and calming people down—requires additional communication, and because of the language barrier it’s just too difficult. Diversity now is such a big factor , both among the staff and among the residents, especially in urban areas.

I live in the Boston area. My husband’s grandmother was in a nursing home here after she developed cognitive impairment. She spoke only Russian, and she had one roommate who only spoke Vietnamese and another who spoke Chinese. Most of the CNAs were Haitian and they did speak some English, but there was really no common language between them. It was surreal how hard communication was for her, and she was very scared of the lift.

On the flip side, you found that certain types of CNAs were more likely to be injured. Who were they and why do you think that is?
Women get injured more often, and so do both younger and older workers. It’s easy to imagine why that might be true for older workers: This is very hard physical work, and I would suggest that with advancing age it gets harder. That may also explain why injury rates are lower among men, who tend to be physically stronger than women. Younger people may be less experienced and reluctant to wear protective gear. If some of the injuries come from resident aggression, maybe they don’t have the life experience or training to know how to handle residents with dementia.

High-turnover workers, people who have had two or more jobs in the last five years, are also more likely to get injured. Maybe they don’t stay in one place long enough to learn the culture, or to learn the ropes of the job. Because the training they receive in injury prevention is very rudimentary.

You found that almost all facilities provide training on how to avoid on-the-job injuries, yet it doesn’t seem to be working very well. Why do you think that is?
I think the training probably is not comprehensive enough. Most of it deals with how to operate the lifts and other equipment, but maybe more needs to be taught on how to pace yourself during the day, how to wait until you can get help for certain tasks. Also how to work with residents who are resistant, how to manage your time, how to work collegially with other CNAs and ask each other for help.

Also it seems that the frailty of nursing home resident is increasing, so CNAs need more help in understanding how you deal with frail residents and how you deal with cognitive impairments. Another piece needs to be on how to communicate with residents and family members when there’s a language barrier. If you explain how equipment works and why it is needed, maybe residents will be more accepting.

What can facility managers and policymakers do to reduce CNA injury rates?
Facilities have to provide a lot of support to CNAs who are new, whether just to the facility or to the occupation as a whole. They should think about providing mentoring, additional training or whatever support they can. And they should do their best to reduce mandatory overtime. Of course that’s easy to say, but when it’s so hard to hire and retain CNAs, the shifts need to be staffed. Managers also need to teach CNAs safe body dynamics, and they need to do it on a recurrent basis because the turnover is so high.

As for policymakers, we still don’t have mandatory universal laws about patient handling. We need them. We also don’t have mandatory staffing ratios across the country. In our model, CNA staffing ratio was not a significant predictor of injuries, but CNAs who reported that they did not have enough time for personal cares had higher rates of injury.

I have to qualify all of this by saying that survey data is subjective: our data on whether CNAs have time to do personal care is all perceptions reported by the CNAs themselves. We didn’t measure time actually spent. But those perceptions are important because lawmakers and policymakers and even employers may think the staffing ratio is what it should be, but CNAs may still feel overwhelmed and feel that they don’t have enough time to do their jobs.