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Occupational Medicine Advance Access originally published online on March 28, 2008
Occupational Medicine 2008 58(5):348-354; doi:10.1093/occmed/kqn026
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Occupational injury among full-time, part-time and casual health care workers

Hasanat Alamgir, Shicheng Yu, Negar Chavoshi and Karen Ngan

Statistics and Evaluation Department, Occupational Health and Safety Agency for Healthcare, Vancouver, British Columbia, Canada

Correspondence to: Hasanat Alamgir, Statistics and Evaluation Department, Occupational Health and Safety Agency for Healthcare, 301-1195 West Broadway, Vancouver, British Columbia V6H 3X5, Canada. Tel: +1 778 328 8013; fax: +1 778 328 8001; e-mail: hasanat{at}ohsah.bc.ca


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background Previous epidemiological studies have conflicting suggestions on the association of occupational injury risks with employment category across industries. This specific issue has not been examined for direct patient care occupations in the health care sector.

Aims To investigate whether work-related injury rates differ by employment category (part time, full time or casual) for registered nurses (RNs) in acute care and care aides (CAs) in long-term facilities.

Methods Incidents of occupational injury resulting in compensated time loss from work, over a 1-year period within three health regions in British Columbia (BC), Canada, were extracted from a standardized operational database. Detailed analysis was conducted using Poisson regression modeling.

Results Among 8640 RNs in acute care, 37% worked full time, 24% part time and 25% casual. The overall rates of injuries were 7.4, 5.3 and 5.5 per 100 person-years, respectively. Among the 2967 CAs in long-term care, 30% worked full time, 20% part time and 40% casual. The overall rates of injuries were 25.8, 22.9 and 18.1 per 100 person-years, respectively. In multivariate models, having adjusted for age, gender, facility and health region, full-time RNs had significantly higher risk of sustaining injuries compared to part-time and casual workers. For CAs, full-time workers had significantly higher risk of sustaining injuries compared to casual workers.

Conclusions Full-time direct patient care occupations have greater risk of injury compared to part-time and casual workers within the health care sector.

Keywords      Acute care; care aides; casual worker; full time; long-term care; musculoskeletal injury; occupational injury; part time; registered nurses


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Evidence suggests that part-time and casual employments are expanding [1]. The shift to contingent work arrangements such as part-time or casual work might have effects on the occupational health and safety (OHS) of workers. The vulnerability to occupational injury might be different, if different employment category exposes workers to more hazardous tasks, less access to relevant training and programmes and less job security. The aim of this paper is to investigate whether full-time, part-time and casual health care workers differ in their work injury experience.

Studies examining the specific issue of employment category and occupational injury in the health care sector are infrequent, but have shown the trend of full-time workers being more vulnerable to injury than part-time/casual workers. Thomas et al. [2] studied injuries among hospital employees and found work-related injuries occurred less often in part-time than full-time staff. In another study, the same authors examined risk factors for work-related injury in hospital employees and again found all injury types most often related to full-time employment [3]. Studies have also demonstrated that compared to other industries, full-time workers of the health care industry experience higher levels of workplace injury than part-time ones [4–6].

In a review of a range of studies on the health and safety effects of part-time/casual employment in industrialized societies, Quinlan et al. [7] reported that from 93 studies, 76 found non full-time employment to be associated with a decline in OHS for injury rates, disease risk, hazard exposures, worker (and manager) knowledge of OHS and regulatory responsibilities. The evidence is weaker for small businesses, and some studies on part-time workers did not find a clear association with the above factors [7]. These trends may depend on the industry and job description; where jobs that require high standard specialization may not result in the factors of inexperience or unpredictable work hours, increasing work injury risks of part-time workers [4]. Further research is needed to more clearly link health effects to specific work practices.

To the best of our knowledge, there has not been any such study in Canada on the whole range of health care workers investigating the association of type of employment with vulnerability to workplace hazards. The Occupational Health and Safety Agency for Healthcare (OHSAH) in the Canadian province of British Columbia (BC) collects incident data on injuries and exposures among health care workers through the Workplace Health Indicator Tracking and Evaluation (WHITETM) database. This database provides an opportunity to investigate injury incidents by employment category. The aim of this paper was to evaluate whether employment type was related to differences in rates of work injury.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
WHITE is a web-based surveillance system developed by OHSAH in collaboration with BC's health regions to facilitate the analysis of workplace incidents and injuries. It provides health care stakeholders with comparative performance indicators on workplace health and safety. WHITE data include the following: descriptions of incidents, demographics of the injured worker, contributory factors related to the location and circumstances of injury, nature and cause of injury, body part involved, etc. Injury classification and coding were developed by OHSAH in conjunction with the health regions and unions. Currently, four of BC's six health regions are tracking incidents using WHITE.

All incidents including near misses and first aid only are reported by the health care worker to their manager/supervisor. Details of the incident are written onto a triplicate form which is filled out by the supervisor/manager, with the worker responding to each question. If an incident requires medical care or time loss, a portion of the form goes to the claims department of the workers' compensation board (WorkSafeBC).

The WHITE database and its intent were reviewed rigorously by OHSAH's bipartite board of directors—the health employers and union representatives. They supported the database and communicated this, and the awareness of WHITE, to their workforces and membership. The WHITE database has many layers of security to ensure that information is only available to authorized persons. This is achieved through personal non-transferable login and passwords that determine the information to be displayed to each user (occupational health professionals) of the system. This is in addition to the health authority network security. Data are used for research and analysis purposes by the health authority, unions, joint health and safety committees and OHSAH. Information collected and used by OHSAH is based upon the anonymity of individual health care workers. This is achieved by removing or encrypting personal information before it is analysed.

The WHITE database facilitates the merging of incidents with workers' compensation and payroll data. Detailed analyses (stratified by occupation, age, sub-sector of employment, experience, etc.) were possible through an Online Analytical Processing (OLAP) database that merged WHITE, payroll and WorkSafeBC databases. The OLAP database could resolve productive hours (denominator values) to the individual level and thus enable rates to be linked to any of the associated variables. Incident rates per 100 person-years were calculated using the health region payroll productive hours (defined as paid and overtime hours minus vacation, sickness absence and workers' compensation time). For this analysis, one person-year was deemed equivalent to 1879.2 productive hours (determined by 261 days at 7.2 h/day) [8]. In payroll data, employment category was categorized by full time, part time and casual.

This analysis includes incidents of three health regions within BC over a 1-year period of follow-up (8 April 2005–23 March 2006) for region A and B, and a 1-year period of follow-up (12 January 2006–27 December 2006) for region C. The fourth region was excluded as they were trying to standardize their payroll data. The study population was narrowed to two large groups of health care workers: registered nurses (RNs) in acute care and care aides (CAs) in long-term care. Since RNs represent the largest group of workers in acute care and CAs represent the largest group in long-term care, these two occupations were selected to explore the study hypothesis for the two large sub-sectors. Both occupations are also highly standardized and should give a clear picture of differences in terms of OHS issues by employment category.

This analysis incorporated all injuries resulting in time loss from work or requiring medical aid and compensated by the workers' compensation board. A second analysis was conducted with only musculoskeletal injury (MSI), as this was the largest injury type found in this investigation.

The analysis was conducted using Poisson regression, with the occurrence of a work-related event as the dependent variable, to examine its association with gender, age group and years of experience. As health care workers are categorized by facility and health region, Poisson regression modeling using generalized estimating equations, with facility and health region as the clustering variables, was used to examine associations [9]. The adjusted rate ratios were presented along with their 95% confidence intervals (CIs). Statistical analysis was carried out using the Statistical Package for the Social Sciences (Version 14.0, 2006).


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
During the study period, among 8640 RNs, 37% were working full time, 24% part time and 25% were casual workers. Fourteen percent reported multiple employment categories. Among male RNs, 51% were in full-time work and only 10% were in part-time work (Table 1). For female RNs, 50% were working as part-timers or casuals. There was a clear relationship between age and employment category (with increasing age, more RNs became full time and less became casual).


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  		Table 1. Number of employees by employment category and variables of interest for registered nurses in acute care facilities and CAs in long-term care facilities

 
A total of 343 injuries were reported by RNs working a total of 5318 person-years. Of these, 276 (81%) were MSIs. The overall rates of all injuries were 7.4, 5.3 and 5.5 per 100 person-years among full-time, part-time and casual RNs in acute care. The rates of MSI, respectively, were 5.9, 4.6 and 4.1 per 100 person-years (Table 2).


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  		Table 2. Injury rates and RR of injury by employment category for registered nurses and CAs.

 
In multivariate models (Table 2), having adjusted for age, gender, facility and health region, it was found that compared to full-time RNs, casual workers had a significantly lower relative risk (RR) of sustaining all injuries and MSIs [adjusted RRs and 95% CIs: 0.7 (0.5–1.0) and 0.7 (0.5–0.9), respectively]. Part-time workers also had significantly lower levels of experiencing all injuries compared to full-time workers [0.7 (0.6–0.9)].

The remaining results presented in Tables 3 and 4 detail the association of occupational injury by employment category for selected variables: age, experience and gender. The adjusted values that test for significance in the relationships between variables present certain trends: with respect to age, 40- to 49-year-old part-time and casual workers were at lower risk of all injury and MSI compared to full-timers of the same age group. With respect to experience, part-timers with 11–15 years of experience had lower risk for all injuries compared to full-timers of similar experience. Part-time female RNs had lower risks associated with all injuries; and female casual RNs had lower MSI rates compared to their full-time colleagues.


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  		Table 3. All injury rates and RRs by age, experience, gender and employment category

 

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  		Table 4. MSI injury rates and RR by age, experience, gender and employment status

 
Among the 2967 CAs, 30% were working full time, 20% part time and 40% were casual workers. Multiple employment category was reported by 10% of the CAs. Among male CAs, 48% were casual workers and 30% were in full-time work. For female RNs, 40% were casual workers (Table 1). There was a clear relationship of age with employment category (with age, more CAs became full time and less became casual).

A total of 378 injuries were reported by all CAs working 1672 person-years with 312 (83%) identified as MSIs. The rates of all injuries and MSIs are 25.8 and 20.8 among full-time, 22.9 and 19.3 among part-time and 18.1 and 15.2 among casual CAs (Table 2).

In multivariate models (Table 2), having adjusted for age, gender, facility and health region, it was found that compared to full-time CAs, casual workers had significantly lower risk of sustaining all injuries and MSI [0.6 (0.5–0.8) and 0.6 (0.5–0.8)].

For CAs in long-term care, casual workers under the age of 50 were at lower risk of all injury. Casual CAs, younger than 40 and older than 50, had lower MSI rates compared to their full-time counterparts. Female casual CAs had lower injury rates for all injuries and MSI compared to full-time CAs.

In general, CAs in the long-term care sector were found to be at three times higher risk for all injury and MSIs compared to RNs in acute care. Among CAs, full-time workers were the most vulnerable followed by part-time workers. RNs had lower injury rates than CAs in all employment categories; however, among RNs, there was a similar trend of lower work injury rates for both injury types for part-time and casual workers compared to their full-time colleagues.

The proportion of MSIs among all injury for direct care occupations was found to be very high with a prevalence of 80% for RNs and 83% for CAs.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
The findings of this study suggest that full-time workers are at higher risk of injury than casual or part-time workers. We also found that CAs are at a higher risk of injury than RNs.

The prevalence of part-time and casual employment is very high in BC's health care sector. Statistics Canada shows that the health care industry holds the third highest proportion of part-time workers among the 16 major employment industries of BC [1]. Our study findings suggest that half the RNs and 60% of the CAs worked either part time or casually.

CAs are required to perform a large amount of patient lifting/transferring [10]. Fourtes et al. [11] has reported that occupations that involve such tasks are 4.84 times more at risk of sustaining a MSI. The same study determined that CAs are 3.3 times more likely to acquire a lower back injury due to the types of tasks appointed to them. As a large amount of CA tasks involve manual handling activities, it is understandable why this group is more injury prone (as MSIs predominate the ‘all injury’ category) when compared to RNs.

Full-time direct care workers were found to be at higher risk of injury than casual or part-time workers. Lower recovery opportunities from strain, heightened fatigue and loss of focus and concentration may account for the increased injury rates for full-time workers who generally work longer hours per week compared to casual and part-time workers [11]. Other studies have also determined that the repetition of strenuous lifting in full-time nurses accounts for their higher levels of injury risk [12]. MSIs have shown to be greatly reduced with the implementation of patient handling equipment in patient rooms [13].

Yassi et al. [5] found that in addition to full-time nurses having higher injury risks compared to part-time ones, younger nurses or ones with less seniority are more prone to injury. Studies have shown that lack of experience or poor training in new/younger nurses results in higher risks of injury [6,14,15]. Workers new to the workplace need to be trained before commencing any job with clear and frequent instructions. Employers have a responsibility to protect workers and inform them of their rights. Studies have shown the efficacy of proper training for new workers in patient handling and ergonomics [16,17]. Our study found part-timers and casuals to be at lower risk (not always statistically significant) of all injury and MSI compared to full-time workers across most of the age and experience strata. However, no clear patterns between age/experience and injury risk were found.

For all injuries, part-time female RNs and casual CAs had significantly lower risks compared to their full-time colleagues. For MSI, female casual RNs and CAs had significantly lower injury rates compared to the full-time counterparts. Males are under-represented in the direct care occupations in the health care sector.

This study calculated injury rates per 100 person-years using the exact health region payroll productive hours. Productive hours are the most accurate means of measuring ‘time at risk’ per person per injury because they exclude paid time not in the workplace. This type of analysis should be able to distinguish the real differences in injury risk for full-time, part-time and casual workers [18]. Our surveillance is very comprehensive and reports incidents more accurately. Previous publications have also used data from the WHITE surveillance tool [19–21].

There are some limitations to this study. The analysis was limited to three health regions consisting of ~10% of the province's health care workforce. This investigation only accounted for time loss events that were reported and compensated for, therefore under-reporting and unaccepted claims limit the study findings. A large number of claims with health care costs only (without any time loss from work) exist. Therefore, real injury rates are likely to be higher than the rates reported in this study [4,22]. The small number of males in the study population limited the ability of this investigation to compare injury trends between and within genders. Further research that probes the discrepancy of higher injury rates for part-time/casual workers based on gender is required. The health care work environment is unique in terms of potential exposures, and therefore generalization of our study findings is difficult. It is also difficult to generalize our study findings to other industries due to the differences in occupational classification, employment contract, types and nature of injury coding and choice of denominator in statistical analysis.

The results suggest that there remains a clear divide of injury risk by employment category in the health care sector. One possible explanation for this result is that employment conditions in the health care sector may differ according to employment category with respect to job tasks. These different employment conditions include exposure to different physical and psychological stressors such as highly repetitive movements, awkward postures, tedious work and heavy lifting with little recovery period. We found no previous studies on health care workers that explored why such differences in injury risks based on employment category exist. These work-related injury differences should be explored further. The findings of our study leave an opportunity to more thoroughly investigate why such trends of injury risks and employment category are experienced in the health care sector. While previous work on the relationship between injury rates and employment category had conflicting findings, the findings of this study could be generalized and would be meaningful to the health care sector.


Key points
  • Full-time direct patient care workers are at a greater risk of injury compared to part-time and casual workers within the health care sector.
  • The prevalence of part-time and casual employment is high in the Canadian health care sector. OHS research in this industry should conduct its studies with consideration of this fact.
  • Work safety policies that aim to reduce risk factors should be aware of the differences in injury trends among part-time, full-time and casual workers.

 


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. BCStats, Ministry of Management Services. Labor Force Statistics November 2002. http://www.bcstats.gov.bc.ca/pubs/lfs/lfs0211.pdf (1 November 2007, date last accessed).

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  3. Thomas NI, Brown ND, Hodges LC, et al. Factors associated with work-related injury among hospital employees: a case-control study. Am Assoc Occup Health Nurses J (2006) 54:24–31.

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  5. Yassi A, Khokhar J, Tate R, Cooper J, Snow C, Vallentype S. The epidemiology of back injuries in nurses at a large Canadian tertiary care hospital: implications for prevention. Occup Med (Lond) (1995) 45:215–220.[CrossRef][Medline]

  6. Walters V, Mcdonough P, Strohschein L. The influence of work, household structure, and social, personal and material resources on gender differences in health: an analysis of the 1994 Canadian National Population Health Survey. Social Science and Medicine (2002) 54:677–692.[CrossRef][Web of Science][Medline]

  7. Quinlan M, Mayhew C, Bohle P. The global expansion of part-time and casual employment, work disorganization, and consequences for occupational health: a review of recent research. Int J Health Serv (2001) 31:335–414.[CrossRef][Web of Science][Medline]

  8. BCGEU. Provincial agreement between the Paramedical Professional Bargaining Association and Health Employee's Association of British Columbia, 2006. http://www.bcgeu.bc.ca/files/c4_para_general_services.pdf (1 November 2007, date last accessed).

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  11. Fourtes L, Shi Y, Zhang M, Zwerling C, Schootman M. Epidemiology of back injury in university hospital nurses from review of workers' compensation records and case-control survey. Occup Med (Lond) (1994) 36:1022–1026.

  12. Owen B, Damron CF. Personal characteristics and back injury among hospital nursing personnel. Res Nurs Health (1984) 7:305–313.[CrossRef][Web of Science][Medline]

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  14. Videman H, Rauhala S, Asp K, et al. Patient-handling skill, back injuries, and back pain: an intervention study in nursing. Spine (1989) 14:148–156.[CrossRef][Web of Science][Medline]

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  16. Stubbs DA, Buckle PW, Hudson MP, Rivers PM. Back pain in the nursing profession: the effectiveness of training. Ergonomics (1983) 26:767–779.[Medline]

  17. Feldstein A, Valanis B, Stevens N, Overton C. The back injury prevention project pilot study: assessing the effectiveness of back attack, an injury prevention program among nurses, aides and orderlies. J Occup Med (1993) 35:114–120.[CrossRef][Web of Science][Medline]

  18. Maizlish N. Measuring injury and disease frequency. In: Workplace Health Surveillance: An Action-Oriented Approach. (2000) 44. New York: Oxford University Press. 95.

  19. Alamgir H, Swinkels H, Yu S, Yassi A. Occupational injury among cooks and food service workers in the healthcare sector. Am J Ind Med (2007) 50:528–535.[CrossRef][Web of Science][Medline]

  20. Alamgir H, Cvitkovich Y, Yu S, Yassi A. Work-related injury among direct care occupations in British Columbia, Canada. Occup Environ Med (2007) 50:528–535.

  21. Alamgir H, Cvitkovich Y, Yu S, Astrakianakis G, Yassi A. Needlestick and other potential blood and body fluid (BBF) exposures among healthcare workers in British Columbia, Canada. Am J Infect Control. (in press).

  22. Hignett S. Work-related back pain in nurses. J Adv Nurs (2006) 23:1238–1246.[CrossRef]


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This Article
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