International Journal of
Environmental Research
and Public Health
Article
Clearing the Smoke Screen: Smoking, Alcohol
Consumption, and Stress Management Techniques
among Canadian Long-Term Care Workers
Iffath Unissa Syed
Faculty of Health, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada; iusyed@yorku.ca
Received: 10 July 2020; Accepted: 17 August 2020; Published: 19 August 2020
Abstract: Background: Currently, there is abundant research indicating that smoking and alcohol
consumption have significant impacts on morbidity and mortality, though little is known about these
behaviors among Canadian health care workers. The objective of this study was to examine health
and coping behaviors, such as smoking and alcohol consumption as well as stress management
techniques, among health care workers consisting of gendered, racialized, and immigrant employees.
Methods: Drawing on a single-case, mixed-methods study in Ontario, Canada, this paper presents
under-researched data about smoking practices, alcohol consumption, and stress management
techniques among health care workers in labor-intensive, high-stress, high-turnover environments.
In particular, it identifies the various mechanisms for maintaining health and well-being. Results:
The findings suggest that 7.7% of survey respondents reported smoking while 43.4% reported alcohol
consumption, which were reported more frequently among immigrants than among non-immigrants.
Participants also reported health-promoting activities in face-to-face interviews, such as mindful
breathing techniques and drawing upon social support, while a few respondents reported alcohol
consumption to specifically cope with sleep disturbances and job stress. Conclusions: Although
smoking and alcohol consumption were both connected with coping strategies and leisure, they were
predominant in immigrant groups compared to non-immigrant groups.
Keywords: public health; health behaviors; health promotion; long-term care; nursing homes;
mixed-methods design; social determinants of health; gender
1. Introduction
Smoking and alcohol consumption can have problematic consequences on human health and
they also impose economic costs to society. Smoking is responsible for more deaths than obesity,
physical inactivity, or hypertension [1], resulting in 603,000 premature deaths worldwide [2], with
work exposures claiming over 200,000 lives [3,4]. Smoking is associated with an increased risk of
morbidity and mortality due to chronic obstructive pulmonary disease, asthma, cardiovascular disease,
including ischemic, rheumatic, hypertensive, and inflammatory heart disease, as well as tracheal,
bronchial, and lung cancers [1,5–9]. In Canada, it is estimated that smoking is attributed to 17% of all
deaths and claims over 36,500 lives each year [5]. In addition to this, smoking-related illness kills 100
Canadians each day [5]. The economic cost of smoking was $16.2 billion in 2012 in Canada alone, with
the largest component consisting of health care costs at roughly $6.5 billion [10]. These costs included
prescription drugs ($1.7 billion), physician care ($1.0 billion), and hospital care ($3.8 billion) [10].
The federal, provincial, and territorial governments also spent $122.0 million on tobacco control and
law enforcement [10].
As with the case of smoking, indicated above, alcohol consumption can also pose problems.
Alcohol consumption is associated with esophageal cancer, liver cirrhosis, liver cancer, as well as toxicity,
Int. J. Environ. Res. Public Health 2020, 17, 6027; doi:10.3390/ijerph17176027
www.mdpi.com/journal/ijerph
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and accidental deaths, among other things [11,12]. It is estimated that alcohol use causes 2.5 million
deaths each year around the world [13] and leads to 370,000 deaths due to road injuries, 150,000 deaths
due to self-harm, and 90,000 deaths due to interpersonal violence [14]. “Mortality resulting from
alcohol consumption is higher than that caused by diseases such as tuberculosis, HIV/AIDS and
diabetes” [13]. Between 4 and 5 million Canadians engage in high-risk alcohol consumption [15],
which is responsible for 40% of motor vehicle accidents in Canada [16].
Previous research suggests that certain health behaviors, coping strategies, and defense
mechanisms are often adaptation processes in response to stress, and include escaping, avoidance,
disengaging behaviors, and diminished health-promoting behaviors such as reduced adherence to
health-promotion practices, dietary restrictions, and smoking cessation [17]. Indeed, occupational
stress may have a significant effect on smoking and alcohol consumption. For example, occupational
stress may result in the use of alcohol and cigarettes as anti-anxiety and anti-depressive agents to release
job stress [18] and result in excessive smoking, increased smoking intensity, and increased alcohol
consumption, which can be modulated by coping abilities [19]. Research on Canadian immigrants
shows that these groups do not report elevated smoking intensity and alcohol consumption as coping
strategies in response to work-related stress [19].
While it has been well known that both smoking and alcohol consumption can be utilized as
coping mechanisms to stress responses [20,21], little is known about these consumption patterns
and various other coping behaviors among workers who are employed in high-stress, high-turnover
environments. In addition, little is known about these activities in long-term care (LTC) workers, who
often comprise a gendered, racialized, and immigrant workforce. The rationale for selecting the study
population consisting of health care workers was because previous research suggests that they face
significant stress on a daily basis [22,23]. Health care workers’ coping and defense mechanisms are
even more important now due to the current circumstances surrounding the COVID-19 pandemic
that may result in increased stress from health workers’ own health risks to COVID-19, as well as the
potential for additional stress from dealing with greater morbidity and mortality related to COVID-19
on the frontlines of care. Thus, studying the coping and defense mechanisms of health care workers
is extremely important. Accordingly, the objective of this study was to examine routine health and
coping behaviors, such as smoking and alcohol consumption as well as stress management techniques
among health care workers. The rationale for selecting this specific group of workers was to gather
knowledge about this population in order to fill knowledge gaps.
2. Materials and Methods
This study was derived from a larger project that utilized a single-case research design, which
involved qualitative interviews, observations, and a survey for quantified description of LTC workers
(Figure 1). The site was selected based on the feasibility of the project, richness of data, and geographical
boundaries in an urbanized region that is known as a settlement destination for immigrants and
visible minorities (VMs). A single-case study design was selected in order to examine the following,
among other things: how do VMs and/or immigrant employees experience work compared to non-VM,
non-immigrant employees in residential LTC? In what ways (and why) are these experiences distinct?
Are there gender differences? These broad questions were developed from the use of feminist lenses
and critical race theory, which guided the inquiry. Feminists argue that society is gendered in such
a way that women and men have fundamentally different experiences and access to power and
privilege [24]. Critical race theorists often focus on racialization, which is an active and ongoing
process in which a dominant group identifies another group as having a race, often based on the latter
group’s physical characteristics, such as skin color [25]. Racialization frequently results in unequal and
unfair treatment of particular groups of women and men [26], and it has social, economic, and political
consequences [27].
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Figure 1. Flow diagram.
The site had a total of 176 workers. Sampling and recruitment for this study was broad and
included non-VMs and men in order to compare and contrast experiences. The recruitment methods
were snowball techniques and direct purposeful recruitment by the principal investigator. Ethics
approval was received from York University’s Office of Research Ethics (ORE) (STU2016-139), and
participant consent was obtained in writing and signed.
An ethnography was the primary data collection technique in which the sources of evidence
were from direct observations and in-depth, key informant interviews. Observations and interviews
were carried out by the researcher over two and a half months at a single LTC site between the hours
of 6:30 a.m. and midnight, which were opportunistic times to observe the workers’ scheduled shift
changes that occurred at 7 a.m., 3 p.m., and 11 p.m. Observations were conducted in secure, locked and
unlocked units/wings at the site; in public spaces within the facility; and at the reception area. These
spaces included hallways and dining areas on the individual units, a recreation space of the atrium
located on the ground floor, an employee break room located at the mezzanine level, and spaces outside
meeting rooms that were located in the basement level of the building. Fieldnotes were generated
during observations, which documented preliminary thoughts, assumptions, and the physical setting.
Observations sometimes included workers who had already participated in interviews. This was a
way to trace and track the status of workers, e.g., immigrant/non-immigrant.
Face-to-face, in-depth, semi-structured interviews were conducted with participants and digitally
recorded. The semi-structured interview guide was broad and asked standard questions about the
participants’ background; how participants started work at the LTC facility; how participants dealt with
stress, either in their job or family life; and how participants felt after a day’s work. In addition, various
probes and prompts were also utilized after responses to these questions. For example, participants
were asked to indicate how they cope, how they unwind, and/or to elaborate and tell the researcher
more about the topic of interest after they discussed their response.
The goal of conducting observations and interviews was to gather rich data about the participants
and their routines. For the quantitative component, an exploratory, paper-based pilot survey was
distributed as well as a separate demographic questionnaire following each interview. The inclusion/
exclusion criteria were that individuals must work within the health care sector in ancillary, support,
or direct services, the worker’s roles must be directly related to the residential LTC facility. In all,
92 respondents filled and returned the survey, i.e., a response rate of 52% was achieved. One survey
was excluded because the worker was not responsible for work that was related to any aspect of the
LTC home. The purpose of the survey was to examine descriptive data such as smoking and alcohol
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consumption and the effects of sex or birth/immigration status. The survey asked participants whether
they smoked cigarettes daily, occasionally, or not at all. The rationale was to assess whether or not
tobacco use was light or heavy. Light or intermittent smoking was interpreted from the response
“occasionally”, and heavy smoking was interpreted from the response “daily”. One person did not
respond and was, therefore, excluded from the analysis. Mann–Whitney U tests were also conducted
to test whether the distribution of being a cigarette smoker and the distribution of alcohol consumption
was the same across categories of sex, immigrant status, and VM status. The survey also asked about
alcohol consumption. Respondents were instructed to choose how often they drank alcoholic beverages
over the past 12 months. There were seven choices to choose from, including an option to choose “not
at all”. The rationale was to assess whether or not alcohol consumption was light/mild, moderate, or
heavy. Light/mild alcohol consumption was interpreted from the responses “less than once a month”,
“once a month”, “2 to 3 times a month,” while moderate consumption was interpreted from “once a
week or 2 to 3 times a week”, whereas or heavy-alcohol consumption was interpreted from responses
“4 to 6 times a week” or “every day”. One person did not respond to the survey and was excluded
from the analysis. For the qualitative component, multiple units of analysis were organized by worker
characteristics such as sex, job titles or roles, VM status, and employment type.
The term VM was used instead of non-White for several reasons. Firstly, the use of dichotomous
terms such as White/non-White has been criticized in the research literature [28]. Secondly, there is
often complexity with the use of such terminology. For example, sometimes South Asians self-identify
as “White” based on skin color, which reflects cultural norms and values and contradicts/conflates
what many researchers refer to as ethnically/racially “White.” Finally, there are issues of colorism that
exist within different VM groups, such as Native American, Asian-American, and Latin-American
communities (ibid). Accordingly, rather than utilizing White/non-White terminology extensively, in
this study, VM/racialized, and non-VM/non-racialized are used, which are also utilized in Canadian
official documents and arm’s-length agencies [29]. Racialized status refers to VMs, i.e., persons of color
or non-White individuals who experience the process of racialization by which “societies construct
races as real, different and unequal in ways that matter to economic, political and social life” [30].
Although qualitative and quantitative data collection was carried out concurrently, there was
“separate data analysis” [31]. For the qualitative data analysis, fieldnotes and interview transcripts were
analyzed with thematic analysis for the study using a selective coding system with the aid of NVivo
computer software program to organize and sort information. Coding of data involved identifying
themes and subcategories that were addressed in the interviews that were a part of the research
questions. Codes were developed in consultation with other researchers, and some of these codes were
also developed and used in previous LTC projects. The codes and the meaning of the themes were
revised and amended as necessary, because coding is an iterative process. The coding list was compiled
with the theoretical frameworks in mind, e.g., feminist political economy is reflected with codes such
as gender, gender stereotyping, gendered work, and gender prejudice. The list of codes also included
the following: immigration, immigrant, migrant, race, racialization, racism, prejudice, discrimination,
support, and so forth. Quantitative statistical data analysis of the demographic questionnaire and
survey occurred with the assistance of Excel and quantitative statistical software program (SPSS;
Chicago, IL). Survey data were reviewed and checked by scholars from York University in consultation
with the Statistical Consulting Service (SCS).
3. Results
Worker demographic data from the interviews and survey responses are indicated in Tables 1
and 2. Typically, most LTC workers did not drink or smoke, though some did participate in these
behaviors (Table 2).
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Table 1. Interview participants’ characteristics (n = 42).
Characteristic
Frequency
%
Sex
Female
Male
35
7
83.3%
16.7%
Employment Type
Full Time
Part Time
32
10
76.2%
23.8%
Race/VM Status
Non-VM, non-racialized, White
VM, racialized
12
30
28.6%
71.4%
Job Title/Role
Trainee
Allied Health
Nurse
Manager
Support Staff
Ancillary
Personal Support Worker (PSW)
3
7
9
4
6
6
7
7.1%
16.7%
21.4%
9.5%
14.3%
14.3%
16.7%
VM: visual minority.
Table 2. Descriptive statistics of the survey sample (n = 91).
Characteristic
Frequency
%
Sex
Female
Male
No response/omitted
76
14
1
83.5%
15.4%
1.1%
Birth/Immigration Status
Born in Canada
Born outside Canada, i.e., Immigrant
No responses/omitted
19
66
6
20.9%
72.5%
6.6%
Race/VM Status
Non-VM, non-racialized
VM, racialized
No response/omitted
11
78
2
12.1%
85.7%
2.2%
Smoking Status
Smoker
Non-smoker
No response/omitted
7
83
1
7.7%
91.2%
1.1%
Alcohol Consumption
Yes
No
No response/omitted
39
51
1
43.40%
56.7%
1.1%
3.1. Smoking and Alcohol Consumption
The survey results indicated that 92.2% (n = 83/90) of participants were non-smokers; however,
5.6% (n = 5/90) indicated “daily” smoking, and 2.2% (n = 2/90) indicated smoking “occasionally”
(Table 3).
Table 3. Smoking status.
Smoking Status
Frequency
%
Daily
Occasionally
Not at all, i.e., non-Smoker
Total
5
2
83
90
5.6%
2.2%
92.2%
100.0%
The survey results also indicated that 56.7% (n = 51/90) of participants reported not consuming
alcohol at all (Table 4). The most frequent consumption pattern was 2 to 3 times a month (14.4%,
n = 13/90), followed by less than once a month (12.2%, n = 11/90), which were light/mild patterns of
consumption. No one reported consuming alcohol 4 to 6 times a week; however, one person reported
consumption every day, which was interpreted as heavy consumption.
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Table 4. Frequency of alcohol consumption.
Alcohol Consumption
Frequency
%
Less than once a month
Once a month
2 to 3 times a month
Once a week
2 to 3 times a week
4 to 6 times a week
Every day
Not at all
Total
11
7
13
1
6
0
1
51
90
12.2%
7.8%
14.4%
1.1%
6.7%
0.0%
1.1%
56.7%
100.0%
The results from the Mann–Whitney U tests indicated that while the distribution of being a
cigarette smoker was the same across visible minority status (data not shown), it was not the same for
sex (U = 406.5, p < 0.0029) (Figure 2) and immigrant status (U = 732.5, p < 0.006) (Figure 3), which were
statistically significant results. The data suggested that cigarette smokers from this LTC site were likely
to be women and immigrants.
Figure 2. Independent-samples Mann–Whitney U test of the distribution of cigarette smoking across sex.
Figure 3. Independent-samples Mann–Whitney U test of the distribution of cigarette smoking across
immigrant status.
The survey responses pertaining to alcohol consumption are listed in Tables 5 and 6. Overall, 56.7%
(51/90) of the respondents reported not consuming alcohol at all, of which 90.2% (46/90) were female, and
the same proportions were racialized (Tables 5 and 6). The next most popular response was consuming
alcohol 2–3 times a month (14.4%, 13/90), which was interpreted as light/mild consumption. 84.6%
(11/13) of these latter respondents were female, and 76.9% (10/13) were racialized (Tables 5 and 6). Only
one female racialized respondent consumed alcohol every day, i.e., heavy consumption (Tables 5 and 6).
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Table 5. Alcohol consumption by sex.
Alcohol Consumption
Response
Less than once a month
Once a month
2 to 3 times a month
Once a week
2 to 3 times a week
4 to 6 times a week
Every day
Not at all
Total
n = 90
Frequency
11
7
13
1
6
0
1
51
90
Sex
%
12.2%
7.8%
14.4%
1.1%
6.7%
0%
1.1%
56.7%
100%
n = 76
Female
9
5
11
0
4
0
1
46
76
%
81.8%
71.4%
84.6%
0%
66.7%
0%
100%
90.2%
84.4%
n = 13
Male
2
1
2
1
2
0
0
5
13
%
18.2%
14.3%
15.4%
100%
33.3%
0%
0%
9.8%
14.4%
Table 6. Alcohol consumption by VM status.
Alcohol Consumption
Response
Less than once a month
Once a month
2 to 3 times a month
Once a week
2 to 3 times a week
4 to 6 times a week
Every day
Not at all
Total
n = 90
Frequency
11
7
13
1
6
0
1
51
90
VM Status
%
12.2%
7.8%
14.4%
1.1%
6.7%
0%
1.1%
56.7%
100%
n = 77
VM
9
7
10
0
4
0
1
46
77
%
81.8%
100%
76.9%
66.7%
0%
100%
90.2%
85.6%
n = 11
Non-VM
1
0
3
1
2
0
0
4
11
%
9.1%
0%
23.1%
100%
33.3%
0%
0%
7.8%
12.2%
The results of the Mann–Whitney U tests indicated that while the distribution of consuming alcohol
was the same across sex and racial status (data not shown), it was not the same for Canadian-born
workers and immigrants (U = 913, p < 0.001) (Figure 4), which were statistically significant results.
Like cigarette smoking, alcohol consumption by workers at this LTC site was likely to occur among
immigrants. These trends may be reflective of cultural differences between Canadian-born workers
and immigrants or a combination of other factors, e.g., life experiences, the process of immigration,
social support, and coping strategies that could play a role in alcohol consumption.
Figure 4. Independent-samples Mann–Whitney U test of the distribution of alcohol consumption across
immigrant status.
The qualitative data from observations did not provide significant findings with respect to
smoking, alcohol consumption, stress-management techniques, or coping and defense mechanisms.
However, interview data indicated that workers were exposed to high-stress environments and often
employed a variety of coping mechanisms in order to minimize its effects. Interestingly, few participants
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disclosed smoking and alcohol consumption behaviors as a coping mechanism during face-to-face
interviews. One possible reason for this trend might be that these activities are carried out as leisure
activities as opposed to coping strategies. Another possible explanation is that there may be stigma
associated with smoking and alcohol consumption, which may be perceived as socially unacceptable
practices to discuss in workplace settings. The latter is important, especially given that the study was
conducted in a health care environment, which could evoke additional pressure or stigma related to
the health-related harms of smoking and alcohol consumption. This may have diminished disclosure
among some interview participants during face-to-face interviews.
3.2. Coping, Defense, and Stress Management Techniques
Individual Methods of Coping and Defense
The data suggest that various health-impacting practices that may be utilized as coping, defense
mechanisms, or stress management techniques were widely practiced by employees in the LTC
home. For smoking and alcohol consumption, only a few participants reported these activities during
interviews, e.g., Participant 5 (Director, Male, F/T), Participant 26 (Support Staff, Male, F/T). Participant
37 (Support Staff, Female, F/T), indicated consumption of alcohol to cope with a sleep disorder rather
than taking prescription medication whereas Participant 40 (Ancillary Worker, Female, P/T) indicated
consumption of alcohol for work-related stress management.
One worker indicated that sometimes she used a dramatic method to regain her peace of mind:
A: “Sometimes when I get too stressed, I go in the washroom and scream. Well it relieves me.”
(Participant 16, PSW, Female, VM, F/T).
Another worker took brief timeouts to practice mindful breathing when work became too stressful
because she said she was becoming unhealthy and had chest pain:
A: “I got sick of the stress. I had a lot of chest pains and I’m like, ‘No. I can’t not [sic] have
stress get to me.’ When I close that door at 2 o’clock, I just have to let it go. And if I see something
bothering me, I’ll just have to breathe [ . . . ] Take my just two-minute break. I’ll just have a two minute.”
(Participant 21, Ancillary Worker, Female, Non-VM, F/T).
When a support staff worker was asked about coping with stress, they indicated the practice of
mindful breathing:
A: “Well, I take deep breaths, breathing technique, you know, and then sometimes I need like
fresh air or cold air on my face, you know. I don’t know, probably to brush it off, but and just to be
quiet, you know, and eat.” (Participant 27, Support Staff Worker, Female, VM, F/T).
Mindfulness and meditation practices were sometimes ritualized:
A: “I love reading. And then, I have a little ceremony. When I know that I’m feeling stressed,
I have a—you know those candles, like [laughs] are they stress free or something, stress free candle.
I have music. And I just lie down, just let loose of your body. Lie down, don’t think of anything. It’s a
[sic] very good, like, yeah, meditation.” (Participant 2, Allied Health Worker, Female, VM, F/T).
A nurse used solitary contemplation to cope with stress:
A: “I don’t really meditate but I really just like to be on my own sometimes and just sit quietly
in a room and not think about anything. I guess that’s my way of meditating, or just lay on the bed
and just look at the ceiling, and just relax for like 10 min. Sometimes I fall asleep, sometimes I don’t.”
(Participant 7, Nurse, Female, VM, P/T).
While the above participants used meditation and mindfulness as strategies of resilience, others
indicated alternative strategies. When asked about how one deals with stress, a manager indicated
that she would have moments where she would just break down and cry. The participant also said
she listened to music, prayed, and had the support of her family. She reflected on religion in order to
achieve a sense of purpose and perspective when confronting difficulties:
A: “I think I cope. I try to cope. There’s moments when I just break down and cry. Crying for me
is a good thing. [ . . . ] I pray. Prayer for me is a big thing. When I feel I’m too stressed, I pray. Praying
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helps a lot. Pray and music. [ . . . ] And family support. I mean my parents, very, very supportive.
My husband, great support.”
Many interview participants reported that they used solitary recreation as a coping strategy and
indicated that they engaged in five forms of solitary recreation, including: watching television, reading,
listening to music, engaging in a hobby (e.g., participants engaged in photography, singing, or playing
the piano), and traveling. When a nurse was asked about relaxation, she said the following:
A: “As soon as I get home I just have to eat, watch my movies or watch my TV series for a little
while and I’ll be fine. I’m back to myself.” (Participant 30, Nurse, Female, VM, F/T).
A manager watched movies on the home television and watched YouTube videos to purge
negative emotions:
“Sometimes I put a movie, like a drama movie that I want to cry or watch YouTube videos that I
just break in tears. Always my kids watch me [ . . . ] they just look at me, ‘Okay, she’s going to cry now.’
They don’t know the stress of my day. I like music. Sometimes I just pump it so loud in the car and it
just give [sic] me this relief” (Participant 32, Manager, Female, VM, F/T).
An ancillary worker said: “for mental repression I watch TV” (Participant 42, Ancillary Worker,
Male, VM, F/T). A PSW said she liked to listen to music and watch movies to de-stress:
I: “You said you listen to music. Is that cultural music or—”
A: “Yeah, yeah. I’m [cultural background]. You know, movie—we have the movies. I love to
listen some music; same time, I have our religious song, too. That’s especially Friday.” (Participant 36,
PSW, Female, VM, F/T).
A nurse said she took short vacations when work-related stress became intolerable:
A: “I go away when it gets too much, I’m off somewhere, I’m just like itching, I need to get away.
When I’m stressed I start to be very irritable [ . . . ] I get tired, that’s when I get tired because I’m just
like I’m done, I need a break and when that happens I know I need to go take time off or take a trip,
I just need to get away because I’m boiling.”
I: “You like to go particular places or do you go any —?”
A: “Niagara Falls or take a trip to the [overseas country] or just stay home, take a—for a couple
days I just stay home, but I can tell when my stress level is not normal, it’s getting—I’m antsy and
I’m bitchy and I’m—I don’t do as much of production as if I’m—no I don’t focus and I get mad at
every little thing and I—they say and I said be because I’m just fed up—no because it’s bad, I just—I’m
stressed.” (Participant 38, Nurse, Female, VM, F/T).
3.3. Drawing on Social Support from Family, Friends, and the Community
Group Dynamics in Coping and Defense
While participants used mindfulness, prayers, and solitary recreation as ways to cope, others
indicated that they had very little time for those sorts of strategies, and instead drew upon social
support from family, friends, and the community as a source of stress relief. For example, an allied
health worker reported that time spent with her young son provided her stress relief:
A: “My stress reliever’s [sic] my son, you know. I make sure I spend time with him, because if I
just, you know, if I went to the gym or go to the gym, you know the time is short that you’re in, you
should spend it with your son. You just read when he’s, you know, he’s playing, just read something
that you know, self-help.” (Participant 3, Allied Health, Female, VM, F/T).
A manager used conversations with friends and sisters as a coping strategy. She indicated that
previously, her stress levels were so high, it affected her health and sleep patterns, to the point that she
eventually resigned from her previous job. She revealed that she was personally against the use of
medication because of their side effects:
A: “Talking to my friends, you know, sometimes relieves the pressure. Talking and chatting.
I have other sisters in other parts, not in Toronto, but you know, sometimes they visit and that kind of
lightens the load a little bit. [ . . . ] 15 years ago, or thereabouts, I had a breakdown, actually. A stressful
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thing because I was trying to manage everything [ . . . ] And so, it all got to me, you know? Eventually.
And it affected me, and I think also the—you give your best and when sometimes there’s no recognition,
I think that also kind of affects your stress levels, you know? Or value given. So, I knew I had to stop.
Actually, I stopped working, I actually resigned from my [previous] job. [ . . . ] And I decided that I
had to take care of my health because I had like, I couldn’t go to sleep and you know, I had all of those
things. So, I kind of—I don’t believe in medication. Cause I know there are side effects” (Participant 6,
Manager, Female, VM, F/T).
For one allied health worker, conversations with friends was helpful and relieved stress:
A: “I also—talking just to like my closest friends, sometimes, have [sic] been the best help. They
don’t even have to say anything—just listening sometimes, you just get it off. And then, you can forget
about [it], right, once you say it.” (Participant 14, Allied Health Worker, Female, Non-VM, P/T).
A nurse indicated that she took leave for vacations and drew upon support by calling and speaking
with friends and coworkers so that they did not feel isolated in their situations in which she would
“vent” to upper management to cope with the stress. She also indicated that her coworkers socialized
with each other:
A: “I go on vacation. I just call up someone and I just vent. Or I vent to these people every day.
Every day I see them I say this and this, and we walk in with that. Just to make it seem like we’re not
alone. When you feel you’re not alone, it feels better. [ . . . ] And then you know we’ll buy food once in
a while, like when it’s someone’s birthday I’ll get her flowers. Like we’ll do things for one another.
I close the door, I’ll sit with my manager, we vent to each other. I listen to her venting and I realize
mine is nothing compared to hers. So yeah, it’s just the feeling of not being alone.” (Participant 17,
Nurse, Female, VM, F/T).
While the above nurse felt she could confide in management, an allied health worker indicated
she drew on support from her colleague:
A: “There’s one in my department—we’re really close. We support each other all the time. We’re
always backing each other up. And whenever there’s a problem with the management, too, we back
each other up.” (Participant 14, Allied Health Worker, Female, Non-VM, P/T).
A trainee also spoke of “venting” to her boyfriend to alleviate stress because she did not have
time for anything beyond this strategy:
A: “So if anything my boyfriend hears a lot about my stress and usually just venting is enough for
me.” (Participant 18, Trainee, Female, VM, F/T).
Another worker had friends who worked in other LTC facilities, and they would meet and
commiserate to de-stress. Other than this, the participant indicated that perhaps stress was a part of the
way she worked and lived now, indicating the level of stress that was normalized in her experience:
A: “venting—a lot of my personal—like my friends outside of work all work in long-term care.
So, probably 90% of them work in long-term care and we just chat. You know, everybody has a best
friend, you call your friend, you chat, you complain about the day. That’s about it. You know, the
odd time you get together and over dinner as you meet with friends and everybody has a chance to
complain about their job or talk about the funny things that happened at the job, that’s it. Other than
that really it is just sometimes the best distress [sic] is just to sleep it away. [ . . . ] Sometimes maybe
it’s just stress is routine which is really scary but when you’re used to being in a stressful job I don’t
think you know any different. So, I may not have a tool, I think it’s just the way I live my life now.”
(Participant 22, Support Staff Worker, Female, Non-VM, F/T).
A different support staff worker said he would read a lot and talked with a close friend to
“unwind”:
A: “I just—I read a lot. [ . . . ] My roommate is a smart guy too, so we can have discussions about
the world, or politics or stuff like that. [ . . . ] That’s—I guess that’s how I unwind. [ . . . ] And then
there’s some guys that we hang out with on the weekends. Other than that, see the guys from back
home every now and again.” (Participant 26, Support Staff Worker, Male, Non-VM, F/T).
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4. Discussion
Previous research has suggested that in Canada, immigrants do not report elevated smoking
intensity and alcohol consumption as coping strategies in response to work-related stress [19].
The findings presented throughout this study challenge previous work, in particular the patterns
of smoking and alcohol consumption while revealing some new information about LTC workers’
health-impacting behaviors. For example, the data from this study suggests that while a majority of
respondents were non-smokers and did not consume any alcohol, those few who did smoke were
born outside of Canada and were women, and those who reported alcohol consumption were often
immigrants, which challenges previous work that showed the opposite, i.e., that immigrants did
not utilize these health-impacting behaviors to a significant degree. This finding about immigrants’
utilization of smoking/alcohol consumption may reflect complex interactions involving work in
high-stress environments combined with cultural differences of particular immigrants and other factors
(e.g., life experiences of women) that could play a role in these behaviors and may be a starting point
of investigation for future studies.
Canadian studies of immigrants, racialized workers, and women suggest that these groups
are often predisposed to high stress, chronic illness [32–34], and difficulties in managing domestic
duties [35] due to work precarization [36], which adversely affects their health and well-being [33].
In addition, research has shown that in the care-work sector, many of these employees experience
work hierarchies and strict divisions of labor [37], while utilizing various mechanisms to regulate
emotional health [38]. This study confirms previous research about stress in LTC and reveals new
information about stress management techniques, which may help to achieve or maintain workers’
social, mental, and physical well-being. Several strategies were identified including mindfulness,
meditation, solitary recreation, as well as drawing on social support, and other personal health practices
or coping mechanisms. Many participants indicated that they routinely engaged in mindful breathing
techniques and meditation or solitary recreation as a source of stress relief. Others indicated that they
simply did not have the time for these things and relied upon social support from family or friends.
These findings shed light on under-researched areas of how social support and other adaptation
processes are used by workers to engage with coping, resistance, and resilience. Understanding the
particular cultural practices, resistance/resilience strategies, and how agency is expressed also points to
possible directions in shifting the current framing of social determinants of health (SDoH) discourses
that otherwise may not be reflective of ethnic, racial, or cultural groups.
Social support is one of the key SDoH [39]. The availability of social support as a key
stress-adaptation process, and for coping and defense, may be crucial for workers so that they
can access and exercise their preferred health/wellness practices, and how care workers realize their
health and well-being, which may be especially important under significantly stressful conditions such
as the current COVID-19 pandemic.
This study is not without its strengths and/or limitations. One of the limitations of this study was
that it was conducted with a single-case (i.e., single site) investigation. Although such an approach
means that the findings may not always be representative of and generalizable to provincial and
national data, a strength of focusing on one site means that certain issues can be investigated in a
deeper way, with a closer look at context. One of the strengths of this study is from its methodological
approach. For example, mixed-methods research design is often rated for higher quality than other
methods [40].
Finally, there are several policy implications of this study. Firstly, given that health care workers
were found to exhibit various coping and defense mechanisms, it may be useful to conduct further
studies to assess their success so that there are opportunities for vulnerable workers who can benefit by
learning these strategies to utilize them. Furthermore, sharing this information may be beneficial as a
part of the organizational-level recruitment and training process. Another policy option is to minimize
stress at its root cause rather than treating stress. For example, workers may be experiencing stress
because of the underlying issues of food insecurity, which has been previously reported in the care
Int. J. Environ. Res. Public Health 2020, 17, 6027
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work literature [38]. Finally, income, employment, and working conditions are SDoH [39]. As one
worker highlighted in this study, there is a need to recognize the value of care workers and to have
mechanisms in place to reward and motivate them. Indeed this is an important point for organizations
in which it is recommended that there are adequate provisions for intrinsic rewards such as interest,
challenge, and personal satisfaction, and also extrinsic motivators (monetary/wages, salaries, tangible
rewards) [41].
5. Conclusions
This work contributes to critical, interdisciplinary health scholarship by contextualizing social
and behavioral health practices and coping mechanisms of workers in high-stress environments.
The findings fill knowledge gaps in the health literature, while also suggesting typical health and
lifestyle behaviors. For instance, workers reported smoking and alcohol consumption. However, these
were rarely communicated in face-to-face interviews, possibly due to either stigma or because such
consumption was not a coping mechanism but rather was for leisure or pleasure.
This study reveals the tension and high levels of stress found in LTC workers in the region of study
as well as coping strategies that could promote health and wellness. Given that chronic stress and
illness are strongly connected to each other, it would be beneficial to explore further follow-up studies
in order to assess the effectiveness of chronic stress management. Another opportunity for future
studies would be to further explore culturally unique practices for health and well-being. Furthermore,
given that this study was small in scope, future research might include a survey with a wider scope
and scale that includes other provinces and jurisdictions across Canada, and also seek to understand
what types of assistance care workers may need, both within and outside of the home.
The evidence from this study demonstrates several important points. Firstly, it demonstrates
that workers in the site of study often rely upon particular resources for support, such as for solitary
recreation, in order to deal with the hazards stemming from their stressful, labor-intensive positions.
The analysis also indicates that workers draw upon support from a variety of sources, including
their co-workers.
While work stress and workloads in the LTC sector are known to be overwhelming, strategies to
address these issues are often limited to behavioral modification, such as diet and physical activity
interventions, rather than including a holistic approach, which considers income, employment,
education (i.e., socioeconomic status), social support, and other SDoH. In order to manage care and
care work (in this case, the care work that occurs in the LTC facility), it might be helpful to utilize
particular initiatives that address and include SDoH, such as Total Worker Health©. Total Worker
Health© initiatives aim to improve the health and well-being, of workers [42–45], through strategies
that involve the home, family, and community of the workers. Given the diversity of care workers in
the region of this study, such approaches would also need to be culturally appropriate, and adequate
supports must be provided to the workers. This means that not only do services and provisions need
to exist, but they also need to be available, affordable, and accessible to the workers who require them.
When such services and support systems are made available to workers, they can perform the work
better, safely, with less of a personal toll on their health and well-being, and with better outcomes for
the recipients of care.
Funding: This research was funded by York University’s fieldwork costs fund for data collection.
Acknowledgments: Many thanks to Rachel Gorman and the three anonymous reviewers for their guidance and
insightful feedback.
Conflicts of Interest: The authors declare no conflict of interest.
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