Barriers to Improvement
Due to the nature of construction work, particularly residential construction, it is hard to quantify precise exposure, yet residential employees are the workers using and being exposed to nail guns the most.  Small crews work on many sites; they do many different tasks, and have many different levels of nail gun use. The challenge in quantifying exposure leads to difficulty in determining risk estimates.  There is also a growing realization that injuries in construction, especially residential construction, are greatly underreported and underestimated. 
Jobsite norms and peer pressure often cause employees to not seek medical treatment for nail gun injuries. If employees do seek care, there is often a poor follow-up rate for care, treatment, and therapy after a patient has initially made a doctor’s visit. This puts a special importance on providers being detail-oriented, thorough, aggressive in treatment and infection prevention, and very clear on wound care and education about the injury, because they most likely will not see the patient again. 
In most construction operations, employees are responsible for furnishing their own hand tools, while the company owners will provide all the power tools that are needed. This is the normal practice; thus, many employees do not have a choice in their power tools or the trigger design that is available on the jobsite. This leaves the vast majority of responsibility up to managers and employers and they have to make the effort to protect employees by purchasing guns with sequential triggers, and replacing or retrofitting guns with contact triggers. 
An Employee Uses an Older Model Company-Owned Nail Gun With Contact Trigger
The sequential trigger is a proven, engineering method to remove a hazard from the workplace and reduce injuries; yet it is still not the industry standard or widely used,  nor is it required by any OSHA regulation. As far back as 1987, recommendations have been made to move to a trigger mechanism that did not allow rapid firing,  and a patent for sequential triggers has been in place for almost 30 years.  Beginning in May of 2003, the International Staple and Nail Tool Association (ISANTA) began calling for shipping sequential triggers on framing nailers and more safety labeling as part of a voluntary ANSI standard. However, contact triggers are still shipped in the same box and the user can easily, and often does, switch back to the contact trigger. [6, 11] Also, as mentioned above, contact and sequential triggers look exactly the same, and you cannot tell the difference by looking at them. The sequential triggers are becoming more known and accepted and making their way onto sites, but Lipscomb’s study  reports that 2/3 of the nail guns on sites still have contact trip triggers. Nail guns are an investment and often will stay around on the jobsite for many years, and sequential triggers can easily be switched out, so the effectiveness of only a voluntary standard appears to be low, considering the prevalence of contact triggers still being reported.
In addition to using a sequential trigger, a complete and effective training program is also required to further reduce injury and protect employees, especially those that are young and inexperienced.  Complete training programs are not the norm, and it is very likely that the safety and handling instructions may not be included or present with tools. If instructions are included, there is no guarantee that the user will read them, understand them, or follow them.  Printed instructions in English pose a special problem for those who cannot read or who cannot read English. Also, as the residential workforce becomes made of more immigrants and non-English speakers, training on proper use becomes increasingly challenging or neglected all together. 
Contact trigger use also continues to be justified because there are some situations, such as sheathing a roof, when materials can slide and creep downwards, that rapid firing of guns and even bounce nailing are almost necessary or can really help the process. There is also a perception that sequential triggers will slow production or actually cause repetitive motion injuries; but, none of these have been substantiated, and production times were actually proven to differ less than 1% between triggers in one study.