Never Good Enough
Health Care Workers and the False Promise of Job Training
Publication Year: 2008
Frontline health care workers have always been especially vulnerable to the perpetual tides of health care 'reform,' but in the mid-1990s in New York City, they bore the brunt of change in a new way. They were obliged to take on additional work, take lessons in recalibrating their attitudes, and, when those steps failed to bring about the desired improvements, take advantage of training programs that would ostensibly lead to better jobs. Such health care workers not only became targets of pro-market and restructuring policies but also were blamed for many of the problems created by those policies, from the deteriorating conditions of patient care to the financial vulnerability of entire institutions.
In Never Good Enough, Ariel Ducey describes some of the most heavily funded training programs, arguing that both the content of many training and education programs and the sheer commitment of time they require pressure individual health care workers to compensate for the irrationalities of America's health care system, for the fact that caring labor is devalued, and for the inequities of an economy driven by the relentless creation of underpaid service jobs. In so doing, the book also analyzes the roles that unions-particularly SEIU 1199 in New York-and the city's academic institutions have played in this problematic phenomenon.
In her thoughtful and provocative critique of job training in the health care sector, Ariel Ducey explores the history and the extent of job training initiatives for health care workers and lays out the political and economic significance of these programs beyond the obvious goal of career advancement. Questioning whether job training improves either the lives of workers or the quality of health care, she explains why such training persists, focusing in particular on the wide scope of its "emotional" benefits. The book is based on Ducey's three years as an ethnographer in several hospitals and in-depth interviews with key players in health care training. It argues that training and education cannot be a panacea for restructuring-whether in the health care sector or the economy as a whole.
Published by: Cornell University Press
Title Page, Copyright
In the years spent writing this book, I have acquired many debts. In the first phase of this project, there are the colleagues, mentors, and friends from the City University of New York Graduate Center. Patricia Clough, Stanley Aronowitz, and Barbara Katz Rothman made a lasting impact on me, intellectually, personally, and politically. ...
Introduction: Health Care and Getting By in America
Hospitals are the economic and social centers of many urban neighborhoods in the United States, but in New York their number and size is unusual. The campuses of major academic medical centers occupy entire city blocks and their buildings loom over the apartment buildings, brownstones, tenements, and public housing projects that surround them. ...
1. The Pull and Perils of Health Care Work
When I met Veronica, a fifty-five-year-old nursing assistant and immigrant from Trinidad, she had been attending school in the evenings and on weekends for close to ten years, while working full-time and taking care of her family. First she spent two years attending a preparatory course offered by 1199 ...
2. Restructuring the New York Way
In the mid-1990s, health policy analysts proclaimed the U.S. hospital was an “institution . . . being shaken at its core foundations.” An influential 1995 report by the Pew Health Professions Commission predicted the closure of “as many as half of the nation’s hospitals and loss of perhaps 60% of hospital beds” ...
3. The Promise of Training
In a 2002 report on training and workforce development in New York City, the Center for an Urban Future, a public policy group, observed, “accessing training dollars has been a competitive tussle amongst over 150 nonprofits, community colleges, private universities, unions and for-profit trainers.”1 ...
4. Too Skilled to Care: Multiskilling
In 1996, the New York Times reported that city hospitals were hiring nursing technicians to do some of the work of registered nurses, including taking temperatures and electrocardiograms (EKGs). Nurses worried “that the technicians, who may have as little as a few weeks of training, are not always up to their new tasks,” ...
5. “It All Comes Down to You”: Self-Help and Soft Skills
When millions of dollars for training the health care workforce became available in the late 1990s, tens of thousands of New York City hospital workers were sent to training classes in such areas as customer service, communication skills, team building and teamwork, cultural diversity, conflict resolution, and leadership training. ...
6. Training without End: Upgrading
In 1970, a prominent health care advocacy group commented, “the stagnant hierarchy, supported by elaborate credentialing requirements and arrogant professionalism, turns most hospital jobs into dead-end jobs: a porter or aide is stuck forever as a porter or aide.”1 ...
7. From Skills to Meaning
Those with a stake in New York’s health care workforce training industry mobilize several arguments in support of their programs. Most prominent is the ubiquitous argument that training and education programs are necessary to compensate for the gap between the skills of the workforce and the requirements of jobs. ...
8. A Common Cause
In the 1990s, 1199 and its leaders formed an alliance with hospital leaders to fight pro-market reforms and state budget cuts and preserve the jobs of its members. The state had been the unofficial third party to negotiations between 1199 and private hospitals since the passage of the Medicaid and Medicare programs in 1965, ...
9. Education as a Benefit
Labor unions have long struck questionable bargains to survive to fight another day, but 1199’s training and education programs are the basis of a strategy that will have lasting consequences and shape future choices about how to respond to the inequities and insecurities that face growing numbers of Americans. ...
Conclusion: A Dose of Idealism
Many frontline health care workers need and want more education. As Marisol, a home health aide, said to the instructor of an in-service I attended, “We don’t have enough education. We have all the responsibility, but we don’t know. Then what we do doesn’t count.” Marisol wanted education ...
Appendix: A Note on Methods