Never Good Enough: Health Care Workers and the False Promise of Job Training

6. Training without End: Upgrading

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 Reports of how health care workforce training grants were spent in New York suggest that by the early 2000s, more efforts were directed toward individual upgrading and tuition assistance programs that supported workers’ attempts to get out of dead-end jobs. This shift was driven by several factors. In light of the nursing shortage, nursing positions became an obvious means of mobility. Industry insiders also indicated that 1199 and the state had begun to question the long-term value of many soft skills training programs (though such training continued). Furthermore, because managed care failed to have radical effects on the health care industry, substantial changes at the organizational level requiring training were also less than anticipated. Finally, hospital and 1199 Training and Upgrading Fund personnel were under pressure to spend the training portion of the CHCCDP grants quickly 140 Never Good Enough (because future cycles of infrastructure grants would not be released until the training portion had been spent). Upgrading and tuition assistance programs were recognized as effective ways to spend down funds. Upgrading programs, in which individual workers are supported in external training or education programs, tend to involve more costs: tuition, paying a salary to the worker while they are released to attend school, and paying replacement salary costs to their employer. In this chapter, we will encounter a number of examples of people who, thanks to training and education programs, have not been “stuck forever” as a porter or an aide. But we will also see the many hurdles that still exist to creating career ladders, including elaborate credentialing requirements and exclusive notions of professionalism, which training alone cannot overcome. The time and commitment required to make a career in health care is substantial, and the way that training and education plays out in the lives of health care workers requires costs and sacrifices inconsistent with the promise and potential of the most prosperous country in the world. Finally, implicit in the very nature of upgrading programs, as in the health care advocacy group’s formulation, is the message that there is something wrong with being a porter or an aide forever. This message is demoralizing to health care workers and may have unintended negative consequences for labor unions such as 1199, for whom training and upgrading is now a signature piece of the benefit package they offer to members. Individual upgrading programs represent the attempt to create career paths, to sustain the dream of upward mobility. As one training program administrator said, “For workers today, learning must be a lifetime pursuit .” A highly touted feature of the so-called knowledge economy, lifelong learning conjures up the image of gradually ascending steps, rather than the circles, detours, and cul de sacs that often characterize it. Allied health care workers’ experiences show what lifelong learning more likely entails for the majority of Americans in a service-dominated economy and the extent to which U.S. workers today must continually study, just to be. Getting Ahead While private corporations and public bureaucracies have traditionally created career ladders internal to the organization, in health care such ladders Training without End: Upgrading 141 are virtually nonexistent. The historical dominance of the medical profession means the practices and responsibilities of allied health care providers, including nurses, were carved out of the physicians’ role or obtained only on the condition—and sometimes fiction—of ultimate physician control. Occupations in health care are organized and regulated through state agencies or professional associations that function across organizations, rather than within them. In addition, professional associations, credentialing agencies, labor unions, and state regulations all contribute to the proliferation and ossification of specialized job titles in health care. Any career progression in health care requires going back to school for new certifications or licenses, and sometimes the “progression” that results is not very tangible. There is little articulation between various certificates and degrees in health care; one does not, for example, get credit toward medical school because of experience as a nurse. Nor does one get credit toward nursing school if one is an LPN or nursing assistant. The same holds true throughout the...