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Never Good Enough

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

Ariel Ducey
Copyright Date: 2009
Edition: 1
Published by: Cornell University Press,
Pages: 312
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  • Book Info
    Never Good Enough
    Book Description:

    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.

    eISBN: 978-0-8014-6013-5
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Acknowledgments
    (pp. ix-xii)
  4. Introduction: Health Care and Getting By in America
    (pp. 1-20)

    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. Seen from above, hospital campuses are as easy to pick out as famous city landmarks; approaching them on the street, they are like magnets, drawing in thousands of workers and patients each day.

    Inside these metropolises, medical students shuffle between lecture halls, the medical library, and patient...

  5. 1 The Pull and Perils of Health Care Work
    (pp. 21-58)

    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 (more precisely, the joint labor-management Training and Upgrading Fund, described in chapter 3) for the general equivalency diploma (GED) exam, so she could obtain her U.S. high-school degree, and passed the exam on her third attempt. Then she enrolled in another union program, one that helps participants prepare for the entrance...

  6. 2 Restructuring the New York Way
    (pp. 59-74)

    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” and the “massive expansion of primary care in ambulatory and community settings.” Surviving hospitals would be those that merged with other hospitals or health systems and expanded into non–acute care services such as home care and outpatient clinics. The health policy analysts saw a silver lining, suggesting...

  7. 3 The Promise of Training
    (pp. 75-88)

    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 Nowhere were the potential rewards of winning the tussle greater than in health care, in which state officials claimed they had invested nearly $1.3 billion between 1996 and 2005 for training, retraining, and retaining the workforce, including $800 million from the Health Care Reform Act (HCRA) and Community Health Care Conversion Demonstration Project (CHCCDP) programs described...

  8. 4 Too Skilled to Care: Multiskilling
    (pp. 89-110)

    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,” and 1,500 nurses at Columbia-Presbyterian Medical Center went on a one-day strike in July to protest the changes. Another hospital, St. Luke’s-Roosevelt, had reportedly laid off more than 100 nurses in the previous two years and the Greater New York Hospital Association reported a decline of 1,316...

  9. 5 “It All Comes Down to You”: Self-Help and Soft Skills
    (pp. 111-138)

    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. These “soft skills” courses were among the most heavily funded areas of training and, like multiskilling courses, presented as necessary preparation for the world of market-driven, competitive health care. In the courses I observed, health care workers were asked to compare their hospitals to Microsoft, McDonald’s, Disneyland, and Singapore Airlines, the...

  10. 6 Training without End: Upgrading
    (pp. 139-158)

    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....

  11. 7 From Skills to Meaning
    (pp. 159-179)

    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. Common as well is the argument that the industry helps people gain access to working-class jobs and can even be the means of meaningful upward mobility. These rationales warrant further examination to come to a more nuanced, and accurate, explanation of this industry’s endurance and ability to command substantial financial, even...

  12. 8 A Common Cause
    (pp. 180-207)

    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, when federal and state governments became the single largest payers for health care services. Once the government became billable, health care costs skyrocketed, so that, by the late 1970s, state actors were focused above all on containing them. As government payers began to impose new payment...

  13. 9 Education as a Benefit
    (pp. 208-232)

    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. Education that is a benefit of employment is a potential obstacle to a public education system that is universal, accessible, and of high quality. At least that is a plausible lesson to draw from the historical record on health insurance in the United States. In the years following World War II,...

  14. Conclusion: A Dose of Idealism
    (pp. 233-244)

    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 both because it might allow her to do her job better and because it might make what she does count. Of course, her job should count, regardless of the credentials behind her name. Health care providers like Marisol, regardless of whether they work in patients’ homes, nursing homes, or hospitals, already have...

  15. Appendix: A Note on Methods
    (pp. 245-252)
  16. Notes
    (pp. 253-278)
  17. Bibliography
    (pp. 279-290)
  18. Index
    (pp. 291-300)