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In Plain Sight

Is Health Care Just Another Chaotic, Low-Wage Job?

Image: Nurses Move a patient

A patient is taken to the operating theater. Christopher Furlong / Getty Images

For many workers, American medical care is going the way of fast food and retail: unstable schedules, punitive employers, and rigid management. That’s according to Unequal Time, a new book by University of Massachusetts sociologists Dan Clawson and Naomi Gerstel that was published on Tuesday. “Across the health sector, work has become increasingly unpredictable,” Clawson says. “And it’s low-wage workers and women whose lives are thrown most into chaos.”

Clawson and Gerstel interviewed dozens of workers, including one certified nursing assistant who she worked unpredictable hours in a nursing home and was expected to come in even when sick. “They say a sore throat is not really a sore throat,” the nurse’s aide told the authors.

In an interview about his new book, Clawson told NBC that the practices workers like this one described have become commonplace.

NBC: You studied doctors, nurses, EMTs and nursing assistants, and found that the sector has become increasingly unpredictable for workers across the spectrum. But you say that nursing assistants, overwhelmingly women and relatively low-paid, are hardest hit.

Clawson: The thing about health care is that there has to be someone on duty all the time. You can’t have a nurse walk off and have the patients not covered for an hour. That’s uncontroversial, but the way that plays out is unequal by gender and class, and it’s absolutely unsustainable for the lives of low wage workers and women.

We studied a high-end nursing home, for example. Most patients are in private rooms, there are a stable number of beds and a stable number of workers. Yet even in this highly controlled setting, we found that over a third of nursing assistant shifts were unpredictable: either they were working an unplanned shift or not working a planned shift. There’s a tremendous amount of unpredictability and churning in a workplace that should be the most stable of employment situations. It’s likely worse in other homes.

NBC: What does that mean for workers? Couldn’t that flexibility really be a good thing for workers with families? You call it unpredictability. But couldn’t it be a result of workers choosing to change their shifts?

Clawson: The question of choice or not choice is a false dichotomy. Employees in the nursing assistant position are usually scheduled for three or four 8-hour shifts a week. They know they’ll have these shifts. But that’s only 24 or 32 hours a week, and workers need 40 hours to be able to come close to supporting their families [nursing assistants, about 90 percent of whom are women, make an average of about $10 an hour]. So when they’re told to come in for a shift that they didn’t plan, they really have no choice. They know every week that they’ll work 8 or 16 hours unpredictably, and they have to work the shifts because they have to pay rent. Many of these workers are women with kids, often single mothers—they happen mostly to be women of color—and so they have to work as many hours as they can. It makes it very hard to schedule the rest of life, to make arrangements with other relatives to care for kids. The key thing is that their lives have to be always at the disposal of the employer, even when sick.

NBC: So how does this function differently for higher paid or more male-dominated parts of the health sector?

Clawson: Some parts of what I’m describing are creeping into the work lives of nurses. One major hospital scheduled nurses for 40 hours per week but the hospital reserved the right to cancel the shift up to two hours before it began. It’s starting to affect higher paid workers too, but less so.

For doctors it’s a different situation, where rather than working an extra shift, they are much more likely to work late because they are working with a patient and are expected to stay until they’re finished. And the thing we found is that half of doctors—who are more likely to be men—had stay at home partners. Others have people they can pay to care for their children. They maybe eat dinner late, but there’s someone caring for the kids.

Another thing we found was that as unpredictability gets worse for lower wage workers, in the more privileged occupations, structural adaptations have been created to help address the problems of unpredictability. There’s now a whole doctor specialist called the “hospitalist” whose job it is to check on the patients and relieve other doctors of long hours.

NBC: You quote workers talking about coming to work while sick because they have so little control over their hours and sick days. There’s also been a lot of criticism of elder neglect in nursing homes, of patients who are not properly cared for. How do the scheduling practices you researched affect the well being of patients?

Clawson: Another gender and class difference in the health sector is about how punitive the scheduling policies are. In many workplaces, like the ones we studied, nursing assistants got six days a year of paid sick leave, but if they used more than four of those days in any 90-day period, they lost their jobs. If you think of it from the perspective of a single mother with kids, the younger kid gets sick and then the other kid gets sick and you get sick, you use up the time. One more, you’re fired.

Because of these practices, when workers got sick, they made every effort to come in anyway. In these jobs, a sore throat is not really a sore throat. Nursing assistants are coerced to come in when sick because otherwise they may lose their job. And this is while they are feeding, washing and caring for 90-year-olds who are in poor health.

And we can see that a hospital has every incentive not to collect information on sick workers. There is no record.

NBC: This sounds very hard for workers, but as you said before, healthcare is not a field where you can simply be understaffed. So how do you avoid the kind of destructive unpredictability?

Clawson: Within healthcare there’s a duty of care: you are required to stay with a patient and can’t leave till there’s alternative coverage. But what we know is that employers are staffing shifts in a very lean way, which means that there’s no slack in the system. The leaner the staff, the more you’ve cut to the bone, the more disruptive every change becomes. The staffing is leaner because increasing profits are central now to the success of the organization. But it would be better for patients and hospital and residents of nursing homes if there were more people available to take care of patients.

This is part of a shift toward greater inequality, toward jobs that are more insecure, and contracted out, and that don’t provide the stability and advancement that they used to. Everyone is vulnerable — some are more vulnerable than others.