Cleaning and nursing in hospitals: Institutional variety and the reshaping of low-wage jobs: Institutional variety and the reshaping of low wage jobs

In their research on low-wage and low-skill work in U.S. hospitals, Eileen Appelbaum and her colleagues (2003) found a high incidence of low-wage work among cleaners and nursing assistants. At the time of their study, U.S. hospitals were struggling with high turnover and difficulties in recruiting low-skilled workers. Rather than raise wages, hospitals, responding in some cases to trade union pressure, experimented with increased training and alternative forms of work organization that broadened job tasks. One of the key assumptions behind these experiments was that creating more interesting jobs and improving job satisfaction would increase the ability of hospitals to recruit and retain labor and that cost savings could be achieved by switching job tasks among nursing assistants and nurses. Nevertheless, such changes have not had a significant effect on the incidence of low-wage work; nor is there any evidence of significant diffusion of so-called high-road human resource (HR) practices in U.S. hospitals. In Europe, the picture varies considerably from country to country. In three countries (Denmark, France, and the Netherlands), there is in fact very little evidence of low-wage work among cleaners and nursing assistants in hospitals. Only the United Kingdom registers a high incidence of low-wage work, at a level close to that of the United States. In Germany, the incidence is increasing among cleaners. Despite these differences, U.S. and European hospitals have faced similar pressures in recent years, including an aging population, budget constraints, concerns over the quality of care, and new demands from patients. In many respects, hospitals have responded in fairly similar ways-with efforts to increase patient throughput, reform funding schemes, and shift the care and rehabilitation of patients outside hospitals. Attempts to reorganize work, however, have varied significantly, in large part because of the reality that human resource strategies are embedded within national employment systems and the diverse roles and influences of the social partners. The first three sections of this chapter set out the background to conditions in the hospital sector. The first describes the commonalities and differences in the hospital sector (ownership, cost pressures, industry organization, and so on) across the six countries. The next section presents the main characteristics of the division of labor and work organization, as well as the labor supply. Unlike the other industries analyzed in this book, the hospital industry presents huge intercountry differences, despite the fact that our analysis focuses on a common set of tasks (cleaning patients' rooms and basic nursing) and similar job titles (cleaner and nursing assistant). We emphasize job categories, qualifications, and training in our analysis because these factors play an important role in our understanding of the incidence of low pay in this sector. The third section compares the incidence of low-wage work in hospital occupations and considers the role of wage regulation and wage structure in explaining country differences. The next three sections of the chapter then focus on three main trends affecting the quality of low-wage, low-skill work. When they are not putting direct pressure on wages, hospitals can develop alternative HR strategies. They can save costs and gain in flexibility by outsourcing their cleaning activities or using alternative "exit options." Depending on the country in question, these possibilities are facilitated or impeded by the main domestic labor market institutions. The European hospitals in our sample have reshaped work organization as part of a more systematic and more positive up-skilling process than that observed in the U.S. hospitals. Another option available to hospitals is to increase workloads; however, the extent to which this has occurred, as perceived by workers, varies across countries. These three trends are an important part of the dynamic of lowwage, low-skill work and are reflected in, among other things, persistently high wage differences in the United States, stability of and/or improvement in the wage and skill positions in Denmark and the Netherlands, and an increase in low-wage work among cleaners in Germany. We conclude by emphasizing the importance of the interplay be tween a broad set of labor market institutions (collective agreements, the minimum wage, training facilities) and health institutions (funding rules, monitoring of care quality) in explaining the development of virtuous or vicious circles in the six countries investigated here. As in the other chapters of this book, our data are derived from the common methodology designed for the entire research project on lowwage work: A mix of industry-level analysis of the hospital sector and in-depth case studies in a sample of hospitals (fifteen for the United States, eight per country for Europe) that involved interviews with managers, union representatives, and workers. To enhance comparability, most of the interviews in the European countries were undertaken in medical wards in general (non-university or teaching) hospitals. Some of our conclusions are more specific to this aspect of hospital care. The U.S. case data were gathered in fifteen community hospitals between 2000 and 2002 (five years before the European research). In addition to over one hundred interviews with managers, supervisors, and union officials, the original U.S. research team conducted a telephone survey of 589 low-wage workers across the fifteen hospitals. Copyright © 2010 by Russell Sage Foundation.