Reproducing Care: Changing Geographies of Nursing Work in the United States by Caitlin Renee Henry A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Geography and Planning University of Toronto © Copyright by Caitlin Renee Henry (2017) Reproducing Care: Changing Geographies of Nursing Work in the United States Doctor of Philosophy, 2017 Caitlin Renee Henry Department of Geography and Planning University of Toronto Nurses provide essential care to people in their most vulnerable times and perform myriad tasks that support the healthcare system as a whole. In spite of their essential role, nurses in the United States have been subject to devaluation individually and systemically, through underinvestment in nurse training, understaffing of facilities, and a lack of recognition for the work that they do. This dissertation is a qualitative study of nursing work in the US, focusing on nurses’ experiences of their jobs since the 2008 financial crisis until 2014. I base my argument on interviews I conducted with 37 nurses working in New York City and St Louis, Missouri. I also analyzed a variety of texts including media stories, union publications, and discussion boards, as a complement to nurses’ own stories. I examine three means of managing nursing work: the restructuring of the built environment of health services, the lengthening of the working day, and the changing modes of measuring and counting nursing work. I demonstrate different ways and scales at which nurses’ work and working conditions are changing during a dynamic period of restructuring in US health care. By drawing on interviews with nurses working in the New York and St Louis metropolitan regions, complemented with secondary textual analyses, I examine how broader changes to the political economy of ii health care, specifically the built environment, shift length, and ways of measuring work, impact the mundane and everyday aspects of the nursing job. Through these three means of governing nursing work, I add texture to theories of social reproduction. Social reproduction, or the reproduction of people and of everyday life and institutions, includes historically feminized work that sustains life, such as nursing work. Health and health care work, however, are under-theorized in the social reproduction literature. This dissertation contributes to feminist geography by foregrounding nursing work and the workplace of the hospital. While there is a rich literature in geography on the global migration of nurses and on the gendered dynamics of work, few scholars have engaged with the everyday experiences of nurses in their most common worksite. Furthermore, health geography has paid scant attention to the crucial roles that health care workers play in the making of health. Therefore, in this dissertation, I contribute to these literatures by focusing on the workers, how they and their work are regulated, and their subjectivities in relation to their work as it is restructured. iii Acknowledgements My research would not have been possible without the generosity and support of my family: Uncle Joe Neufeld for setting me up with a place to live in New York, my mom for helping me make connections with nurses in St Louis, and many others for both research and personal support – Elayne Dix, Marianne Neufeld, Ray Neufeld, Tom and Eleanor Neufeld, Greg Neufeld. And to all my family who sent me emails of support in the week before my defense. Thank you to my parents, Maggie and Mike, and my brother, Tim, for providing encouragement, moral support, and a safe haven when I need to escape from the drudgery of the diss. My mom gave me the inside scoop on nursing for most of my life and always helps me pick myself back up when I’m down. Most of what I know – and most of what follows here – I learned from her. Thank you to my committee and additional readers for all of the feedback, engagement, encouragement, and healthy skepticism over these past 6+ years: Matt Farish and Emily Gilbert, and Michelle Buckley, Mark Hunter, and Margaret Walton-Roberts. And to my supervisor, Rachel Silvey: my cheerleader, engaged critic and mentor, generous hugger, and most enthusiastic reader of my work; I am so deeply indebted. Thank you, also, to many faculty members who constituted my shadow committee: Mike Ekers, Andre Sorensen, Deb Cowen, Judy Han, Raj Reddy, Sharlene Mollet, and Alana Boland (I’ll see you on the squash court!), as well as the faculty in the Center for Global Social Policy with Ito Peng. And of course, a big thank you goes to all of the nurses who generously shared their time, thoughts, experiences, emotions, and opinions with me in interviews. My reading group was one of the best experiences over my time as a graduate student. Thank you to Martine August, Dan Cohen, Martin Danyluk, Kanishka Goonewardena, Prasad Khanolkar, Brett Story, and Laura Pitkanen. The texts we read and discussions we had are reflected in my dissertation’s weird reference list and my meandering and promiscuous way of thinking. I’ve learned a lot over my time at UofT, and much has been through union service. Thank you more than I can say to those who fought the good fight with me. Some of you pretty much saved my life in the hard times and were so life-giving all along, especially Sara Suliman, Ashleigh Ingle, James Nugent, and Amy Buitenhuis. And three years later, in the strike, Deltas Forever: Joe Curnow, Rebecca Bartel, Anjali Helferty, Maddy Whetung, Kevin Edmonds, Omar Sirri, Abe Singer, and Victor Lorenz. Similarly, friendships made through politics teach you a lot, and I’m grateful to all the friends I made working on the UofT General Assembly and all that you taught me: Faraz Vahid Shahidi, Alex Conchie, Zexi Wang, Vivian Endicott-Douglas, Will Nakhid, and Johanna Lewis. iv Thanks to my housemates over the years at the Wright House, Jen Ridgley, Patrick Vitale, Simon Vickers, Annie McKenzie, and Katie Mazer. You provided support, compassion, laughs, and so much good food. I am so grateful for the community we have created and sustained together over the years. Thank you to a great network of friends outside of the university for keeping me grounded: Kat Snukal, Andrew Kohan, and Marta Chudolinska in Toronto; in New York, Francesca Hays, Ana Djordjevic, Pedja Bilinac, Varuni, Joey Neufeld, Luis Gallo, Edward Djordjevic; Chad Watkins and Lindsey Schaffner in St. Louis/Belleville; Maria in Seattle. Over this time in academia, I’ve benefited more than I’m worthy of from the friendship, encouragement, and collaborations with in ways small and big: Kim England, who got me into researching nurses initially and continues to shape my academic work; Caroline Faria made me a geographer in the first place back in 2005; Brit Gilmer, Josh Akers, and John Paul Catungal, who, without, I never would have even made it through my MA to do a PhD; Paul Jackson for our discussions on health and social reproduction, global health, and dogs; Lisa Freeman (#FemFrontlines for life); David Seitz for the invaluable support in teaching, especially during the death threats against feminists in the fall of 2015; and to the many more including Yui Hashimoto, Ann Bonds, Magie Ramirez, Tish Lopez, Carmen Teeple Hopkins, Raili Lakanen, Ozlem Aslan, Jaby Mathews, Jacob Nerenberg, Emily Reid-Musson, Jeff Biggar, Charles Levkoe, David Roberts, Nick Lombardo, Annie Bartos, Ayesha Basit, Sanchia DeSouza, Elizabeth Lord, Elsie Lewison, Cynthia Morinville, Lia Frederikson, Rebecca Osolen, Alex Marques, Shiri Pasternak, Heather McLean. And, crap, I’m sure I’ve forgotten many more of you. Everyday, I am amazed by the support and love of those closest to me: my long-time housemate, rabble-rouser, co-dependent, Katie Mazer; Patrick Vitale for support, laughs, homegrown arugula, and an always compassionate ear. Jerry and Whitney Neufeld-Kaiser for being the best of friends to me, giving undying support and laughs, and being the greatest travel buddies and cousins. And to Nick McGee for keeping me calm, letting me rant, making me laugh, and much much more. I’m so lucky to have landed in such a vibrant and political department. Reflecting on the dynamism in the department, from my time as GGAPSS president to annual trivia nights to Intersections speakers to long discussions at pub nights, I don’t think I would have finished my PhD if I were in a different department. v Table of Contents Chapter 1: Introduction 1 Chapter 2: Hospital Closures: The Sociospatial Restructuring of Labor and Health Care 46 Chapter 3: Time and the Social Reproduction of Health Care 83 Chapter 4: The Abstraction of Care: What Work Counts? 114 Chapter 5: Conclusion: Towards a More Just Geography of Nursing Work and Good Health 144 References 162 Appendix 1: Participant Biographies 183 Appendix 2: Interview Guide for Nurses 189 Copyright Acknowledgements 192 vi List of Figures Figure 6: St John’s Queens Hospital, fall 2013. 62 Figure 7: Closed Hospitals and Residents of Color by Census Tract (2010) 66 Figure 8: Closed Hospitals and Household Income by Census Tract (2000) 67 Figure 9: Closed Hospitals and Household Income by Census Tract (2010) 68 Figure 10: Free-standing emergency room 72 Figures 11 and 12: The new condominiums replacing St. Vincent’s Hospital 73 vii Chapter 1 Introduction Nurses provide vital labor that sustains and reproduces health care systems. Yet, their work, which is feminized, suffers from chronic undervaluation that manifests in decades of stagnant wages and underinvestment in resources and training programs (Aiken 2007; Buchan and Aiken 2008; Mignon Duffy 2010; Kingma 2006). This dissertation investigates three different ways that nurses’ jobs in the US are managed in the everyday.