In New York City, more than one hundred thousand health care workers work in voluntary hospitals and nursing homes. Most of those institutions belong to the League of Voluntary Hospitals. Many of the workers are represented by 1199, the National Health and Human Service Employees Union. Together, the League and the Union administer a Training and Upgrading Fund, which offers a variety of education and training opportunities to union members. The Fund is attempting to develop a comprehensive plan for its future activities in light of dramatic changes underway in the city’s health care system. As part of that planning process, the Fund issued a Request for Proposals to conduct an assessment of the work-related and general literacy skills of a representative sample of health care workers.
The Division of Adult and Continuing Education at CUNY’s Office of Academic Affairs submitted a proposal and was selected to conduct the assessment.
In response to the Request for Proposals issued by the Fund, we planned to:
- provide a useful description of the general and job-related literacy skills of a representative sample of 1199 members working in hospital settings;
- provide a description of the types of texts used and the types of literacy-related tasks performed by hospital workers;
- describe the relationship between literacy proficiency and substantive occupational knowledge;
- identify opportunities for education and training efforts in the context of various scenarios of workplace and workforce changes;
- situate the description of skills in broader contexts of health care workers’ education, experience and literacy habits.
In order to ensure that our findings were valid and useful, we also wished to ensure a consistently high quality design and conduct of the assessment. We took great care to design and develop appropriate instruments and to utilize consistent procedures for all of the following project activities:
- workplace observations;
- document collection and analysis;
- participant selection;
- participant survey;
- participant assessment;
Detailed descriptions of instrument development and procedures are provided in Section I.
With some relatively minor changes, the project followed the design specified in the original proposal submitted to the Fund. Eventually, nine different health care institutions participated in the Health Care Worker Assessment Project. They were the following:
Catholic Medical Center/St. John’s Hospital
Columbia-Presbyterian Medical Center
Kingsbrook Jewish Medical Center
Lutheran Medical Center
Maimonides Medical Center
Montefiore Medical Center
Mt. Sinai Medical Center
St. Luke’s-Roosevelt Hospital Center
St. Vincent’s Hospital & Medical Center.
Over a period of several months in the spring of 1994, specially trained field researchers conducted approximately thirty-five observations in the different hospitals. A formal observation protocol was designed by the project staff and was used by all field researchers. The choice of areas to be observed was made on a joint basis with the Human Resources staff. Although efforts were made to visit all of the different types of work areas, the ultimate selection was limited by considerations of scheduling and accessibility.
The observations were conducted under widely varying circumstances (in some cases, virtual guided tours by supervisors and, in others, relatively free access to work areas). As a result, the distinctive perspective of the workers themselves on what they do and how they do it was unevenly represented. All of the field researchers submitted write-ups for the different work areas, covering many different job titles. Those write-ups included original field notes, document samples and annotations (specifying a document’s point of origin and use) and narrative summaries of the observations.
Two of the researchers reviewed all of the observation reports to determine which parts or wholes best illuminated the ways in which Local 1199 members do their work and the place of reading and writing in different jobs. They have produced a composite narrative which supplements our more formal findings. A third researcher reviewed and catalogued all of the different documents collected in the hospitals.
In order to insure that the project yielded an accurate portrait of the literacy skills of the unionized workforce in the hospitals, we developed a plan to identify a representative sample of those workers. The Fund had requested that we assess seven hundred individuals. We obtained from the union a current list of total membership in each and secured complete lists of Local 1199 members employed in those institutions. We intended to assess the following numbers in each institution:
|Hospital||Size of Intended Sample|
|Catholic Medical Center/St. John’s||42|
These numbers were calculated on the basis of information provided to the project by Human Resources personnel of the various hospitals on June 16, 1994.
We identified twice the number of participants needed because participation in the assessment was voluntary and we anticipated that some individuals would either not be able to participate (because of illness, vacations, and so forth) or would not be willing to do so. Once the sample had been selected, staff members of the Fund worked closely with us and with the staffs of the Human Resource Departments in each of the hospitals to notify the individuals who had been selected and to solicit their cooperation. Unfortunately, the number of individuals who actually participated was substantially less than we had expected. In spite of numerous efforts to increase the rate of participation, a total of just over 400 individuals came forth. The hospital-by-hospital numbers were as follows:
Catholic Medical Center – 15
Columbia-Presbyterian – 53
Kingsbrook – 43
Lutheran – 34
Maimonides – 55
Montefiore – 27
Mt. Sinai – 77
St. Luke’s – 38
Roosevelt – 19
St. Vincent’s – 53
Total – 414.
The breakdown by job classification was as follows:
Clerical – 121
Service – 197
Maintenance – 19
Professional – 22
Technical – 55.
The lower than expected turnout does not, we believe, interfere with our ability to answer the essential questions concerning the literacy skills of unionized hospital workers. We are able to draw conclusions concerning the performance of a number of different groupings of the participants (by sex, by age, by diploma/degree, by years on the job, by frequency or reading at work and at home, and, perhaps most important, job classification. In addition, we are able to analyze the performance of individuals in selected job titles. We are not, however, able to conduct analyses for all of the varied job titles nor, as we had hoped, on a hospital-by-hospital basis.
We are, of course, aware that the approach we employed had some built-in biases that need to be kept in mind. The participants were, in fact, volunteers. It could be argued that their willingness to participate resulted in an over-sampling of individuals who at least thought that they could read and write well enough and, correspondingly, in an under-sampling of those with concerns, if not embarrassments, over their perceived skills. The alternative, however, of mandating participation would have almost certainly resulted in an overall depression of performance since many of those who would have participated would have been upset at such a mandate and would have made less than a satisfactory effort to complete the tasks.
The second built-in bias is a related one. Individuals who speak little or no English might, in fact, have not understood the letter they received nor been especially willing to speak over the telephone with one of the field researchers. We have no way of knowing this for certain. Nonetheless, we were encouraged by the fact that when we did make the telephone calls, our field researchers encountered very few individuals who were not able to communicate in English over the phone. In addition, our selection procedure did result in the participation of a substantial number of individuals who reported that their native language was different from English. As will be evident in the report on our findings, those individuals usually did less well than native English speakers.
Each individual participant was asked to complete a comprehensive questionnaire on selected personal characteristics (sex, age, ethnic group, country or origin, and so forth); on education (years completed and diplomas/degrees received); on work experience; on reading and writing activities at home and work; on the use of mathematics; on the use of computers, and on their participation in education and training activities.
In order to insure that the form and content of the booklet were consistent with the purposes of the project, we utilized a step-by-step developmental process in its design. Those steps included the following:
1. collection and annotation of documents from hospital observations;
2. collection of documents from the general print environment of New York City;
3. evaluation of typicality and frequency of use of different types of documents;
4. enumeration of substantive and stylistic features of selected documents;
5. evaluation of difficulty of selected documents;
6. selection of documents and development of tasks for prototype assessment booklet;
7. piloting of prototype with varied groups;
8. revision of document selection and task wording;
9. second stage pilots;
10. finalization of document/task contents.
After we had collected a variety of documents, we initiated a process of sorting them into various categories according to our understanding of their formats and purposes. In the case of the documents collected from outside the workplace, we utilized some of the same classifications and also attempted to identify ones that shared fundamental features with those from the workplace. At the same time, we realized that certain types of documents were seldom present in the workplace. Most important, these documents included narratives of various types.
From the annotations provided by the field researchers, we knew approximately how frequently different documents were utilized and from the overall collection of workplace documents, we were aware of the relative prevalence of different types of documents. In addition, special diaries maintained by other individuals (who were not members of Local 1199) allowed us to draw conclusions concerning the frequency with which different types of documents were encountered outside work.
In addition to selecting documents, we devoted a good deal of time to the development of task formats. In some cases, respondents would be asked to enter data on the actual document. In others, they would be asked to mark up the original document. In only one case were respondents asked to select an answer from multiple choices. In a number of cases, they would be asked to write in a more or less open-ended fashion. We were especially interested in these open-ended responses since we intended to evaluate the quality of the participants’ writing and because we were convinced that written responses would illuminate some of the thought processes that individuals used as they attempted to answer.
For purposes of piloting the prototype, we enlisted the cooperation of several quite different groups of people–our field researchers (who had not been involved in the booklet development process), students in a Fund class, students enrolled in an adult education class conducted by a literacy program, and students enrolled in a workplace education program sponsored by another labor-management entity–whom we asked to read the documents and complete the tasks. We also asked them to share with us their reactions to the items and, especially, to point out any confusion they experienced.
As we reviewed the results of the initial piloting, we gradually determined which documents would be included in a second stage. At this time, we asked several other individuals to complete a full booklet. We were especially concerned to determine how much time completion might take–so that we could accurately inform the hospital administrators and the actual participants of the time involved. The second stage of pilots resulted only in relatively minor changes to the document collection. However, the apparent inclination of some to give an unexpected interpretation to some of our questions led us to review all of the language used in the tasks. In particular, we thought it important to guide the participants by including quite specific directions for individual documents.
The contents of the booklet were as follows:
- Document #1 – Application (for Training & Upgrading Fund)
- Document #2 – YMCA Schedule (for various exercise classes)
- Document #3 – A Day in the Life (an article reprinted from The Daily News)
- Document #4 – Vital Signs (a hospital chart used to record patient blood pressure and body temperature)
- Document #5 – The Flowers (a short story by Alice Walker)
- Document #6 – Universal Precautions (a universal notice concerning appropriate hygienic procedures to be followed in hospitals)
- Document #7 – Family Problems (a story by a hospital worker, initially published in a Local 1199 publication of student writings)
- Document #8 – Doctor’s Schedule (a chart used to record the date and time of day of patient visits to different doctors)
- Document #9 – Supplies ( a receiving form)
- Document #10 – Middle Ear Infections (an article originally published in a health information newsletter)
- Document #11 – Suicide in Alaska (an article from The New York Times
- Document #12 – Medical Codes ( a page from a manual used for coding diagnoses)
- Document #13 – Budget Cuts (a table from The New York Times)
- Document #14 – Life Threatening Situations (a memo originally posted in a hematology lab)
- Document #15 – Poetry in Motion (a poem, “Adolescence,” by Rita Dove which appeared in the Poetry in Motion series on the subways).
The documents were intentionally placed in a sequence that would result in a variation of document type and level of difficulty since we wished to insure that most participants would be able to make an effort on as many items as possible and that all participants would encounter at least some of the more difficult items.
Each document was situated in the context from which it had been taken. Thus, individuals were informed that a particular form was used for some purpose or that a story had been written by some particular person. All of the selected documents were typeset in a format intended, in all but one case (Document #15), to result in an exact replica of the original. In the case of the hospital documents, the names of the actual institutions were replaced by “General Hospital.” They were typeset to ensure a uniformly high quality of reproduction. 
As the assessments were being completed, two field researchers were assigned the task of developing a scoring guide. During this process, a team of nine evaluators was selected. The actual scoring was completed over a several week period. Each completed booklet was scored by two evaluators. Periodic cross checks of evaluators’ scores were conducted in order to insure consistency in approach. The scores of the two evaluators on each item, in each completed booklet, were averaged and that score served as the measure of the relative proficiency for each individual participant. In addition, averages were calculated for each of three different document groups. The document groups were as follows:
Document Group #1 – Work Related:
+ Application (#1)
+ Vital Signs (#4)
+ Universal Precautions (#6)
+ Doctor’s Schedule (#8)
+ Supplies (#9)
+ Medical Codes (#12)
+ Life Threatening Situations (#14)
Document Group #2 – General (non-continuous text):
+ YMCA Schedule (#2)
+ Budget Cuts (#13)
Document Group #3 – General (continuous text):
+ A Day in the Life (#3)
+ The Flowers (#5)
+ Family Problems (#7)
+ Middle Ear Infections (#10)
+ Suicide in Alaska (#11)
+ Adolescence (#15).
Both the average score on each item and the average score on each of the document groups were considered for purposes of evaluating the overall patterns of proficiency.
A customized data base was designed and installed to allow us to conduct a variety of analyses on the characteristics of participants, on their performance, and on selected relationships between characteristics and performance. The software utilized for the data base was SPSS, Statistical Package for the Social Sciences. A coding scheme was developed for all possible entries and a data framework was established that would allow for the entry and analysis of both the questionnaire data and the performance scores.
After the data entry was completed, we initially conducted frequency analyses of all the questionnaire data–which we have utilized for the preparation of the participant profile information included in this report. Subsequently, we explored the relationships between average scores and the following:
Country of Birth
Years of Education
Years on Current Job
Selected Job Titles
Frequency of Reading & Writing
¨ Hours/day at work
¨ Hours/day out of work.
Those reports were drawn upon directly in the development of the findings.
After the scoring was completed, all participants were sent letters informing them that results were in. They were also told that they could call the project office to speak to a staff member about their performance. Approximately 60 people responded with telephone calls to the project office. During each phone call, project staff went through Booklets with participants item by item, answering questions and giving counseling as needed. Test items were discussed as sensitively as possible, so that no participant felt that he or she had “failed the test.”
This report is intended to describe the project in sufficient detail to allow the Training and Upgrading Fund to determine its overall quality, to present our findings in appropriate detail and to make recommendations concerning the implications of our findings for the Fund’s future activities. All of the activities reported on herein can be described in greater detail if that seems necessary and all raw data can be made available to the Fund upon request.
What follows is a summary and discussion of what we discovered about the following:
the current demands of hospital work;
the implications of changes in hospital work organization;
the implications of changes in technology;
the significance of reading, writing and other skills;
the reading and writing activities of hospital workers;
the reading and writing skills of hospital workers;
the training experiences and interests of hospital workers.
Current Demands of Hospital Work
The satisfactory performance of many different types of work almost always involves cooperation and communication. This is seen quite straightforwardly in both laboratories and medical records offices where it is common for workers to discuss their findings and conclusions with each other, and/or with supervisors, before determining which data to record. Such collaboration, we believe, represents both the continuing importance of shared knowledge and of the significant ways in which less experienced and less knowledgeable workers “stretch” themselves in the course of doing their work. Although we would not be surprised to find out that such “stretching” causes some anxiety, we also believe that workers eventually are pleased to discover their own ability to do more than they might have first thought possible.
In addition, satisfactory performance requires what our researchers came to refer to as “acquired judgment.” This capacity to make decisions about what to do and how to do it came to be understood as perhaps the essential work skill. Our researchers also concluded that the capacity to make critical judgments–concerning matters such as anticipated demands for services or supplies and priorities–was acquired over time in the course of actually performing work and was seldom possessed by individual workers when they began. This conclusion suggests that there are few effective substitutes for on-the-job learning. In the section on recommendations, we will have more to say about the most appropriate mix of pre-service education and on-the-job training.
Effect of Work Reorganization
Hospital workers’ work is being dramatically reorganized. A small, but revealing, indication of this was our researchers’ difficulty in securing written job descriptions for the occupational positions they observed. More often than not, they were told that the job descriptions were being revised. But apart from the written word, we encountered many situations where workers are being asked to do more than they used to. Most of the time, more work does not mean more skilled work; it just means more. In a number of food service and materials management departments, for example, workers who previously had somewhat discrete work responsibilities are being asked or told to shift from area to area as the needs of the department warrant it. For example, whereas previously receiving shipments might have been the responsibility of one or two designated individuals, now many or all of the individuals who work in a materials management department are expected to be prepared to receive shipments. The literacy tasks might be different from the ones they have been accustomed to but they are not inherently or necessarily more difficult.
A quite different situation, however, is also emerging. As the result of a continuing tendency to shift some hospital functions to non-hospital ambulatory care settings, new configurations of jobs are being established. Some individual workers in these settings will have to perform both clerical and medical tasks. For them, it will not only be a matter of more work, but more demanding work. It may be that the responsibilities of Medical Assistants in clinics approximate the kinds of responsibilities that others will have to assume.
One cautionary note is necessary. Although we certainly do not understand the full magnitude of health care workforce shifts underway, it does not appear likely that the absolute number of new positions will equal the number of old positions that are eliminated. Thus, while literacy-related education and retraining efforts might enable some to obtain and perform the new positions, there will not be enough of those positions.
Impact of Technology
The increased use of sophisticated technology is evident in all of the hospitals. In the most extreme cases, hospitals might appear to be heading for a paper-free workplace. Even those institutions which are far behind what might be considered the cutting edge or state of the art in technology use computers for many different purposes.
Few individuals appear to be confident about their ability to use computers and many are nervous. At the same time, the mere use of computer-based applications does not necessarily represent an upgrading of skills for those using the computers. For example, the increasing use of bar codes and scanners obviously involved the introduction of more sophisticated technology into different work environments. But, the individual workers who wield the scanners are, in many important ways, being asked to use fewer of their own skills to identify people or things, or even for that matter, words, since the bar codes almost always replace printed labels.
Nonetheless, the use of computer files seldom results in the elimination of hard copy. Partially because of legal requirements and partially because of a concern about system malfunction, most institutions maintain redundant records. Some individuals use the computer files exclusively; others rely on paper, and still others go back and forth. It’s an interesting moment in the transformation of reading and writing technologies.
We saw little evidence that the proliferation of the use of advanced technology is the result of any dissatisfaction with the literacy skills of the workers involved. Instead, it appears to be the result, in part, of a somewhat general fascination with and conviction about the benefits of technology. At a somewhat more mundane level, there is apparently some hope that bar codes will reduce the all but inevitable confusion that results from sloppy handwriting or careless check marks. This is, in turn, connected to a rather prevalent concern with quality control and efficiency. Not so surprisingly, many efforts are being devoted to standardizing procedures–for example, the same menus on each of the seven days of the week, with the same foods being prepared the same way. Once again, such a development need not result in a demand for greater skill since individual versatility in the preparation of distinctive foods will not be required or valued.
It is often, and with good reason, expected that the introduction of new technology will result in more work being done by fewer people and, as a result, fewer jobs. We would caution the Fund however not to be surprised if it doesn’t quite work out that way and that the increased use of computers results in more jobs in some areas, rather than less. It is perhaps obvious that computers allow us to do many old things much more quickly than before, but they also allow us to do many new things and those new things have a way of generating still more work to be done. Thus, for example, although computer applications can result in the elimination of some hard copy material, it is also the case that, since individuals can produce much more copy on a computer than on a typewriter, there is that much more stuff to be read in one form or another.
Significance of Reading & Writing
Only some of the demands placed on workers involve reading and writing as essential components. It bears repeating that a good deal of work in the hospitals can be and is completed satisfactorily without very much reading and writing. As a result, there are correspondingly few literacy demands placed on many workers. At the same time, much other hospital work fundamentally depends on reading and writing and individuals in certain positions must be versatile and proficient in a wide variety of reading and writing tasks.
Not surprisingly, this difference in the significance of reading and writing for task completion is reflected in the experiences of workers in the five different job classifications. Many, if not most, service and maintenance workers do relatively little reading and writing. The technical and professional workers do a fair amount, mostly to document the other work they perform. Only the clerical workers devote many hours of each day to reading and writing.
When they do read and write, hospital workers deal with a lot of forms. Those forms are used to:
communicate information, and
Many of the reading and writing tasks that they have to perform with these forms are very routine. In other words, they use the same forms for the same purposes, in the same ways, day after day. The routine character of literacy tasks extends throughout the hierarchy of the hospital workforce. Doctors and other professionals also fill out forms routinely. But the routine character of the tasks obscures the fact that a great deal of other knowledge is required in order to complete the routine tasks efficiently and satisfactorily.
Perhaps the most basic question to be asked and answered about reading and writing in the hospital workplace is–how important are they. There is, unfortunately, no easy answer to the question. On the other hand, it is almost certainly the case that few decisions in the workplace are completely dependent on the ability of a solitary individual to “read” some document. Therefore, it is neither necessary nor helpful to think of the relatively undeveloped literacy skills of some hospital workers as posing any serious threat to the safe functioning of the institutions. However, the institutions would almost certainly be able to function more effectively and efficiently if many hospital workers had more advanced skills than they currently possess.
It is probably helpful to think of the essential reading and writing skills as skills of versatility and proficiency. Those hospital workers who do a lot of reading and writing need to be able to do many things, sometimes all at once, and they need to do all of them very well. Although the individuals in all job classifications are not now faced with quite the same skill requirements, it is likely that those skills will become more important across the various job classifications. If work is re-organized and workers are expected to do many things and, perhaps, to enter some record of what they have done into a computer, they too will need to be versatile and proficient.
We also think it helpful to recall the prevalence of routine documents in the hospital workplace. The documents themselves are ones that many people unfamiliar with medicine or health care could figure out how to read and/or fill out. The difference, however, is that they would likely not know what it meant. From this, we conclude, at least provisionally, that literacy development might be more important for what it enables health care workers to learn about substantive matters related to work and somewhat less important for the execution of the literacy tasks of the workplace. This is especially important in those cases where individuals need to complete degrees or obtain licenses in order to maintain positions or to gain promotions.
Fortunately, such literacy development is the type that will fit well with the demands for versatility and proficiency that we anticipate to be coming the way of hospital workers.
Reading and Writing Activities
Overall, participants reported significant levels of reading and writing activity, mathematical activity and computer-related activity. There were remarkable differences in the reports of reading and writing activity at work across the different job classifications. Service and maintenance workers consistently reported low levels of such activity while the other three classifications reported very high levels.
What is noteworthy is that the breadth of reported literacy activity provides a very sound starting point for further literacy development. In other words, since hospital workers are already doing a good deal of reading and writing, it should be relatively easy to provide assistance of various kinds (for example, making available books and other printed matter) which can allow individuals to expand their repertoires of reading and writing activity.
Reading & Writing Skills
Virtually all participants revealed some degree of proficiency in reading and writing. Of all respondents, fewer than ten left all items unanswered. While it is not possible to know for sure that those unanswered items indicate a lack of ability, it seems fair to conclude that the individuals involved were not able to read sufficiently well to record even a minimal response. Beyond that, however, participants did respond. Some did not complete all of the items. This occurred most often in the case of the last few items in the booklet. Although there was no time limit set for the assessment, practical matters did prevent some from going all the way to the end.
Our major findings concerning literacy proficiencies are the following:
1. There were no significant differences between male and female participants.
2. Workers with relatively few years on the job appeared to do somewhat better than those with more.
3. Individuals with more advanced educational credentials did better than those with less or none.
4. Native English speakers did better than those whose native language is not English.
5. Younger workers did better than older ones.
6. Those who read more outside of work did better than those who read less.
7. Professional workers did best of all.
8. Service workers did least well.
9. Members of the different groupings we analyzed appeared to have at least rudimentary skills.
10. Patterns of difficulty persisted across the groupings. The most difficult documents were always the same ones.
Some of these patterns are, we believe, reflections of the fact that, while individuals’ characteristics can be separated for purposes of analysis, those individuals are themselves composites of their distinctive characteristics. By way of example, if those who hold advanced degrees are also more likely to be younger, more likely to hold technical/professional positions, more likely to be English speakers, more likely to read more outside of work, and so forth, it is not surprising that evidence of their superior performance would be evident in all of the different groupings that they happen to be members of.
The fact that individuals in the service classification did least well is, we believe, the most significant finding of the entire project. While service workers performed at least moderately well on the five documents categorized as easy, they performed only at a low level of proficiency on five of the seven documents categorized as being of moderate difficulty. This is probably of greater significance than their relatively low level performance on the documents considered difficult since even the professional workers performed at a low level on the poem and only at a moderate level on the other two difficult documents.
If the jobs of those in the service classification are among the most likely to be restructured or eliminated and if the jobs that are most likely to be maintained or expanded have substantially greater literacy demands (which they do), then it is all but certain that service workers will have to be provided with a broad range of educational opportunities if they are to have any reasonable chance of preparing themselves for the jobs that they might obtain–especially in light of the fact they do relatively little reading and writing in their current jobs. If they have few opportunities to become more proficient and versatile through the work they do, the only opportunity for them to achieve versatility and proficiency will be through participation in education programs.
What is especially noteworthy is the consistent pattern of comparative performance across the different documents–as is made clear by the graph on the following page. Although professionals did best, their scores fluctuate in the same manner as the scores for the other classifications. The difficulty of documents and tasks quite clearly affects performance. What makes them difficult is a combination of their structure, their content, and their relative familiarity.
What’s Good Enough?
Whether the literacy skills of hospital workers should be good enough to handle even the difficult documents is a matter for continued discussion and needs, in part, to be based on a recollection of which documents fell into which categories.
Four of the five easy documents are workplace documents (three of which were forms which required the entry of information) and the fifth is a reprint of a news story from The Daily News. Two of the seven moderately difficult documents are workplace documents (neither of which required the entry of information); one is an autobiographical story written by a hospital worker; two are reprints from The New York Times; one is a reprint from a health information newsletter and the last is a schedule of exercise options at a gym. The three difficult documents include a short story, a poem and a very technical workplace memo on procedures.
Should hospital workers be able to read and interpret an unfamiliar, almost esoteric, memo? Should they be able to read a somewhat intricate short story? Should they be able to read a suggestive poem? And how well should they be able to do so? While we’re reluctant to offer absolute answers to those questions, we suggest that it would be desirable for all hospital workers to be better readers and writers than they are and that these particular texts are representative of a whole range of printed matter that hospital workers would, in some cases, find useful and, in other cases, find moving or beautiful. Both purposes seem worthwhile.
We would also suggest that proficiency and versatility are necessary but not sufficient skills for hospital workers. In almost very case, now and in the future, they need to be joined with skills of judgment and critical thought. Although reading and writing short stories and poetry may have little in common with the routine literacy demands of work in the hospitals, they have a great deal to do with the development of wisdom and good sense.
In closing, we would like to echo the remarks made in the Project Description section on the relationship between the performance indicated on this Assessment and the actual proficiencies of hospital workers. All assessments out of context distort, and probably weaken, performance. On another occasion and in a different setting, it is likely that many of the participants would be able to do some of what they appeared unable to do. Nonetheless, our findings are, we believe, valuable starting points in the effort to design education and training initiatives for hospital workers.
Training and Education
There appears to be a significant discrepancy between the high levels of interest expressed in education or training (75%) and the relatively low levels of actual participation (20% previously and 12% current). It also appears that the information available on educational opportunities is insufficient. Some light on this matter is shed by the findings on obstacles to participation.
On the other hand, Fund personnel reported that less than fifty percent of those who sign up for classes actually come to class and that those who sign up represent only a fraction of those who receive informational materials. The Fund staffers suggested that much of the fall-off occurs when individual workers realize the difficulties involved in attending classes. It may be that workers need extended opportunities to discover both the benefits and difficulties of participation before they make decisions.
There appear to be substantial levels of interest in all of the kinds of education and training activities that the Fund has offered and/or is likely to offer in the future. Obstacles to participation appear to be substantial but not overwhelming. Scheduling problems are clearly the most important but both lack of opportunities (which may be closely connected to scheduling) and personal hesitation are also significant. The reports of personal hesitation might also reflect some of the ambivalence about participation discussed above.
There appear to be substantial levels of interest in a fairly wide variety of preferred occupations. It is worth noting that all of the expressed preferences, except maintenance, would require that individuals complete formal courses of study–up to, and including, the baccalaureate (or possibly even masters) level.
The Health Care Worker Assessment Project has resulted in what we believe to be a useful profile of the literacy skills of hospital workers in the contexts of the demands they encounter at work and the literacy activities they regularly engage in. We hope that the profile assists the Training and Upgrading Fund in the development of effective education and training opportunities for all hospital workers. On the basis of our findings, we have a number of recommendations to make concerning the design of those education and training opportunities and the on-going assessment of individuals that will be a necessary complement to the opportunities.
Education and Training Opportunities
Effective education and training opportunities need to be crafted with a comprehensive understanding of:
what will be needed in the hospital workplaces of the future;
the current literacy activity of hospital workers at work and outside of it;
the literacy skills currently possessed by hospital workers;
perhaps most important, a realistic understanding of how long it takes for individuals to achieve various goals from a variety of different starting points.
The effectiveness of education and training is, of course, dependent on many factors–appropriate enrollments, well-designed curriculum, attentive teaching among them. But it also requires hard work on the part of students. Individuals can be expected to put in such hard work only when the goals seem worthwhile and the approach of the educators is convincing.
It is clear that no single model program can meet the varied needs and expectations of hospital workers–especially when the demands of their work obligations and their personal lives make participation in an educational activity a very taxing reality. What is probably needed is a judicious mix of classroom-based and on-the-job training learning situations and a flexible configuration of academic and vocationally oriented offerings. We are not, however, in a position to advise the Fund on the full range of educational services it should be providing.
We would like to focus our recommendations on the implications of several of our findings:
that service workers did the least well, do the least reading and writing at work and are the most vulnerable to the effects of work reorganization;
that high school graduates, as a group, performed quite well on the assessment (they scored at a high level on the easy documents, moderately well on the moderately difficult documents and at a low level only on the difficult documents);
that current participation in education and training activities appears to be less than hospital workers would like and less than would appear to be warranted by our findings concerning overall literacy proficiency.
Let us take the first two together. We would recommend that one of the goals of the Training and Upgrading Fund should be to enable each interested hospital worker, and especially those in the service classification, to obtain a high school diploma. In almost every case, this will mean that those individuals will have to take the Tests of General Educational Development (GED).  A program of substantial preparation–involving extensive reading, writing and math activities in the classroom and outside of it–for that examination will, we believe, significantly enhance individuals’ abilities to read and to write. It will also prepare some of them for the challenges involved in postsecondary education where they will have to go if they are to obtain the credentials necessary for many of the jobs they would like to obtain.
Such a program of preparation will require a commitment of resources to curriculum development and teacher training since there are few ready-made materials or curricular plans that can be utilized. The alternative to what we are recommending is a fairly common program model that consists of what has been called “skills and drills.” That type of program will all too often fail to engage students sufficiently to allow for genuine development. While such a program, delivered either through hardcopy or electronic worksheets, might enable some to pass the test, it will leave all too many behind–without a diploma and without the substantial literacy-related development that appears essential.
The scheduling constraints and other obstacles to participation cited by participants suggest that educational opportunities need to be as convenient as possible for all hospital workers–especially those who work evening and night shifts–to participate. Perhaps obviously, the most convenient opportunity is one that is incorporated within the hours of the workday. Since that is seldom a realistic alternative, we would suggest that the Fund explore opportunities to enrich the regular training that occurs within the institutions by perhaps providing literacy teaching assistants who could work with hospital trainers to incorporate literacy learning into the training curricula.
But in addition to convenient scheduling, it is also clear that hospital workers also need good advice concerning the benefits of educational participation and the real demands that such participation will place on them. Thus, it appears necessary for the Fund to devote resources to a program of educational advisement which, linked to comprehensive assessment, can enable individual hospital workers to make wise and realistic choices. Any judgment concerning the appropriateness of the education and training preferences of hospital workers needs to accord those preferences their due respect. At the same time, those preferences are, almost certainly, informed by a partial understanding of employment opportunities and career paths. Thus, it may be the case that the relatively large preferences for training as X-ray technicians or physical therapists will prove to be ill-advised and that the relatively low preference for training as maintenance workers, especially if opportunities outside the health care industry are taken into account, is also ill-advised.
But beyond wise choices concerning fields of study, hospital workers need to know how long the achievement of some intermediate or final goal will take. They need to know where they are starting from, how far they have to travel, how much work they will have to put in, and how they are progressing as they go. These needs of individual hospital workers are complemented by the need of the Fund to use its resources strategically. Therefore, we recommend that the Fund staff develop a planning guide to all of its various education and training options and that such a guide include reasonable precise estimates of the time necessary to complete each option.
The on-going assessment of hospital workers should be designed to accomplish several rather broad purposes:
to provide individuals and staff members of the Training & Upgrading Fund with information about the skills of individuals in different contexts and across contexts;
to discover the expectations of potential and/or actual participants in education or training activities;
to clarify the goals of potential and/or actual participants;
to identify appropriate short and long term possibilities of education, job training and/or career paths for individuals;
to situate individuals with reference to appropriate external benchmarks, such as the GED Tests or CUNY’s Freshman Skills Assessment Tests;
to promote conversations between staff and participants concerning appropriate investments of time, energy and other resources;
to promote informed participation in education and training activities.
To accomplish these purposes, the Fund should consider the following steps:
develop a common assessment instrument consisting of a sequence of documents and tasks arranged in approximate order of difficulty for use in all of the Fund’s programs below the postsecondary level; 
develop a brief interview protocol to evaluate individual interests, experiences and predispositions related to literacy development;
determine appropriate benchmark performance levels for effective participation in a variety of different education and training activities.
It was clear during the conduct of the Health Care Worker Assessment Project that many hospital workers were curious about their literacy skills but that they were also worried about what any assessment might reveal. Most important, they were concerned that a poor performance might result in the termination of their employment. Considering the importance of these concerns, we recommend that the Fund’s staff members become reasonably expert about matters of literacy assessment and about the related counseling topics so that they might work closely with individual workers in the interpretation of results and the identification of suitable educational opportunities.
We hope that these recommendations are helpful and assure the Fund that we are quite willing to assist its staff in any way that we can.
Necessary permissions to reprint were secured from newspapers and publishers.
 The GED Tests are administered across the country and in Canada. They are developed and maintained by the GED Testing Service of the American Council on Education in Washington, D.C.
 If the Fund chose to use some of the actual documents and tasks included from this Project’s Assessment Booklet, the description of the relative difficulty of the different documents included in the section on Findings would probably be a sensible place to start.