For Tabitha Waugh, it was another typical day of chaos on the sixth-floor cancer ward.
The fire alarm was blaring for the second time that afternoon, prompting patients to stumble out of their rooms. One confused elderly man approached Ms. Waugh, a registered nurse at St. Mary’s Medical Center here, but she had no time to console him. An aide was shouting from another room, where a patient sat dazed on the edge of his bed, blood pooling on the floor from the IV he had yanked from his vein.
“Hey, big guy, can you lay back in bed?” she asked, as she cleaned the patient before inserting a new line. He winced. “Hold my hand, O.K.?” she said.
Ms. Waugh, who is 30 and the main breadwinner in her family of four, still had three hours to go before the end of a 12-hour shift. But despite the stresses and constant demands, all the hard work was paying off.
Her wage of nearly $27 an hour provides for a comfortable life that includes a three-bedroom home, a pickup truck and a new sport utility vehicle, tumbling classes for her 3-year-old, Piper, and dozens of brightly colored Thomas the Tank Engine cars heaped under the double bed of her 6-year-old, Collin.
The daughter of a teacher’s aide and a gas station manager, Ms. Waugh, like many other hard-working and often overlooked Americans, has secured a spot in a profoundly transformed middle class. While the group continues to include large numbers of people sitting at desks, far fewer middle-income workers of the 21st century are donning overalls. Instead, reflecting the biggest change in recent years, millions more are in scrubs.
“We used to think about the men going out with their lunch bucket to their factory, and those were good jobs,” said Jane Waldfogel, a professor at Columbia University who studies work and family issues. “What’s the corresponding job today? It’s in the health care sector.”
In 1980, 1.4 million jobs in health care paid a middle-class wage: $40,000 to $80,000 a year in today’s money. Now, the figure is 4.5 million.
The pay of registered nurses — now the third-largest middle-income occupation and one that continues to be overwhelmingly female — has risen strongly along with the increasing demands of the job. The median salary of $61,000 a year in 2012 was 55 percent greater, adjusted for inflation, than it was three decades earlier.
And it was about $9,000 more than the shriveled wages of, say, a phone company repairman, who would have been more likely to head a middle-class family in the 1980s. Back then, more than a quarter of middle-income jobs were in manufacturing, a sector long dominated by men. Today, it is just 13 percent.
As the job market has shifted, women, in general, have more skillfully negotiated the twists and turns of the new economy, rushing to secure jobs in health care and other industries that demand more education and training. Men, by contrast, have been less successful at keeping up.
In many working- and middle-class households, women now earn the bigger paycheck, work longer hours and have greater opportunities for career advancement. As a result, millions of American families are being reconfigured along with the economy.
“The culture still has traditional attitudes about who does what, who brings home the bacon and who scrambles the eggs,” said Isabel Sawhill, co-director of the Center on Children and Families at the Brookings Institution. “The economy is now out of sync with the culture, and I think that’s creating tensions within marriage.”
A New Springboard
At the Waughs’ house, it is T.J. Waugh, 33, who picks up the couple’s two children from the babysitter when he leaves his afternoon shift at a small plant in Huntington.
By the time Ms. Waugh arrives home in rural Salt Rock from her shift, often far later than her 7 p.m. quitting time, the children have been bathed and fed.
The house is usually messy. The bathroom walls are covered with scribbles from bath crayons; dirty clothes pile up. Ms. Waugh often jams six 12-hour shifts into one week, leaving little time for cleaning and laundry. Mr. Waugh mows the lawn and will run the vacuum cleaner now and then, and if there are no clean towels, Ms. Waugh will do a load of laundry. Otherwise, housework waits until she has a stretch of days off.
“I’m just really tired when I get home,” Ms. Waugh said.
Ms. Waugh is the keeper of the family’s books. That she out-earns her husband — a pipe fitter who hunts deer and plays men’s softball on the weekends — is an unspoken given.
“She doesn’t rub that in,” he said.
Without missing a beat, Ms. Waugh adds, “It doesn’t matter where it comes from.”
Most of the new jobs produced by America’s sprawling economy — especially since the turn of the century — are either in highly paid occupations that often require an advanced degree, or, more predominantly, in lower-paid positions providing direct services that cannot be sent overseas and, at least for now, are difficult to automate.
But even with a hollowing out of the job market and a broad stagnation in wages, an analysis by The New York Times has found, a set of occupations has emerged that holds promise as the base of a more robust middle class.
Many are in health care, which has grown sharply over the last few decades.
Economists at the Labor Department project that by 2022, as baby boomers age, health care and social assistance will absorb nearly 20 percent of consumer spending, double the share of manufactured goods. The sector is expected to support over 21 million jobs, five million more than today. This includes half a million more registered nurses.
A Rare Green Shoot
The reordering of the economic landscape can be seen all over West Virginia’s old coal country, where billboards along the highways that run through the region advertise a new cardiac center and an orthopedic clinic; and where a strip mall houses Scrubs Unlimited, a medical outfitter, its retail floor crammed with nursing uniforms in 38 colors and Peter Pan prints.
Hugging the Ohio River as it bends around the Appalachian foothills, Cabell County, which includes Huntington, has often found itself on the wrong side of economic change. The population — about 97,000 today — has shrunk 10 percent over the last three decades, as the old have died and many of the young have left.
The railroad that helps shuttle coal to Huntington, one of the nation’s busiest inland ports, is still a source of jobs. But manufacturing employment — once clustered at the long-gone glassmaking plants and furniture makers — has dwindled to fewer than 5,000 jobs. Recently, a 1920s-era nickel alloy plant laid off dozens of workers after a bankruptcy, a corporate acquisition and weak sales.
In real terms, wages in Cabell County now are lower than in the 1970s, stumbling along well below the national average. One in five residents lives in poverty.
The health care industry — which added 3,000 jobs here over the last 10 years — is one of the few green shoots in a struggling economy.
West Virginia has been battered by the same forces that have reshaped the nation since the late 1970s, when global competition, an overvalued dollar, declining unions and advanced technology began to undercut the jobs created during America’s industrial heyday, deepening income inequality. And since 2000, the share of middle-income workers has been squeezed and wages have stagnated.
Yet many of the jobs added in medical services here and across the nation have turned out to be surprisingly good ones.
That was what motivated the only male registered nurse colleague of Ms. Waugh’s on the sixth-floor cancer unit, Johnny Dial, a former highway construction worker and heavy equipment mechanic. More men are joining nursing, but they still make up only 10 percent of the ranks, compared with 4 percent in 1980.
As Mr. Dial contemplated supporting a family, it came down to health care or the railroad if he wanted job security and benefits. He chose what he thought would be a more fulfilling career, and the same one as his wife, who is also a nurse.
“You get to help people,” Mr. Dial said.
Women Stepped Up
Similar thinking was behind the career choices of Ms. Waugh’s fellow female R.N.s. They include a former waitress, a former journalist, an ex-administrator in a metals factory and a former store clerk at Bath & Body Works. In addition to the satisfaction of the work, they all said, the wages are generally better in health care than they could find in other fields.
Ms. Waugh has urged her husband to try to move up at his company, where he earns about $40,000 in regular wages, plus pay for occasional extra shifts, or to switch to a more lucrative career, maybe even in health care as a radiology technician.
But for Mr. Waugh, the only way up at the plant is to go into sales, a promotion he already turned down because he said he did not want to “deal with people.” He could earn more in the coal mines, but that work is dirty and dangerous.
Mr. Waugh has talked about trying college again; he dropped out twice in the past. At one point, his wife even filled out application papers for him to jump-start his re-enrollment, but he did not pursue class work.
“My philosophy is he is lazy,” Ms. Waugh said, standing in the hospital’s white hallway. “That’s what makes me so mad.”
For all the troubles associated with traditionally male jobs, women have not had an easy ride through the economic turmoil, either.
“The occupational structure has not somehow become more women-friendly,” said David Autor, an economist at M.I.T. who has studied the changing American job market. In fact, he added, “the hollowing out of middle-skill jobs was larger for women than for men.” The process intensified sharply during the financial crisis and the ensuing economic downturn.
But in general women have reacted much better, climbing the educational ladder to capture more of the better jobs. Today, 38 percent of women in their late 20s and early 30s have a college degree, compared with 15 percent 40 years ago. The completion rate for young men is now 7 percentage points lower than for women — back then it was 7 points higher.
This has given women an edge in the new job market: Today, almost 58 percent of registered nurses have a bachelor’s degree or more, compared with about a third in 1980.
This is true across the range of occupations capable of supporting a middle-class life. In 1980, 55 percent of workers who earned the equivalent of $40,000 to $80,000 in today’s dollars had at most a high school diploma, according to the analysis by The Times, which reviewed census returns for employed people ages 25 to 64. Only a quarter had a college degree. Today, the share of college graduates has risen to about 41 percent, while just under 31 percent have completed no more than high school.
“The days when a very, very substantial share of the work force would be able to make good middle-class incomes from jobs that did not require post-high school training are just not the case anymore,” said Francine D. Blau, an economics professor at Cornell University.
Men still hold most of the top jobs in the economy, including seven out of 10 jobs that pay over $80,000 a year. But women are rapidly moving up the ranks. Women hold 44 percent of middle-income jobs, compared with about a quarter 30 years ago.
These trends may not hold forever. Though educational attainment continues to rise for women, their progress in the workplace — in terms of both wages and jobs — has slowed significantly. Tighter controls on the cost of health care could weaken the job growth and pay raises helping support the new American middle. And while the industry is largely immune to foreign competition, it may be affected by advances in labor-saving technology.
Even as more women get ahead, many men are struggling to grab a handhold into higher-paying jobs. After her husband was laid off from a string of auto mechanic jobs, Donna Colbey, 53, urged him to switch careers and become a radiology technician.
It was a job Ms. Colbey knew would offer a good salary and require only two years of training. She had taken the same route, which eventually led her to a nursing career at a Washington hospital.
He enrolled in the courses but dropped out after a few months.
“He got tripped up over the math and didn’t go back,” said Ms. Colbey, who regularly picks up extra shifts to support her family.
A Relentless Pursuit
Far more is expected of nurses now than even two decades ago. Medical advances have kept patients alive longer, meaning many are sicker with more complex illnesses than in the past. Nurses must master technology that helps both treat and track patients, and they are called on to coordinate not just with doctors but also social workers and physical therapists.
At St. Mary’s Medical Center, Ms. Waugh, in her navy scrubs, fed potassium on a recent day into the vein of one woman with a broken hip who was on the cancer floor because of a lack of beds. She gave anti-nausea medicine to a moaning young man with liver cancer in the midst of chemotherapy and prepared pills for a half-dozen other patients, documenting it all on a computer.
An outpatient arrived for his regular blood-drawing and, squatting alongside him in a waiting room, Ms. Waugh unbuttoned his shirt and collected blood from an access port in his chest.
Ms. Waugh’s pursuit of learning to advance her career has been relentless. By her own count, she has been out of school for no longer than two years since kindergarten.
All that education has come with a cost. The couple has amassed about $50,000 in student debt. Ms. Waugh would like to send her children to a better school, but the $10,000 annual tuition that would require is out of reach. “I can’t save for their college and send them to private school,” she said.
To her husband’s co-workers who are raising families on pipe fitters’ salaries, the Waugh family is rich. Ms. Waugh’s purchase of a new Toyota S.U.V. raised eyebrows around the plant.
“We’re not wealthy,” Mr. Waugh said, “but we’re not poor.”
It hasn’t been easy getting to this point. As she made the rounds at the hospital, Ms. Waugh explained how her family was set back in 2008 after Collin was born. She stayed home for one year with the boy, who had digestive problems and required expensive formula. Living on just Mr. Waugh’s salary, they ran through their savings and they accumulated credit card debt that they are still paying off.
“That was a horrible financial situation,” Ms. Waugh said.
But later this year, when her classes and other course work are finished, Ms. Waugh will qualify as a nurse practitioner, a job that she expects will allow her to earn at least 50 percent more than her current salary. And she will be prepared, she believes, for almost anything to come.
“I knew if I was a nurse I could be self-sufficient,” she said, “and wouldn’t have to rely on anyone to take care of me.”