The shortage of nurses in the U.S. is going to get worse for 3 structural, systemic reasons, according to a trusted expert.
Last night, I had a great conversation with a long-lost friend, the quasi-infamous M. Treloar, radical workplace organizer/meatpacker turned registered nurse. We talked about the nursing shortage in the U.S.
When I used to work as a paralegal and investigator in jail and prison conditions litigation, I heard a lot about this problem. It was one of the stock excuses trotted out by sheriff's departments, county boards, and state departments of corrections -- and reiterated faithfully in the local corporate press -- for why people who came into jail or prison relatively healthy wound up crazy, sick, or dead.
The county jail or state prison simply couldn't afford to hire competent nursing staff. There was a national shortage of nurses, which drove up salaries, and which also meant that competent nurses didn't have to choose to work in a crappy workplace like the Big House. Or so the authorities told us.
Let's leave aside the two big begged questions -- does government have a Constitutional obligation to pay competitive salaries in order to provide a community standard of care to persons to whom it denies liberty, and, what about nursing professionals who would choose to work in correctional or detention setting out of principle. (I've met well-paid, smart M.D.s whose goal from day one of medical school was to work in correctional medicine out of intellectual and moral conviction.)
I never doubted that the "national shortage of nurses" was a real thing (in addition to a lame excuse; the two are not contradictory). My only question was, "Why."
Why, in the wealthiest nation-state in the history of nation-states, was there a shortage of the professionals who provide basic care in homes, hospitals, and nursing homes (most folks don't care about jails and prisons)?
My homie M. Treloar gives this capsule answer.
1) Shortage of nursing professors.
As with every victory of an insurgent social movement, feminism's achievements in the health-care professions pealed back another onion layer. Thirty years ago, in the early 1970s, sexist discrimination against smart women with inclinations toward science and medicine kept them out of medical schools. They opted for nursing. They were every bit as smart as the men in medical school. They got Ph.D.s, worked as R.N.s, and frequently became the nursing professors who taught the next generation of R.N.s.
As social pressure, including litigation, forced medical schools to admit more female applicants, more of these women became M.D.s rather than nurses. The number Ph.D.-qualified nursing professors declined. Now, there aren't enough nurses teaching new nurses.
2) Shortage of nursing education programs.
We live under a capitalist economy. Health services are funded by a flawed public-private, multi-payor system. Health-care education is under-funded relative to need. There aren't enough resources dedicated to training the next generation of nurses.
3) The need is expanding.
Remember that stock pop-culture moniker for a generation, "Baby Boom"? Repeat after me: BOOM! BOOM!
Old folks are living to be truly old. They are already accostomed to a certain standard of care. They want to keep getting it, at home or in the ever-more-class-divided nursing homes. This drives costs up and drains nurses into new nursing "markets" and away from basic care; and forget about care for poor folks or folks who are locked up.
In fact, according to M. Treloar, the expanding need is too great to filled by importing nurses (and nursing can't be outsourced).
"It's like that movie A Day Without Mexicans," M. Treloar said. "For a while, I worked on a ward that was 80 percent Filipina nurses. Barely a Green Card among them. Great nurses. I mean, really competent, really skilled care providers. It was great. And I imagined, what if you took all of them out of here for a day? Every hospital in the state would close."
M. Treloar opined: "Even you emptied the entire Indian state Gujarat of its nurses, you couldn't fill the expanding need in the U.S."
Lesson: You can't import enough. You can't outsource it. You could re-direct resources from, say, endless, illegal war to creating more programs to train new nurses.
I said above that relatively healthy folks get locked up and get crazy, sick, or dead. Don't believe me? Let me give you two examples, Cedrick and Hubert.
Cedrick was relatively healthy when he was at home and taking his meds. There was always some dispute among the shrinks I talked to after I became his advocate over what his diagnosis actually was, so it's not for me to say. Everybody agreed, though, that he'd be basically okay if he just got his pills.
In jail, that means nurses either bringing the pills on time to the prisoner, or having the prisoners transported to the place in the jail where the nurses pass out the pills. I don't care how you want to do it, sheriff, it's your jail, and, anyway, the Supreme Court is clear that people like me can't monkey around with your legitimate correctional interests.
All I want is to know that when your nurses fill out a "medicaton administration record" (MAR or pill chart) saying they passed the pills, that they actually did! I don't want to talk to Cedrick and have him bouncing around the interview booth crying that he never gets his pills.
Well, Cedrick bounced around enough that the jail sent him to one of the few remaining state-funded psychiatric hospitals. They got him stabilized, because they know how to pass pills on time. In the meantime, Cedrick missed his court date and got a bench warrant. Have you ever tried to get one of those quashed? This nightmare went on for a year, and I'm not going to tell the whole story here.
Suffice to say Cedrick "bounced" between the county jail, where the nurses couldn't pass pills, to the psych hospital, where they could, and we all got very familiar with a fancy word, "decompensate."
It's a true story that the abstract villain here was the "national shortage of nurses."
Hubert, likewise, was relatively healthy in the community. He had tested positive for HIV nine years before and at the time of his arrest was compliant with a regimen that included a protease inhibitor and two "nukes" -- a drug combination called, in those days, the "cocktail." His T-cell count wasn't great, but, paradoxically, that worked to his advantage. The county funded two HIV outpatient clinics, and which one you went to depended on whether your T-cell count gave you an "official" AIDS diagnosis. Hubert ended up going to a great clinic and being treated by one of the finest doctors I've ever met.
By the time I met Hubert, he was six months into what would be a ten-month stay in pretrial detention. (How long it really takes to get to court on a felony shoplifting case is another rant for another time.) At our first interview, he disclosed that he was now refusing his meds. He'd had it dinned into his head before jail that, if he screwed up his drug regimen, the virus could develop resistance to the drugs, and his course of treatment would become dangerously limited.
He never got his drugs on time. He never got the correct ones at the correct time of day. He could never comply with the dietary instructions. He was facing threats from deputies and nurses alike over what they called his "pill strike."
Our advocacy got the nurses to fill out the MARs. Hubert went back on his meds, but always maintained that the problems persisted.
Hubert's family told me he looked 10 years older after 10 months behind bars.
During the calendar year that Hubert was locked up, that jail averaged a death a month. That was a typical year in those days. Later, a court-appointed monitor testified that this mortality rate was more than twice as high as one would expect for a facility of this type and size.
Individual people weren't to blame, we were told. Even a "system" or an "organization" (like, say a sheriff's department) wasn't to blame. The villain was a "phenomenon," namely the national shortage of nurses.
All of which basically adds up to, "Eat my shorts, you non-violenct offender with a Hepatitis C diagnosis, doing two years in state prison," and "Smoke me, you really kooky, annoying, high-maintenance weirdo with a DSM-IV-TR Axis II diagnosis, who keeps tweeking out on inmates and staff and needs to be thrown in the hole!"
"We don't have enough nurses for this crap!"
Well, thanks to M. Treloar, at least we've got an analysis. Now all we need in a way forward.
Regular readers will recognize this as a re-post from earlier this year.
Tags: Nursing shortage, public health, policy, health economics, capitalism, corrections, correctional health-care, correctional medicine, mental health, HIV, AIDS, prison litigation.
Very interesting. I used to represent nurses and nurse aids (who are also in short supply). The shortage benefited my clients, who were able to get pretty good wages -- I even had an employer ask the union if it could increase pay mid-contract, to keep nursing staff from leaving for greener pastures. M. Treloar's explanation largely confirms my own hunches.
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