By Grace Hood

They're a rare breed in an increasingly rare profession. While most nurses flock toward the monochromatic world of public hospitals and doctors' offices, correctional facility nurses interact with a slightly different clientele, one they say is highly challenging but well worth the extra effort.

Jackie Jorissen, supervisor of Health Services for the Boulder County Jail, says recent shortages at the jail have created a less-than-desirable work environment for nurses, who are already over-worked on a daily basis.

"We have recently hired some [nurses] who either left or had to be terminated because they were very inappropriate," she says. "It's exhausting for a staff to orientate people who they know aren't going to make it."

The shortage is nothing new to nurses at the Boulder County Jail. For several years, the openings have dipped as low as two, and gone as high as five for an overall group of 11. To fill the current shortage of four-and-a-half open positions, Boulder County approved a pay raise (1.5 percent). In addition, Jorissen took a creative approach to hiring, employing several licensed practical nurses (LPN), who require more supervision than registered nurses, but enable the county to increase its staff.

Having exhausted all options, Boulder County is now considering a relatively common solution to nursing shortages and rising medical costs in the jailhouse world: privitization. Boulder is one of two counties remaining in Colorado (of 64) that hasn't yet privatized medical care for county jail inmates. Nationwide, medical services for jails is a $2 billion industry. With so much momentum building in the direction of privatization, many officials are hard-pressed to reason why outsourcing wouldn't work. However, county jail nurses and labor-rights advocates contend that privatization diminishes the quality of care they tirelessly administer, in addition to muddying the waters of individual accountability.

In this changing tide, Boulder County's anti-privatization advocates are faced with an uphill battle in convincing others. Despite the myriad additional benefits an outside contractor may provide, they say that Boulder County's values inherently oppose privatization. According to these advocates, Boulder is one of the few counties that can—and should—take a higher road.

Supply and demand

Boulder County Sheriff Joe Pelle says that he headed down the path of privatization by accident. Given the liability that the shortage places on the jail, Pelle started pricing contracts so that he could have ammunition when talking to county commissioners about further increasing pay and benefits for nurses.

"When we got the proposals back, the cost differences weren't that great," he says. "It sort of causes me to scratch my head and say, 'Wait a minute, are we really being smart running our own program?'"

While Pelle won't disclose the names of the two contractors that the county is considering, he says that the two bids would cost the county about $1.6 million annually for all medical costs at the jail, as compared to the $1.3 million that the county currently pays for nurses, doctors, dental care, pharmaceuticals, ambulance services and limited patient hospital care.

"I think it will keep our costs relatively similar. What it would do is it would take away a tremendous administrative headache," says Pelle. "It would also free up a tremendous amount of staff time we spend with our personnel people trying to attract and hire nurses."

An outside vendor could bring the county's medical record keeping to the electronic age, in addition to ensuring that they abide to HIPA regulations, says Pelle. Both contractors also guarantee American Medical Association certification, he says, which gives the county an advantage should a legal dispute arise.

"We don't have the staff or time to do the certification at this point," says Pelle.

While Pelle is ready to relinquish what has been a constant headache during his three years at the jail, he readily admits that there are disadvantages to the potential transition. Considering that he's ultimately responsible for what happens at the jail, Pelle says he has some hesitancy to give up direct control. Both contractors have promised to hire an administrator who would oversee the day-to-day operations.

The biggest drawback for Pelle is the impact on existing nurses. There are a handful of nurses who have worked for the county for more than a decade. According to Pelle, both contractors have expressed interest in retaining nurses at the jail. However, the switchover would mean the loss of county benefits, including the PARA retirement benefit plan, he says.

But while he would hate to lock out Boulder County nurses, Pelle says he's exhausted all other options.

"We are competing in a market where there is a severe nursing shortage, and there are a lot of new hospitals and clinics in our area that are paying premium dollars for coverage," says Pelle. "So we're working in a tight, tight market, and we're running a jail, which is probably not as attractive to people as a nice clinic or hospital setting."

Grayson Robinson, sheriff of Arapahoe County, the second and only other county in Colorado to not have privatized jail services, agrees that it's a challenging market out there.

"It's very difficult to recruit and retain nurses, particularly when you open the want ads and you see $10,000 and $15,000 signing bonuses," he says. "That's very attractive, and that's something county government can't possibly compete with."

Robinson says that his county has partially privatized medical services, like pharmaceuticals and medical services, but hasn't fully made the transition due to costs.

"It's a subject that I monitor closely," he says. "During the first quarter of 2006 we will do another study and look at another business plan just to make sure we're not missing something."

In the meantime, Robinson's county struggles with a nursing shortage much the same way that Boulder County does. In terms of advice, Robinson says he doesn't have much hope to offer Pelle.

"Other than a sheriff from another county should never come to Boulder to recruit, it would be a little difficult for me to give anyone advice in that area," says Robinson. "I'm faced with the same exact challenges that my colleagues are."

Forming a partnership

Gina Jones, a nurse at the Boulder County Jail for the past five years, has reservations about the potential change. Jones worked at the Jefferson County Jail months before it transitioned to private care.

"I think that nurses could keep their job if they wanted, but it wouldn't mean Boulder County benefits," she says. "I've worked places before where they went to contract, and most of the nurses usually leave."

Jones says that having more of a voice at work could be an important first step toward attracting more nurses.

"Nurses feel like they want to be part of what goes on in the medical unit there. They want to bring up their ideals and be listened to and increase better communication," she says. "I think that's more important than any money issue—that the nurses feel like they're being listened to."

Jones says that she would like to see a labor-management partnership, which she believes would put nurses and management on a more equal playing field. Other county employees are joining together and asking for a voice in their work, and the nurses should be no different, she says. In order for any union to engage in a direct form of collective bargaining, county commissioners would need to pass a resolution to set terms for bargaining activity.

"I don't think outsourcing is the answer because it's not going to address the day-to-day problems that we face at the jail," she says. "It just passes the buck to other companies who aren't accountable to taxpayers, and that involves liability to taxpayers and the community at large."

Leslie Moody, president of Denver Area Labor Federation, says that privatization impacts morale of employees because they no longer directly report to counties or cities.

"Having a voice on your job is huge. It increases your performance and increases your commitment to stick with it," she says. "It's common sense. You employ somebody, they're accountable to you. You subcontract out the management of that system, and the accountability is very watered down."

Engaging nurses more directly in decision-making is the No. 1 factor in improving efficiency, saving costs and improving morale, says Moody.

"The bottom line is that it's worth taking those steps first and giving the benefit of the doubt to those folks who were providing the work before," she says.

Moody also points out the hidden costs of privatization, which most counties don't consider when they're comparing numbers, she says. When Denver International Airport privatized some systems, Moody says that lower salaries and decreased benefits resulted in employees returning to the county for social service help.

However, it seems that in the case of medical services for jails, chronic nursing shortages and a powerful trend toward privatization stack the cards against Boulder County Jail nurses.

Not true, says Moody.

"Just because it's a trend doesn't mean that's the way that government should go. Progressive governments like Boulder and Denver really should think twice," she says "And I think that the arguments back around Boulder would be that Boulder can take the high road."

Out of ideas, out of time

From Jackie Jorissen's perspective, taking the "high road" hasn't exactly panned out for the county.

"I think that Boulder County Personnel have been tireless in their efforts, but there just aren't a lot of nurses out there," she says. "And a lot of nurses you can't convince to work at the jail."

Jorissen says that she's extended many invitations for jail visits, but many nurses assume that the work will be too dangerous, she says. If they don't visit, they can't appreciate the creativity and flexibility that jail work demands, she says.

A huge source of pride for jail nurses is the ability to interface with Boulder County rehabilitation programs, says Jorissen.

"It's a therapeutic community which is very enlightened for a jail. We work well with Mental Health Center," she says. "It's a pretty superior jail system."

The biggest defeat that could come from privatizing, Jorissen says, is the loss of nurses who have invested more than 10 years at the county jail. Without the PARA retirement program, Jorissen wonders what other incentives would retain her staff.

At the same time, Jorissen looks forward to the day when she and other nurses don't have to work double-shifts to fill regular vacancies.

"The other sad thing is that you can't invest in your nurses. You can't give them continuing education, and you can't do creative scheduling if you don't have a full staff," she says. "You have to utilize every hour of their time with direct care, which is exhausting."

While they haven't scheduled a meeting to review the two proposals, Pelle and the commissioners expect to meet by the end of January. County Commissioner Will Toor says that he and his colleagues have only received informal briefings on the issue and will await Pelle's presentation before coming to any conclusions.

"I have not yet seen an analysis comparing either the costs or the level of medical care available to inmates in a privatized scenario as compared to the existing scenario, so I don't have a whole lot of information yet," says Toor. "I will certainly want to evaluate that information prior to making any decisions."

In the meantime, the current shortage presents a real Catch-22 for Jorissen.

"I think that's what this is all about: Either having someone come from the outside or having the commissioners look at ways to allow us to hire nurses," she says. "Everything that I've been able to think of, we've done. And so I don't know what else to do."

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