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Nursing: Low pay, high turnover
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Beth Heath’s biggest frustration as Madison County nurse manager is when she can’t help someone, when she has to turn someone away.
“There are patients that leave [the health department], and we worry about them because we don’t know what they’re going to do,” said Heath.
As Georgia’s public health resources shrink, so does the list of conditions the health departments can treat. Since Heath has been with the health department, ear infections, pink eye, sinusitis, and sore throat have dropped from the list. The Northeast health district used to have a nurse that provided acute care, but she was laid off.
While Georgia’s population has grown by an estimated 1.5 million since 2002, the public health nursing workforce is nearly 22 percent smaller. In 2002, the state had 1,817 filled public health nursing positions; today there are 1,423, according to Meshell McCloud, assistant chief nurse for the Georgia Department of Community Health, Division of Public Health Office of Nursing.
The state has also lost scores of other public health professionals, all a result of layoffs and high turnover due to the state’s severely low salaries.
With annual salaries at around $20,000 below market, fewer nurses are taking and keeping jobs in public health. The starting pay for a public health staff nurse in Georgia is $36,753, while Georgia’s market starting rate is upwards of $61,200.
Nurses and other specialists who’ve stuck with public health take on the duties of those who’ve left, and many also work second jobs so they can afford the first.
“It’s very worrisome to know that many personnel are working two jobs to make ends meet or they’re either getting food stamps or they’re borderline food stamp candidates. We worry about their ability to stay well and concentrate,” said Carole Jakeway, RN, director of field operations and chief nurse of the Office of Nursing for the Georgia Department of Community Health, Division of Public Health. The impact of health departments short-staffed with overworked employees is significantly more serious than sore throats.  
Many public health graduates begin their careers in state or local public health settings, gain valuable experience, and leave for higher salaries after a couple of years, said Phillip Williams, Ph.D, dean of the University of Georgia College of Public Health.
When nurses leave for higher paying jobs, the state faces the challenge of recruiting new ones. “We can’t talk about retention until we get that person through the door, but the salaries are so low we can’t even get them through the door,” said M. Rony Francois, MD, state health officer and director of the Georgia Department of Community Health, Division of Public Health. Faced with the impending retirement of the baby boomers, the Office of Field Operations has launched a recruiting initiative that will involve, if approved, raising salaries for entry-level nurses as well as five other public health disciplines.
A below-market salary explains why it took more than a year to fill a nurse practitioner position in Lowndes County, said Lynne Feldman, MD, director of the South District that serves Valdosta and the surrounding area. “And I don’t know if she’s going to stay,” Feldman said. “You can make a lot more money than the state can pay.” This type of turnover further slows the delivery of care as it takes 12 to 15 months to train a public health nurse. 
In Clayton County, four nursing positions have been open for more than a year because the district has not had the money to fill them, said Alpha Bryan, M.D., district director. In the Rome-based Northwest Health District, nine positions, including three nursing positions, are open and need to be filled. Still the district has 51 other vacant positions, of 395 total positions in the district, and no budget to fill them.
Public health is not only nurses in free clinics. “Public health is as much for people who have nice jobs with wonderful benefits as it is for people who live in public housing,” said Williams. 
“We take for granted that we can drink from any water fountain, order off of any menu. Seatbelts, no smoking in restaurants, that’s all public health,” Williams said.
Environmental health professionals who inspect restaurants and drinking water, among a host of other duties, are also in short supply. In Fiscal Year 2008, there were a total of 493 environmental health specialist positions statewide. By Fiscal Year 2010, 46 of those positions had been eliminated and another 43 positions were vacant –a 20 percent total decrease in manpower, according to the environmental health branch of the Georgia Division of Public Health.
Recruiting and training one new environmental health inspector costs about $44,000, which is another barrier to filling these vacancies, according to Chris Rustin, deputy director of the state Environmental Health Office. As a result, “We are forced to focus on quantity versus quality of inspections as we are mandated to inspect facilities a certain number of times per year,” Rustin said.
Environmental health, due to a shrinking workforce, has been reduced to restaurant, hotel, pool and septic inspections, according to C. Todd Jones, Chatham County environmental health director. In some counties, Jones said, specialists can no longer assist homeowners with well testing, septic evaluation, food service training, or pest control. In some parts of the state, surveillance for West Nile virus and investigation of hazardous molds have been abandoned. 
The fact that some districts have only one environmental health specialist for multiple counties weakens emergency preparedness.
“A sufficient workforce is critical to the ability to prevent or mitigate the spread of disease, mobilize a response to any disaster and to ensure the health needs of the community are met during these events,” said Annette L. Neu, R.N., director of emergency preparedness and response for the Coastal Health District. 

Collins is a writer for the Georgia Public Health Network.
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