On rural nursing (and rural exceptionalism)

One of the five most emailed stories on the Washington Post website yesterday was this one about a state senator in Washington state (Maureen Walsh-R), who had said a few days earlier, in legislative debate, that nurses "probably play cards" at work.  That the part of the quote that made it into the WaPo headline, anyway.   Here's the lede for Allyson Chiu's story:

A Washington state senator apologized on Monday after drawing nationwide backlash for saying nurses in smaller hospitals “probably play cards for a considerable amount of the day” during their shifts.

State Sen. Maureen Walsh (R) made the comment last week while debating a bill that would give nurses uninterrupted meals and breaks at work and protect them from mandatory overtime. Walsh was arguing that hospitals in rural communities should be excluded from the measure because the requirements would place too much strain on those facilities.

Needless to say, I'm picking up on the story here because it is, in many ways, a rural story.  Walsh was taking up an issue sometimes taken up by legislatures, both state and federal:  should exceptions be made, as in the context of employment regulation, for small and/or rural institutions because they are under greater resource constraints?  (a related question is whether exceptions should be made for rural folks who have difficulty meeting work requirements for public benefits, something debated here and here).  We might call this rural exceptionalism, and one of most common settings in which it occurs is the exemption of agricultural enterprises from various employment protections, including child labor (read posts here and here). 

Another thing that is rural is the correlation between so-called "critical access hospitals" and rural.  When she put her foot in her mouth, Walsh was speaking about a particular subset of hospitals that have fewer than 25 beds.  Here's more from WaPo, including direct quotes from Walsh who, being from a rural area 200 miles from Olympia and served by a critical access hospital, might be more "understanding" of the challenges these hospitals face:

Walsh’s trouble began when the Senate convened last week to debate the bill and started with a discussion of an amendment that would exempt “critical access” hospitals, which usually have 25 beds or fewer in rural areas with small populations.

Regarding the bill, Walsh said: 

I understand helping with employees and making sure that we have rest breaks and things like that, but I also understand that we need to care for patients first and foremost.  I’m in an underserved area and all we’re doing is making it more difficult to be served. 

By putting these types of mandates on a critical access hospital that literally serves a handful of individuals, I would submit to you that those nurses probably do get breaks. They probably play cards for a considerable amount of the day.

Walsh concluded that these hospitals may not be able to survive if they have to comply with the bill. Walsh's statement triggered a national backlash on social media, but little if any of it (at least not what was featured in the Washington Post) acknowledged rural difference, purported or real.  Walsh subsequently apologized and explained: 

Again, I was simply trying to differentiate between the staffing needs of the small rural critical access hospitals with a handful of patients, versus the large urban hospitals with hundreds and hundreds of patients,” she said. “I have the greatest respect for nurses, for their hard work, tremendous compassion, and the excellent care they gave me when I ended up in the hospital last year.

Regarding her effort at rural exceptionalism, the Washington Post wrote:   

Walsh continued to justify her stance on why “small-town hospitals” should be exempt from the bill altogether, explaining that a number of critical access hospitals in the state “are already operating in the red,” and the legislation “will make them redder.”