It's time for us to buck up

July 15, 2009 -- Today U.S. President Barack Obama gave a short speech at the White House surrounded by nursing leaders, in order to promote his health care reform policies. The event was notable not only in that it reflected Obama's continuing use of nurses (the "most trusted" workers) to promote his reform efforts, but also because the speech reflected an understanding of nursing that is unusual in a political figure at the highest level. The President's speech suggested that he understood some of the basic elements of nurses' clinical work, including patient advocacy and the teaching of new physicians, as well as the centrality of nursing care in underserved communities, in EDs and obstetrics. Even Obama's introductions of and remarks about the nurses who were present show the public that nurses can be health care leaders. Unfortunately, the speech did focus on nurses' caring, virtue, and hard work, rather than their life-saving skills, which are probably the most important aspects of nursing that the public must understand in order for us to resolve the nursing crisis. And it is not clear from the speech whether Obama believes not just that nurses are supporters and potential beneficiaries of reform, but also that a greater investment in nursing education and clinical practice is critical to the success of reform and the future of health care generally. On the whole, though, the speech sent very helpful messages about nursing, so we commend the President and others who played a role in the speech for advancing understanding of the profession.

President Obama began by introducing those present, then described his positive personal experience with nurses in caring for his family, as he has before. He argued that nurses understand the need for reform because of their clinical experiences, and that reform would actually help to relieve the nursing shortage. Here (in blue) are relevant excerpts from the speech (excluding major portions that provide detail about reform principles):

Hello, everybody. Good afternoon. I am pleased to be joined by not only some of my former colleagues and outstanding legislators, but also by nurses. And I think I've said this before -- I really like nurses. And so to have them here today on behalf of such a critical issue at a critical time is extraordinary.

Let me introduce a few of them. We've got Becky Patton, who's the President of the American Nurses Association here. Raise your hand, Becky. We have Dr. Mary Wakefield, who's a nurse and happens to be the Administrator of the Health Resources and Services Administration at HHS, our highest-ranking nurse in the administration. We've got Keisha Walker, an RN, currently a senior research nurse at Johns Hopkins University's Bloomberg School of Public Health. We have Dr. Rebecca Wiseman, nurse and assistant professor of adult health at the University of Maryland School of Nursing. And I'm also joined by Representative Johnson, Representative Capps, Representative McCarthy, Chairman George Miller, and my friend Chris Dodd.

I am very pleased to be joined today by the representatives from the American Nurses Association on behalf of 2.9 million registered nurses in America -- men and women who know as well as anyone the urgent need for health reform.

Now, as I said before, I have a longstanding bias towards nurses. When Sasha, our younger daughter, was diagnosed with a dangerous case of meningitis when she was just three months old, we were terrified. And we were appreciative of the doctors, but it was the nurses who walked us through the entire process to make sure that Sasha was okay.

When both my daughters were born, the obstetrician was one of our best friends, but we saw her for about 10 minutes in each delivery. The rest of the time what we saw were nurses who did an incredible amount of work in not only taking care of Michelle but also caring for a nervous husband and then later for a couple of fat little babies.

So I know how important nurses are, and the nation does too. Nurses aren't in health care to get rich. Last I checked, they're in it to care for all of us, from the time they bring a new life into this world to the moment they ease the pain of those who pass from it. If it weren't for nurses, many Americans in underserved and rural areas would have no access to health care at all.

And that's why it's safe to say that few understand why we have to pass reform as intimately as our nation's nurses. They see firsthand the heartbreaking costs of our health care crisis. They hear the same stories that I've heard across this country -- of treatment deferred or coverage denied by insurance companies; of insurance premiums and prescriptions that are so expensive they consume a family's entire budget; of Americans forced to use the emergency room for something as simple as a sore throat just because they can't afford to see a doctor.

And they understand that this is a problem that we can no longer defer. ... And every single day we wait to act, thousands of Americans lose their insurance, some turning to nurses in emergency rooms as their only recourse. ...

America's nurses need us to succeed, not just on behalf of the patients that they sometimes speak for. If we invest in prevention, nurses won't have to treat diseases or complications that could have been avoided. If we modernize health records, we'll streamline the paperwork that can take up more than one-third of the average nurse's day, freeing them to spend more time with their patients. If we make their jobs a little bit easier, we can attract and train the young nurses we need to make up a nursing shortage that's only getting worse. Nurses do their part every time they check another healthy patient out of the hospital. It's now time for us to do our part.

I just want to be clear: We are going to get this done. Becky and I were talking in the Oval Office. Becky just pointed out, we need to buck up people a little bit here. And that's what nurses do all the time -- they buck up patients, sometimes they buck up some young resident who doesn't quite know what they're doing. You look at Becky, you can tell she knows what she's doing. And what she's saying is it's time for us to buck up -- Congress, this administration, the entire federal government -- to be clear that we've got to get this done.

Our nurses are on board. The American people are on board. It's now up to us. I'm confident it's going to get done because we've got a great team behind us.

Many aspects of the speech send helpful messages about nursing. Consider the very presence of nurses at the event and Obama's remarks about them. Of course the nursing role serves Obama's political goals; he uses nurses' "trusted" image to promote the reform he seeks. But political leaders have pushed many health-related policy initiatives in recent decades and we cannot recall many, if any, who have placed nurses in such a prominent role, repeatedly making positive and relatively detailed statements about them.

The most visible organization representing U.S. nurses is the American Nurses Association, and it seems pretty clear that ANA president Rebecca Patton has developed a positive relationship with Obama ("You look at Becky, you can tell she knows what she's doing"). In fact, it appears that Patton gave Obama what we might consider the theme of the speech: that "we need to buck people up a little bit" about the need for reform. Obama liked that idea so much that he went on to stress that nurses know all about "bucking up," since they often do so for patients--and for "some young resident who doesn't quite know what they're doing." It's rare for a U.S. President to explicitly recognize the role of nurses in teaching resident physicians, something that some Hollywood hospital dramas have failed to recognize in hundreds of hours of programming focused on just such residents.

And consider the other introductions, which send a number of helpful messages about nurses' ability to be health care leaders. First, there is Health Resources and Services Administration head Mary Wakefield. Obama refers to her as "Dr.", yet also makes clear that she is a nurse, indeed, "our highest-ranking nurse in the administration." Similarly, he calls University of Maryland's Professor Wiseman "Dr.", but also notes that she is "nurse and assistant professor of adult health." And Keisha Walker is "a senior research nurse at Johns Hopkins University's Bloomberg School of Public Health."

What's the big deal? These introductions simply state the facts, but they place nurses in influential positions in policy-making and academia, where much of the public is not used to seeing them. When doctorally prepared RNs are introduced in the media, it is unusual for an explicit statement to be made that the person is both a PhD and a nurse. Often viewers are left to assume that the "Dr." teaching at the nursing school is a physician--a damaging idea to give the public since it undermines nursing autonomy.

Certainly no one would ever imagine that such doctorally-prepared nurses existed based on television dramas--including even the new nurse-focused dramas Nurse Jackie (Showtime), Mercy (NBC), and HawthoRNe (TNT), none of which has so far suggested to viewers that nurses can play such roles. Obama did not have to introduce the nurses in these ways; he could have just mentioned where they worked. Note also that Obama did not call any of them "former nurses," a common way of referring to nurses who are not at the bedside that implies nursing consists solely of physical care, unlike professions like medicine, which presumably require thinking. Obama also introduces the three nurses in Congress (Reps. Johnson, Capps and McCarthy); he might have noted that they were nurses, which would have even further underlined the idea that nurses can be policy leaders.

Obama also briefly discusses his personal experience with nurses. He explains that his "longstanding bias towards nurses" stems from their care for his children. When his daughter Sasha had meningitis when she was three months old, he and Michelle were "terrified," and "appreciative of the doctors, but it was the nurses who walked us through the entire process to make sure that Sasha was okay." Similarly, he notes that the couple only saw their friend the obstetrician "for about 10 minutes in each delivery." The rest of the time the Obamas saw the "nurses who did an incredible amount of work" taking care of the family. This is certainly positive, and simply making clear the central role nurses actually play in bedside care, and the amount of work they do, is much better than the standard Hollywood vision of hospital care, which often suggests that it is physicians who provide all important care. We might have wished for something a little more specific than working hard and walking the family through, which frankly might have been done by persons with little health training. Did the bedside nurses explain exactly what would happen and why? Did they demonstrate physical or psychosocial skill? In any case, from this experience Obama says he came to "know how important nurses are, and the nation does too." Well, isn't it pretty to think so? (#6) In reality, if the nation knew how important nursing was, there would be no starvation-level funding for nursing education, research and residencies, and a "nursing shortage that's only getting worse."

Obama also addresses the overall role of nurses in health care, which he argues gives nurses a special perspective on the need for reform. He rightly says that nurses bring new life into the world and ease the pain of those who are dying, and that nurses provide the only health care that many in underserved and rural areas get. And he even notes in passing that nurses "sometimes" speak for patients, presumably a nod to their patient advocacy role (it would probably be reading too much in to suggest that he is gently chastising nurses for not speaking up more to protect their patients from poor care). These are excellent points, and while we would have loved a little more detail--who are these nurses providing solo care to the underserved?--it's rare to see such recognition at this level. Obama also notes that nurses see the "heartbreaking costs" of the current health care crisis, not just in the obvious ways of hearing the stories of those without access to affordable care, but because some without access to care must turn to "nurses in emergency rooms" even for simple problems. We might add they also turn to ER nurses to address complex and deadly problems that could have been prevented or managed.

We are a little uneasy about the comment that nurses "aren't in health care to get rich." Of course, nurses' perceived altruism is part of why Obama keeps putting them front and center. We understand that such comments are meant to be a tribute to nurses, and it's also not hard to see them as a dig at physicians. Ironically, though, these comments often reinforce the idea that nursing is not so much a modern profession as it is a noble calling, which is critical to the angel-oriented imagery that has long undermined nursing. If nurses are so noble, they probably don't need as many resources as others do; all they need is our love, and a cute little teddy bear on Nurses Day!

Finally, Obama briefly explains how reform might actually help the nurses we admire so much. Nurses themselves need reform to succeed, he argues, because investing in prevention will mean nurses don't have to treat conditions that could have been avoided. And electronic recordkeeping reforms will "streamline the paperwork that can take up more than one-third of the average nurse's day, freeing them to spend more time with their patients." Making nurses' job easier, he suggests, will help to attract and train those needed to address the shortage.

There is truth in all this. The point about prevention is on target; certainly a proactive approach that focused on helping people stay healthy, rather than the reactive model that responds only after a health catastrophe, would ease nurses' work tremendously. The ER nurses he mentioned earlier are obvious examples. And nurses would certainly love to see paperwork streamlined. But we've grown tired of hearing that this will "free ... them to spend more time with their patients," not because it's wrong, but because such comments tell people nothing about the skills nurses are using when they "spend time" with patients, but instead make nursing sound very much like unskilled hand-holding. Inadequate time with patients is a major problem for primary care physicians also, but we don't often hear it described this way, and even when it is, the physicians can count on widespread understanding that when they "spend time," it involves the application of advanced skills. Nurses can't. In addition, it often seems like what underlies these comments is the idea that nursing has nothing to do with paperwork. But no serious health profession can function without some paperwork, to help the health team evaluate various aspects of patients' changing conditions and plan care effectively based on all relevant factors, tasks that can be very complex. The implication that nursing has nothing to do with records suggests, again, that the profession is all about physical labor and lifting spirits. Presumably the physicians handle all the complicated detail.

This brings us to a concern that underlies some of the comments in the speech. For all the positivity and impressive grasp of nursing, nothing here really conveys to listeners that nurses use their advanced skills to save lives. Instead, nurses are here to "care" for us, to "work hard," to "spend time," and to "buck us up." The comments that Patton "knows what she's doing" and that the nurses "walked [the Obamas] through" the care process get better, but given prevailing attitudes, not good enough. Of course, all of these nursing actions are great, but in the current climate, how many billion dollars are they worth?

In addition, while nursing would of course be helped by health financing reform, the profession is actually central to making reform work (and is itself in need of a great deal of reform). Real long-term change will require a significant direct investment in nursing education, research, and clinical practice (the kind physicians now receive), not just better record-keeping and expanded insurance coverage. And investing in prevention means, to a great extent, investing in nursing, since prevention has always been a critical aspect of nursing, with its holistic practice model. Nurse practitioners are central to a preventative future, and it is they who provide much of the care to the underserved populations that Obama mentions. Based on other comments, we believe Obama probably understands much of this--he knows what a nurse:patient staffing ratio is, and he reportedly endorsed mandatory minimum ratios during the 2008 campaign--but it's not here.

Of course, we're holding Obama to a high standard, because of his obvious grasp of and interest in complex policy issues, and because of the power of the Presidency to shape public understanding. On the whole, his comments are unusually helpful to nursing, and we thank him and the others who played a role in the speech.

See the full transcript of the speech. Or see President Obama's speech on YouTube. You can write to the President here. If you do write, please send us a copy of your letter at letters@truthaboutnursing.org. Thank you!