Problem: One key way to improve the health care system is to transform the workforce so that it allows for more interdisciplinary and team-based patient care and enables nurses to practice to the full extent of their training. But the path from fragmented care to a system in which all professionals are free and able to work together as full partners is murky.
Background: Formerly chief of staff to then-Senate Majority Leader Bob Dole of Kansas, Sheila Burke is widely known for the powerful voice she had, and continues to have, in national debates over health care and other weighty policy matters. Less well known is the fact that Burke—once considered “the most powerful woman on Capitol Hill”—started out her illustrious career as a registered nurse. Burke’s experience at the bedside gave her deep insights into the implications of changes to health care policy as she climbed to the top of the Capitol Hill power structure and beyond.
One of the first lessons Burke, R.N., M.P.A., F.A.A.N., learned as a nurse is now, four decades later, at the forefront of her mind in her new role as chair of a blue ribbon panel. The panel is guiding a massive, multifaceted campaign funded by the Robert Wood Johnson Foundation (RWJF) to transform the nursing profession to better meet the nation’s health care needs at a time of significant demographic and health system changes.
The lesson she learned was a simple one: Collaboration among all members of a health care team is critical for quality patient care. At times as a clinical nurse in Berkeley, Calif., in the 1970s, Burke saw firsthand the benefit to patients of full participation of nurses and of mutual respect and good communication among all health professionals.
“From the earliest days, there was this clear indication to me of the importance of working with your colleagues,” she recalled in a recent interview. “We serve the patient best when we share information and help the patient navigate through the system. It requires a keen appreciation of what folks do and what they are best at doing.”
Burke carried this lesson across the country when she joined the National Student Nurses Association in New York in 1974 and then to the nation’s capital a few years later when she joined Dole’s congressional staff and managed health policy legislation.
Soon after, Burke accepted an offer to serve as one of Dole’s aides on the powerful Senate Finance Committee, a panel that has jurisdiction over mammoth government health programs under the Social Security Act, including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and Temporary Assistance to Needy Families (TANF). Nine years later, Dole—a Republican who eventually rose to lead the Senate and earn his party’s presidential nomination—asked her to serve as his chief of staff. That job put her at the heart of negotiations over monumental battles over health care, welfare and numerous other policy issues.
Throughout her legislative journey, nurses and nursing have been at the forefront of her mind. As evidence, she points to more obscure victories she had a hand in during her career such as legislation that supported expanded access to home health services and rural health clinics—both of which are largely staffed by nurses and bills addressing hospice care and nurse anesthetists.
“The work I have done over the years has certainly been influenced by my knowledge of nursing practice,” she said. “That helped me appreciate and understand the contributions that nursing can make.”
Burke left the Senate in 1996, when Dole retired to run against President Clinton, and became the executive dean and a lecturer in public policy at the John F. Kennedy School of Government at Harvard and an adjunct faculty member of the Georgetown University Public Policy Institute. She has also served on National Advisory Committees of programs funded by RWJF to improve health and health care in America.
Solution: While continuing in her roles at two of the nation’s most prestigious universities, Burke is now sharpening her focus on nurses and nursing as head of the strategic advisory committee of the Future of Nursing: Campaign for Action, an effort designed to implement recommendations of a groundbreaking report on the future of nursing that was released by the Institute of Medicine (IOM) last year.
Called The Future of Nursing: Leading Change, Advancing Health, the report says that nurses’ roles, responsibilities and education should change significantly to meet the increased demand for care that will be created by health reform and to advance improvements in America’s increasingly complex health system.
One of the report’s key recommendations reflects the lesson she learned long ago as a rookie R.N. “The focus of the report is that the health care delivery system is not what we would want it to be,” she said. “It doesn’t fully acknowledge the value of nursing…Our goal is to make sure that nurses have the opportunity to fully participate.”
Limitations are evident in laws that restrict nurses from performing to the full extent of their training and education; reimbursement methods that favor physicians over nurses; a cultural bias toward institution-based care as opposed to community-based care, where nurses play a large role; a relatively weak emphasis on preventive care, which is often led by nurses; and a historic societal bias that views nurses as subordinate to other health professionals, Burke said.
As chair of the strategic advisory committee, which comprises 11 other health care luminaries with expertise in public policy, social justice, business and science, Burke plans to cultivate the many relationships she has built over decades of public service and to develop strategies that can be utilized at all levels of government to move the agenda forward.
The panel met for the first time in January and is urging the campaign to pursue the “widest possible outreach” among many sectors of society and to implement a state-by-state strategy because obstacles to the report’s recommendations differ by state, she said.
The barriers to success are high and range from nurse practice laws that vary by state, to the absence of financing at a time of fiscal austerity, to resistance from some professional groups, she said.
But Burke remains confident she and her allies will prevail and sees encouraging signs in efforts already under way to reform the nation’s health care system. The new health reform law, for example, shined a light on the need for more community-based care, the value of interprofessional collaboration, and the need for more nurses to curb a looming shortage of health providers—all points made by the IOM report.
“The time has come when there ought to be efforts made to fully incorporate nursing to the fullest extent possible,” she said. “Nurses ought to take a much higher profile role, and we are prepared to do so.”
Burke, in fact, has demonstrated this herself with a conscious effort to identify herself as a nurse leader. “In some cases,” she says, “it’s as simple as identifying as a nurse, which I always do and always have. There are lots of ways nurses can advance the cause of nursing.”
RWJF Perspective: The Robert Wood Johnson Foundation is a strong champion of efforts to transform the nursing profession to improve health and health care. The Foundation supported a study committee that reviewed scientific literature on the nursing profession and held a series of public forums about challenges to nursing. The product was the IOM report on the future of nursing, and the Foundation is backing the campaign to implement its recommendations.