My Life As a Dog
Bad Nurse, No Donut!
November 4, 2004 -- Tonight's episode of NBC's "ER," physician Lisa Zwerling's "An Intern's Guide to the Galaxy," was in most respects a standard one. It focused on the training of new physicians, showing physicians doing tasks that nurses do in real life, and suggesting that nurses are peripheral to important ED care. But one thing really caught our attention: the episode's lighthearted but repeated suggestion that an intern might purchase more responsive work from nurses by periodically feeding them sweets, as if nurses worked for physicians and their patient care was akin to the tricks a dog might perform for treats. The silliness of this plotline is matched only by its contempt for nursing. Woof! Woof!
The episode followed one difficult ED shift for three new interns: Abby Lockhart, Neela Rasgotra, and Ray Barnett. Resident Greg Pratt sets these three up in a competition to see who can clear the most patients, with 25 as the goal for each. Pratt spends the shift tracking the interns' progress on a white board, as the interns themselves struggle and clash. The clear speed winner is the competitive Barnett, who works quickly and delegates to medical students but also cuts corners. At the end of the shift, as we see that all three have more or less met Pratt's goal of 25 patients, the show offers one of its classic pats on the head to the nurses whose work it has mostly ignored. As the shift is changing, we see that nurse character Sam Taggart has scrawled on the bottom of Pratt's white board "Sam 75," meaning that while the three interns have strained to clear 25 patients each, she has done all 75. This is almost brilliant. On the surface a subtle compliment to nurses, the message in fact reinforces the show's overall misportrayal of ED nurses as being far less numerous than ED physicians, a portrayal that is constantly reinforced by its 10:1 major character ratio. On "ER," nurses are so peripheral to important care that they can do their little handmaiden thing for three times as many patients. As has generally been the case in the 228 previous episodes of "ER," what we have mostly seen the nurses do in this episode is tell physicians vital signs, hand physicians instruments, ask for physician help, and take physician orders. It's quite credible that a nurse could do those tasks for three times as many patients as a physician. But back in the real world, level one trauma centers generally have a nurse-physician ratio of about 1:1, and of course, most other hospital units have far more nurses. The reason is that nursing care is complex, largely self-directed, and central to patient survival.
But the most striking part of the episode for nurses is Barnett's practice of buying better and more responsive treatment from the ED nurses by periodically giving them donuts and other treats. This is not an isolated vignette, but a theme repeated throughout the episode, and one remarked upon by the other characters, especially Lockhart, who is also a nurse and who marvels at its effectiveness. The show does not spoil the fun by having any character suggest, even lightly, that nurses have an independent responsibility to their patients, and that they would not or should not streamline care for a patient because an intern has handed them a 50-cent pastry. Of course, ED staff--typically nurses or attending physicians--do sometimes bring food to share with other staff. But we are not aware of an intern specifically directing it at nurses in order to get better treatment. This is a small, silly plot device, but in our view it reveals contempt for nurses. Hospital nurses are autonomous professionals with independent legal and ethical obligations to their patients. They do not work for physicians. They do not provide better care based on doggie treats. And they can afford to buy their own sweets. Can anyone imagine "ER" suggesting that a physician would collaborative more effectively with colleagues or provide better care because someone regularly gave her donuts?
The plot device also cleverly implies that interns actually give food to nurses, rather than taking it away. This is Orwellian in its up-is-down black-is-whiteness. Many nurses have complained that physicians, especially interns and residents, have an unfortunate tendency to steal nurses' food from the staff refrigerator. John McPherson's "Close To Home" cartoon to the right captures a more realistic relationship among nurses, physicians and food.
Nurses do wish to relate to physicians in a collaborative and collegial manner. Research shows that better nurse-physician relationships lead to improved nurse satistfaction and retention. But better relationships flow not from physicians buying nurses pastries, but from work environments in which nurses are treated with respect as full-fledged members of the health care team. See American Journal of Nursing editor-in-chief Diana Mason's inspiring
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