Changing how the world thinks about nursing

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October 7, 2004 -- Tonight's episode of NBC's "ER," written by David Zable, focuses on the transition of new ED intern Abby Lockhart from her prior role as an ED nurse, which leads to tension with the other ED nurses. The episode sheds some light on the nurse-physician relationship, with the show's veteran minor nurse characters playing unusually large roles. Unfortunately, the episode is highly physician-centric, and it reinforces the notion that hospital nurses report to physicians. Given "ER"'s proven influence on millions of viewers, we see that as a big problem.

In the episode, entitled "Damaged," Lockhart creates resentment in veteran nurse Haleh Adams by changing the rate of a dopamine infusion without consulting her, thinking that Haleh's dosing is too low, when in fact Haleh simply mixes her drips at a higher concentration than Lockhart does. Because nurses are responsible for monitoring patients' blood pressure and titrating dopamine drips to keep the pressure in a normal range, the idea is that new intern Lockhart is having trouble moving away from the nursing role. Adams notes that because of Lockhart's action the patient's blood pressure could rise quickly, which, though the show doesn't quite say so, could be deadly. This exchange underlines the importance of the nursing task involved, at least for viewers paying close attention. In any case, Adams (and soon fellow nurses Chuny Marquez and Malik McGrath) resent Lockhart's second-guessing, and may resent what the show sees as Lockhart's elevation to the rank of physician. The fundamentally decent Lockhart struggles through this conflict, and by the end of the episode appears to have reached a respectful understanding with Adams and the others.

We have no problem with the show exploring what might happen given that Lockhart has chosen to pursue graduate education in medicine--though she would be at least 50 times more likely to have done so in nursing, perhaps becoming an ED Clinical Nurse Specialist. We were also encouraged to see the show make greater use of its minor nurse characters than it has in some time, and to show at least a little more of what ED nurses actually do.

But as usual, all the patient interactions revolve around the physicians. For the most part in the episode, the nurses are there to do what the physicians ask and help them do their important work, which includes tasks that nurses generally do in real life, such as patient support, discharge planning, triage and medication administration. Marquez is part of an extended interview Lockhart has with a terrified Mexican sex slave, but as a translator, rather than conducting it herself. When Lockhart initially asks Marquez for help with this, Marquez responds that "H&P's" (histories and physicals) are a "doctor's job."

However, nurses do perform histories and physicals, though they aren't usually assigned the name "H&P," and the suggestion that physicians are entirely responsible for this is inaccurate and damaging. Nurses who fail to collect adequate histories and physically assess patients can't care effectively for their patients, because nursing is a constant cycle of nursing assessment and nursing intervention. When a translator is required, histories may be done by physicians and nurses simultaneously. Nurses are generally better positioned to conduct deeply personal interactions, and more likely to do so, bringing issues to the attention of physicians who may be unable to elicit sensitive information from patients. (By contrast, in one of the better episodes last year, the show did have major nurse character Sam Taggart conduct this kind of interview with a sexual assault victim.) But here, it was the physician (Lockhart) who did it all, then showed the initiative to (perhaps unlawfully) help the slave escape back to her family. However, a nurse would also be more likely to spearhead such holistic after-care efforts, which can require the psycho-social expertise and patient advocacy skills that nurses have.

As it has in the past, the show heightens the dramatic conflict with an unrebutted statement that plainly tells viewers that nurses report to physicians. At one point, attending physician Kerry Weaver tells Lockhart that she needs to become more efficient by "delegating" certain tasks to the medical students and the nurses. Veteran nurse Lockhart would be far more knowledgeable than the average new intern, but this still sends the unmistakable message that nurses are, like medical students, a type of sub-physician, rather than members of an autonomous profession with a unique knowledge base and skill set. Of course nurses and physicians work together, but physicians know little of many nursing tasks, such as wound care and discharge planning, and they could hardly "delegate" such tasks to nurses. On the contrary, nurses in teaching hospitals actually do significant informal teaching of interns and residents, teaching that goes unrecognized on "ER," since it does not fit the show's physician-centric vision.

The show reinforces the message that everything revolves around physicians in a climactic scene in which Lockhart is the sole physician handling a code with Haleh Adams and Malik McGrath. Overwhelmed and losing the patient, Lockhart appears to be doing everything that should be done, but in desperation asks the nurses whether they have any ideas. Adams responds knowledgeably as to what they are doing, apparently implying this is all they can reasonably do. Taggart, who has now inexplicably left her own critical patient to come stand idly watching Lockhart perform, is non-committal and seems at a loss. McGrath likewise looks at Lockhart as if only she could have any answers. Adams ultimately delivers the show's bottom line, telling Lockhart: "You're the doctor." Later, Lockhart accuses attending Luka Kovac of leaving her to flail ineffectively in the code, noting that she had to "ask the nurses" for their ideas, clearly implying that only a desperate physician would do that. Kovac tells her that the nurses "respect that openness, they respond to being treated like members of the team", and that the patient would have died regardless of what she did. In real life, good ED physicians commonly ask everyone involved in a failing code, including nurses, for ideas. But by presenting such a scene as an anomaly, the show suggests that nurses are not qualified to offer advice in such settings, and that physicians alone bear the ultimate responsibility for patients. That is all false. Sadly, it is a regular "ER" practice to present a nurse doing something that real nurses commonly do, such as defibrillation or correcting physician errors, as if it was extraordinary and could only reflect physician impairment or some other problem. Kovac's comment does not help. He is just saying that asking for nurse input is good for workplace relations, not that the nurses might actually have had something useful to say in the code.

In these respects, we found the episode well-named, at least when it comes to the nursing image. Recent research indicates that "ER" has a significant influence not only on school students and the public, but on medical students, who will now be encouraged to think that their role as interns will include "delegating" to nurses who report to them and who will rely on them to make all key decisions. It is not clear whether the show will pursue Lockhart's nurse-to-physician transition further, or simply focus on her internship from now on, and on the new crop of medical students. The training of young physicians and medical students has been a major theme of the show since its 1994 debut. We're still waiting for the show to introduce any new nursing graduates or nursing students.

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