Changing how the world thinks about nursing

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The young quarterback

January 18, 2005 -- Tonight's episode of NBC's "Scrubs," written by Mark Stegemann, presents nurses as wide-eyed subordinates whose job during codes is to call out a vital sign or two, then wait for heroic, all-knowing physicians to issue commands and save the day. The episode, directed by Ken Whittingham, is entitled "My Ocardial Infarction." It could have been worse; the nurses are shown to have some knowledge and some role in codes. On balance, it's not much of an improvement for "Scrubs," which has virtually ignored nursing this year, though it may be a step up for Stegemann, whose horrific 2003 episode "My Fifteen Seconds" purported to teach nurses that nursing was all about shutting up and following physician orders.

The main plotline of tonight's episode involves the delicate practice interaction between co-chief residents J.D. and Elliott, whose relations have bounced back and forth between competition and support (and friendship and romance) since the show's beginning. This episode presents Elliott as the master of running a "train wreck code," a task at which J.D. clearly struggles. However, J.D. prides himself on his skills as a diagnostician in less emergent cases--until Elliott shows him up in that respect as well. J.D. eventually accepts some good advice from Elliott--that during intense codes he should simply take a breath, remain calm, and he will find that everything slows down--and by the end of the episode he is running a code with more confidence.

The problems are in the depiction of the two codes. During the first code, recurring minor character Nurse Roberts appears to inform J.D. that a patient is "coding." Elliott happens to be there also, but J.D. apparently has responsibility. After the physicians rush to the bedside, two more nurses pop up out of nowhere, each to announce a different discrete aspect of the patient's condition that underlines the emergent nature of the case. Then all three nurses do nothing but stare expectantly at J.D., as if they could not possibly think of anything to do without direction from the omniscient physician. J.D. is lost, and Elliott tells J.D. "I've got your back" and takes command, issuing a flurry of orders, to which the nurses then jump. (We see her from J.D.'s perspective, as a kind of Hindu goddess, with six arms to perform multiple tasks--an interesting vision of Hollywood medicine, where it must be physician characters' many limbs that enable them to do so many of the critical things that nurses do in real life.) Here the problem may in part be the direction and the acting; the nurses' lines aren't absurdly inappropriate, but they are delivered in such a stilted way, and the actresses stand around so expectantly, that you would never know they had anything to do but await orders. Had the actresses been directed to do something, it might have been less of a problem.

And the later code is somewhat better in that respect. In this one, J.D. is already with the patient. As he flatlines, J.D. is quickly surrounded by a huge number of nurses, probably more than we've ever seen on the show before (and no physicians, presumably to isolate J.D. as the lone hero). The nurses rush around doing things for the patient--at first without any apparent direction from J.D. But as the scene unfolds in one of J.D.'s usual quasi-dream states, he takes Elliott's advice and everything does slow down for him. He breaks out of his reveries and issues the expected physician commands, and the nurses scurry to comply, as he begins chest compressions. During this scene, we hear "All Kinds of Time," a 2003 song by gifted alt-rock band Fountains of Wayne. The song is about a "young quarterback" who steps back to pass as his team confronts a desperate situation, but who then seems to enter a kind of grace state--a "strange inner peace"--as he thinks of his family and fiancee and finds that he's got "all kinds of time"--"[t]he whole world is his tonight." The song plays over the entire scene and those that follow, so we hear virtually all of the lyrics. (See the video in broadband or hear a clip of the song).

Obviously, J.D. is the "young quarterback," the emerging star who finds a way to cope with the extraordinary pressure he's under and comes through, doubtless earning adulation from the adoring multitudes. The nurses seem to be other members of the team, who wait for their leader's commands and run off to execute his plays. This is hardly a novel view of physicians; in fact, it's better than some. On "Scrubs" and other Hollywood shows, nurses are seldom more than cheerleaders. Here, at least nurses are on the team, and they do work hard and display some technical knowledge; at least they don't haul out pom-poms. But it is obviously not an accurate vision of what nurses really do during codes, which involves significant autonomy and expertise. Nurses do expect physicians to do their jobs, but they are not unable to function without physician direction. In real life, a young physician who hesitates is likely to be met with specific, knowledgeable advice from experienced nurses, even though the nurses will be busy with their own work. In many cases, it is nurses who "have the physicians' back." But that is almost never shown in the mass media.

In another scene, the show's major nurse character, Carla, seems to be having a meeting with "her nurses" (we were not aware that she had any formal position of authority, such as being a nurse manager, but whatever). She tells them she sees a problem: they are not getting to know their patients, not asking "why" a physician has ordered Haldol, whether a patient is prone to sundowning, or to psychotic breaks that may call for restraints (here the camera cuts to a nurse with a bruised face). Nurse Roberts says they're too swamped for that; Carla says if they "care about" their patients they'll go the extra mile. This is an odd scene, because it never quite establishes why--to use its own word--the nurses should get to know the patients. We'd like to think it's because that is part of the nursing process, and no nurse should carry out a care plan without considering why it is being done, or evaluating its likely effect on the patient. Effective nursing results in measurably better patient outcomes, including saved lives. We'd like to think the show is saying many nurses today are too "swamped" to do the most critical things needed to save and improve patient lives because of the shortage. But we fear the show, and most of its viewers, will simply see this as part of the well-known nursing imperative to let patients know nurses "care about" them. Though emotional support is important, without explanation or much understanding on the part of the audience, this "care about" theme fits too easily into the standard nurse-as-handholding-angel script.

On balance, the episode presents an inadequate and in some ways inaccurate vision of nursing to the show's millions of viewers around the world. This kind of depiction must improve, because in light of the global crisis in the profession, nurses--and their patients--don't have all kinds of time.