Changing how the world thinks about nursing

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Sweet Little Lies

A lie is the worst thing in the world. Art is the ability to tell the truth, especially about oneself.

                                                                           -- Richard Pryor

January 22, 2006 - Tonight's episode of ABC's "Grey's Anatomy" included a surprising (if minor) subplot in which nurse characters complained about short-staffing, began a sick-out, and even threatened to strike--which will actually occur in the Jan. 29 episode. In the Jan. 22 episode, the nurses try desperately to cope, while the hospital ignores their concerns. We haven't seen these issues addressed in any significant way on a U.S. prime time show since a January 2002 episode of Lifetime's "Strong Medicine." We give "Grey's Anatomy" credit for trying. But we also note that: (1) in this episode, the nurses' jobs seemed to consist of managing hospital room occupancies and paperwork, with no hint that they play any important role in direct care; (2) the show's 10 physician stars continued to provide all significant care, including much that nurses do in real life; (3) the episode wrongly told its 21.3 million U.S. viewers that the disgruntled nurses report to the chief of surgery, and nurse managers remained nonexistent; and (4) the episode continued the show's association of the few, unpleasant nurses who do occasionally appear with problems (bureaucracy, infidelity, STDs, failure, strikes, and so on). The show seems to be saying that the nurses are bitter serfs, but if physicians ignore or abuse them enough, they will strike back. The well-named episode, "Tell Me Sweet Little Lies," was written by Joan Rater and Tony Phelan.

In one scene, on a hospital unit, earnest intern George hears an older patient, Sophie, call for assistance. George glances at an older nurse nearby, a sour character we remember from the show's November 6 episode. (In that one, the nurse punished intern Cristina for suggesting nursing was all about bedpan-type tasks--by paging Cristina to help her do gross bedpan-type tasks.) Now this nurse, who is named Debbie but is not named in this episode, tells George that patient Sophie "had hip replacement surgery a month ago and was discharged last week." George asks, mildly enough, why the patient is still there. Debbie: "Because I am not a bouncer and this is not a nightclub. I am doing what I can with extremely limited staff and resources, and if you have a problem with that, take it up with the chief." She delivers these last words to the approaching chief of surgery, Richard Webber. Pretty clearly, this means he is in charge of nurse staffing. The chief ignores what Debbie has said, and tells George to get rid of the patient.

Later, we see the chief walking down the hall with his older assistant. This assistant is reading aloud, apparently from a note written by a nurse, perhaps Debbie: "The surgical floor has become a dumping ground for patients who aren't even surgical. We are overworked and exhausted. This makes for a--"The chief breaks in: "The nurses again? Can't you do something about this? You used to be one of 'em. Don't you speak nurse?" The assistant, who is no pushover herself, calmly notes: "That's why you don't get any respect from the nurses. Surgical arrogance." The chief denies that, but she says: "You're killing them with that workload. Look at the [OR] board." The chief examines the board and pronounces it "beautiful." But the assistant has the last words: "It's a crowded board. We need more nurses."

Still later, we see intern Alex looking for a Japanese patient who has seriously injured her esophagus through competitive eating. Not finding the patient, Alex calls rudely to a nameless nurse: "Hey, the translator's here. Where's the patient? Miyazaki." The nurse notes that she "left with her friend about 20 minutes ago." This is bad because her "friend," actually her coach, does not believe the physicians' assessment that his star food athlete could exacerbate her injury if she engages in further competition. Clearly, physician Alex knows the patients far better than some anonymous nurse, who is hauling some papers and looking harassed. When Alex tells the nurse that the patient was not discharged, she responds: "Sorry, we're short staffed. I assumed someone else had done the paperwork."

Finally, near the end of the episode, the chief is operating on a patient, along with a full OR crew. Debbie appears outside and knocks on the OR door window. She is holding a formal looking one-page document, which she holds up to the window--somewhat idiotically, since the chief is pretty far away and in the middle of a complex surgery. The chief looks at the paper, and turns back to the operation. Debbie comes into the OR, at least holding a mask over her mouth. She tells the chief: " I tried, but you wouldn't listen. It's now 6:07, the second shift nurses start at 6:00. They're not coming in." The chief: "Do you have any idea what a sick-out would do to this hospital?" Debbie says she has "already put in the call for temps," and she puts down the document. She tells him it's "[o]fficial notification. We go on strike in 10 days." As a kind of jokey coda to this, the chief later sees his two star attendings outside the OR, and tells them: "You are all a bunch of arrogant surgeons."

Let's start with what's positive. Obviously, in the midst of a devastating shortage driven by short-staffing, we have to applaud the idea of a short-staffing plotline in one of the hottest shows on U.S. television. The minor plotline really consumes only a few minutes of screen time at most. But it does show nurses struggling to cope with unreasonable demands on their time, including a hospital administration that does not take them seriously, at least until they stage the sick-out. At that point, the chief suddenly seems to realize that a lack of nurses could be a problem. Debbie and the chief's assistant are nursing advocates making apparently well-grounded points about short-staffing and physician "arrogance." Of course, Debbie is not exactly someone you'd want to hang with, and the word "battleaxe" does spring to mind. But her concerns are effectively endorsed by the more positive and reasonable assistant. Moreover, Debbie is not torturing patients, but acting assertively to protect nurses' interests, which (though it's not clear how well the show understands it) are actually vital to patients' wellbeing.

Unfortunately the bad still far outweighs the good. In this episode, all we see the nurses do is push papers and snap at physicians. They seem to be in charge of managing certain facilities, but as usual, they have no significant role in patient care. To pick up the slack, the physician characters do lots of nursing, including all patient monitoring, all important procedures, and all patient interactions (Debbie does have a brief argument with Sophie's daughter about why Sophie has not left the hospital yet).

The episode also clearly tells its tens of millions of viewers that the nurses report to the chief of surgery. In fact, real hospital nurses are managed by other nurses in a chain of command reaching up to hospital leadership. Nurses manage nurses, physicians manage physicians. To our knowledge, this simple point has eluded almost every prime time show episode Hollywood has produced in the last decade, the notable exceptions being a very few of the hundreds of "ER"s. This basic inaccuracy is a devastating one for an autonomous profession in the midst of a huge global shortage. Nursing is a very challenging job, and it's not surprising that many people would not want to take it on if they thought it amounted to being a physician handmaiden. Here, as in so many other shows--including the "Strong Medicine" episode noted above--there are no nurse executives or managers.

Moreover, while we are not complaining that the episode highlights a key problem for nursing, we do wish that nursing would have some role on the show besides as an all-purpose dramatic "Other" to be set up in opposition to the show's physician heroes. Nurses have never been presented here as colleagues working together with physicians (to say nothing of on their own) to achieve important patient outcomes. They are always working against the physicians, demanding to know what they should do, demanding breaks, demanding compliance with procedure, trying to dump unpleasant tasks on the interns, gloating over intern misfortune, helping the interns cheat on each other by providing cheap sex, giving the interns STDs, being bogeymen for what the interns will become if they fail medical boards, being objects of general derision among the interns, symbolizing the grotesque and menial aspects of health care, or the bitter legacy of workplace obsession. In other words, they are plot devices, and not good ones.

We saw a few other inadequacies in the short-staffing plotline. Though viewers get that there are not enough nurses, we never hear why that might be, and why it has in fact occurred in so many real clinical settings. Perhaps the next episode will make this clear. We hope it will at least suggest that this is not an isolated problem, as many U.S. hospitals reduced their nursing staffs in the 1990's because of perceived budget constraints, and an apparent lack of understanding of the critical things nurses do to improve patient outcomes. Indeed, despite the chief's reference to what a sick-out "would do" to the hospital, the episode never actually makes that clear--will patient care be directly affected? Or will it be more a case of paperwork backup and a lack of grunts to do menial tasks so the physicians can save lives? On a more minor note, the chief's remark that his assistant "used to" be a nurse suggests that you stop being a nurse the moment you take a different role in health care. But we doubt the show would have said the same about a physician; even physicians who leave health care entirely are not usually deemed former physicians. The fact that this person left the bedside to be the chief's assistant might also suggest that the show views that as an upward career trajectory, though we suppose it could also indicate that she had had enough of current bedside working conditions.

On balance, this minor plotline makes a remarkable effort, within the show's many constraints, to suggest to its audience that there is a problem for nursing, at least at this hospital. But the show's overall vision of nursing, including what we see in this episode, is so negative and so inaccurate that the net result is unlikely to be positive.

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