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Everything about the hospital

Hawthorne, Bobbie, KellyJune 2011 -- Later this month, TNT's drama HawthoRNe returns for a third season. Last season, which aired in summer 2010, featured more heroics by super-nurse executive Christina Hawthorne and her skilled nursing team, who fight through inept fellow nurses, resistant physicians, and resource shortages to provide good care. After Hawthorne's old hospital in Richmond (Virginia) closed, she and her nurses ended up at a marginal nearby hospital. But Hawthorne remained a strong nurse leader, an advocate for patients and nurses, and an expert direct care nurse. The show was relatively good on nursing autonomy, at least in scenes involving Hawthorne; it showed a nursing chain of command, with the formidable Hawthorne presented basically as a peer of the chief of medicine, both reporting to the hospital CEO. Over the course of last season, Hawthorne got life-saving transplants for addicts and death-row inmates, and she often had time to step in and provide critical bedside care herself. Hawthorne's staff nurses are also patient advocates, and they excelled in psychosocial and technical care. The young pediatric nurse Kelly Epson was especially impressive, caring for patients ranging from a boy with serious burns to a teen with priapism whose adoptive mother was reluctant to reveal his biracial status. Some nurses were better than others, like the physician characters on other Hollywood shows. Hawthorne's "co-director of nursing" was mostly a bitter, can't-do bureaucrat, though she eventually revealed a better side. And some of Kelly's nurse colleagues in peds were lazy and unskilled, with no regard for patients; with them the show may have gone more negative than any current show about physicians. Sadly, the show has never been great on men in nursing or on the wannabe physician stereotype. Staff nurse Ray Stein is not a horrible nurse, but last season he was fairly weak and he still dreamed of medical school, though he failed the MCATs the first time, reinforcing the stereotype of male nurses as men who are not smart enough to be physicians. Still, HawthoRNe continued to tell millions of viewers helpful things about nursing skill and how nurses affect patient outcomes. We thank those responsible.

A peds nurse screwing up the OR schedule

Throwing a flag on the play

Skyping Commando Barbie

Who would keep all of you in check? 
 

A peds nurse screwing up the OR schedule

KellyThe June 22, 2010, season premiere, writer Glen Mazzara's "No Excuses," shows how Hawthorne and her team end up at their new hospital. The episode's focus on the shifting nursing hierarchy there is a rare Hollywood look at the actual authority structure of hospital nurses, though the episode is not entirely free of suggestions that nurses report to physicians. The episode also displays some skilled nursing care, particularly a life-saving drug interaction catch by Kelly (right), and it draws a distinction between Kelly's skill and commitment and the incompetence of some colleagues.

At the beginning of the episode, John Morrissey (below right), the CEO of Richmond Trinity Hospital, meets with chief nursing officer Hawthorne and her counterpart and love interest Tom Wakefield, a surgeon who seems to function as the chief of medicine (the show sometimes seems to share Grey's Anatomy's assumption that the chief of surgery is automatically the chief of medicine). Morrissey says Richmond Trinity will be closing because of chronic budget problems (high costs, low reimbursement). Morrissey will be taking over as CEO of the nearby James River Hospital, and he wants Hawthorne and Wakefield to join him in trying to keep that troubled hospital open, so there is at least one local hospital for those who are not wealthy. John MorrisseyHawthorne declines, and although she apparently gets her staff nurses jobs at James River, she lines up some undefined home health job for herself. However, as she and Wakefield are saying goodbye to Richmond Trinity's last patient, they encounter a gunshot victim, and they drive him to James River.

James River's ED is a crowded mess, and after Hawthorne and Wakefield push past triage with the patient, Hawthorne clashes with the apparent "director of nursing" of this hospital, Gail Strummer, who wants them to stay in the waiting room. Hawthorne notes that a patient lying nearby is dead. Gail says the morgue is full, so they'll move him in a little while; she pretends he's alive so as not to alarm other patients! Gail also seems to take a hands-on role in running the ED nursing. Later, Gail resists giving a patient with acute abdominal pain the attention that ED nurse Bobbie Jackson thinks the patient needs. Bobbie is a close friend of Hawthorne's who was the ED nurse manager at Richmond Trinity. Gail explains why that patient can wait:  "Folks here like to lay it on thick so they can cut to the head of the line."

Bobbie JacksonHawthorne goes to see Morrissey, who can tell she is intrigued by the chaos of James River. She asks what he plans to do with his "existing director of nursing." He says he'll "deal with that." She tentatively agrees to come on board, though she'll have to convert a waiting room as her office. The season's challenge is set here:  Morrissey says that the Joint Commission will inspect the hospital in six months, and that funding will be cut if they do not bring their rating way up.

The episode shows Hawthorne's rough integration into the new hospital order through the plotline involving the ED patient with abdominal pain. Bobbie is thrilled to hear that Hawthorne has signed on as director of nursing, but she is confronting a problem:  The abdominal patient has been waiting more than five hours, and her boyfriend is angry and already threatening to sue. Hawthorne starts trying to bring the situation under control, but Gail doubts her authority. The patient's boyfriend starts to lose it. He threatens violence, and actually knocks a male clerk down, though the clerk seems uninjured. Hawthorne directs Bobbie to see the patient. Hawthorne, Bobbie, and the nice, competent ED physician Steve Shaw examine the patient. He wants an abdominal series of x-rays and Hawthorne wants it to be a rush. Hawthorne goes to find Morrissey, apparently to get confirmation of her authority. Meanwhile, Gail gets the police to cuff the boyfriend for attacking the clerk and threatening her. Hawthorne returns and tries to persuade Gail that the arrest was a bad idea. Gail suggests Hawthorne can't just waltz in there and take over. Hawthorne says Morrissey will talk to her. Unfortunately, the patient codes, apparently because she has a perforated bowel. Hawthorne goes for a crash cart, but it crashes to the ground when she tries to move it because, as it turns out, it is chained to the wall. Gail says they did that because they had one stolen. Shaw intubates the patient. But despite the team's efforts, the patient dies. As Bobbie is preparing the woman's body to leave the ED afterwards, physician Shaw actually helps. In part that is because he likes her, but it is indicative of the collaborative approach between nurses and physicians in the scenes showing the team's care for this patient.

Gail StrummerLater, we see Morrissey ask Hawthorne and Gail (right) to explain their mismanagement of the case, which has become widely publicized. Hawthorne says it was a systemic breakdown and will take a while to fix. Morrissey says he has decided to split the nursing department, with Gail handling critical care (the ED and ICU) and Hawthorne managing everything else. Hawthorne protests, but Morrissey says that JCAHO is now coming in three months. Hawthorne says that the ED patient died unnecessarily, that Gail is more concerned with not being shown up than giving good care. Gail responds that Hawthorne is just another know-it-all with no clue who will eventually move on, "following doctors to better jobs"--a comment that is never explained. Certainly, it is an unhelpful reinforcement of the handmaiden stereotype, and the image of the nurse as a golddigger more interested in her relations with physicians than in her own career. Morrissey says Gail knows where the bodies are buried. Hawthorne says that's because she buried them.

Tom WakefieldToward the end of the episode, Hawthorne checks on the gunshot victim she and Wakefield (right) brought in earlier that day. Wakefield is there, and it becomes clear they will both be staying (which does not quite fit Gail's formulation, since neither of them really followed the other, and Hawthorne's job will clearly be worse than her old one). In this episode, Hawthorne and Wakefield are basically presented as peers, at least in the hospital management structure.

Hawthorne's early scenes at James River, which mainly involve her interactions with Morrissey and Gail, generally present a helpful picture of a nursing management structure, one in which physicians play no evident role. Some elements are more realistic than others--Hawthorne's continuing role in direct care remains unlikely--but simply showing that this structure exists and that nursing is essentially self-governing has great value. Virtually no other Hollywood show does that--not even Nurse Jackie, which at times suggests directly that nurses report to physicians, and on which the supervisor Gloria Akalitus sometimes seems like a nurse manager, and at other times seems to have authority over pharmacy and even some over physicians. HawthoRNe's indication that one nurse manager is clearly better at her job than another is also fine. It's something Hollywood does with physicians all the time, where there is a constant focus on who is "the best," a focus that underlines how expert and important physicians are. Here, Hawthorne is a strong, skilled manager confronting entrenched dysfunction.

Malia PriceOther plotlines in the episode also draw a marked contrast between different nurses, and reveal more of Gail's counterproductive, even dangerous, management style. In one plotline, pediatric nurse Kelly finds that a colleague, nurse Malia Price (right), is both incompetent and indifferent. When Malia cannot find a vein in a boy who burned himself while cooking for his sisters, Kelly finds the vein but tries to be sensitive about it; Malia blames the veins. Kelly provides great psychosocial care to this boy, supporting him as he waits to go to the OR for a skin graft, although he is not even her patient. After the boy has gone to the OR, Kelly discovers that Malia has given him oxacillin even though he is allergic. Kelly runs to the OR. Malia couldn't care less. Later, Gail appears to tell Kelly that Gail just "got a call about a peds nurse screwing up the OR schedule." (It's not clear if the OR people blamed Kelly for giving the wrong drug, or for telling them about it and ruining their surgical plans.) Kelly tells Gail what the problem was without blaming Malia. Gail snaps at Kelly: "How did you miss that?" Kelly notes that it was not her patient. Gail examines the chart, chides Kelly for not following "protocol" when she ran into OR to stop the surgery, and tells Kelly and Malia, "I'm writin' you both up." Malia resents Kelly for not "having her back." Kelly notes that she helped the patient, and says that she does have Malia's back, noting that Malia should ask for help if she needs it. Malia gives Kelly the cold shoulder. But Kelly has better luck with the boy, who is depressed. Kelly persuades him to play ping pong with her; this will not only strengthen his injured right arm, but also lift his spirits.

Ray and MarshallAnother plotline concerns the somewhat confused nurse Ray Stein (right), who is torn here between an affair he is having with the nasty physician Brenda Marshall and his urge to protect some of his nursing colleagues from her wrath. At one point, Marshall arrives at a nurses' station, seeking a computer terminal. There she finds gossiping dimwits, apparently nurses, doing nothing and unwilling to accommodate her. Marshall notes acidly that she's sure their "word find" can wait. Later, one of the lazy nurses confides that she won't help "[Marshall's] patient" no matter what, because Marshall is a "stone cold bitch." Still later, we see Marshall explaining to the word find nurse, as one might explain something to a small child, that "NPO" is Latin for "nothing by mouth," so that one particular patient should not be eating a BLT. Ray tries to mellow Marshall out a little. She says the other nurses are idiots, but she ultimately promises to try to be nicer.

These staff nurses, along with Malia, are not just anonymous or disagreeable characters, but, to be honest, they are inept monsters who seemingly don't care if patients live or die. Gail isn't much better. So if they are really supposed to be registered nurses, they are somewhat overdone, and it doesn't help nursing for the public to be told that people this awful could actually function as nurses at all. On the other hand, the plotlines do show that nursing is not something just anyone can do, and they allow Hawthorne and Kelly to shine. As for the physician Marshall, she is abusive to the nurses. It's hard to feel too bad for nurses this dangerous and mean, and Marshall does seem to accept Ray's persistent urgings that she be nicer. On the other hand, the plotline does not show what a serious threat to patients physicians like Marshall really are, since their hostility disrupts the open communication needed to save lives and contributes to nursing burnout. 
 

Throwing a flag on the play

Christina HawthorneThe June 29 episode, titled "The Starting Line" and written by John Masius and Erica Shelton, also highlights Hawthorne's strong advocacy and Kelly's skilled psychosocial care. But it begins with more nursing management interactions between Hawthorne and Gail.

We see Hawthorne meeting with Gail about improving care in advance of the JCAHO inspection. Hawthorne proposes some care process improvements with cute acronyms. Gail says they've tried all those without success. Hawthorne suggests they can cut wait times with a fast track for suture removal and basic followup. Gail rejects this and other ideas, displaying a "can't do" attitude. Hawthorne notes that CNOs all over the country are implementing these procedures. Gail says those nurses wear suits (!). Hawthorne guesses that Gail has a problem with the concept of a "chief nursing officer," but she says that "director of nursing" is archaic, and puts them below the CEO and the CFO. This is odd; administratively, the CNO is below the CEO, as is the chief medical officer. Anyway, Gail has little to say, but vows she will not let a stranger from a failed hospital (Hawthorne) meddle with her ER. Hawthorne reminds Gail that they will be shut down if they fail the inspection. This scene reminds viewers that nursing leaders know about innovative care processes and have significant responsibility for hospital outcomes. Of course, the Gail character suggests that even nursing leaders have self-esteem problems.

Bobbie and ChristinaLater, Hawthorne recognizes an ED patient named Valerie as a former Richmond Trinity patient who had a heart valve replacement the prior year. Valerie has two young daughters. Now her valve is infected, and she will need another. Paul Hyun, the chief of surgery and a friend of Wakefield's, wants to schedule the surgery, though Valerie has no insurance. But Gail, whose job seems to be more about preventing care than providing it, stops Bobbie (right) as she is wheeling Valerie from the ED to surgery. Gail notes, correctly, that Valerie has "a drug problem," and Gail says the "doctors" want to treat her addiction first. Valerie says she will die without the replacement. Gail says she is sorry. Later, Valerie explains to Bobbie that she got hooked on painkillers after her prior surgery. When Hawthorne visits Valerie, she promises that Valerie will get her surgery and that they will find her the right rehabilitation facility. But Bobbie concedes that it will be three months till the surgery.

Hawthorne has not given up. She argues to Gail that the delay in the surgery could kill Valerie. Gail says Valerie could infect the new valve. Hawthorne argues for a second chance, but second chances are not really Gail's style. Gail says Hawthorne can take it up with the hospital's Ethics Committee. Gail notes that she is a member as "director of nursing." Hawthorne, of course, wants to be on the committee too, but Gail says there are five seats and no vacancies. A little later, Hawthorne gets information about the committee from the ED clerk Marcus:  Reverend Samuels always approves of care when it is questioned, but Gail and "that accounting dude" say no. Hawthorne questions why a bean counter would even be on the committee, noting that it should be "medical professionals" like physicians, nurses, and social workers. (Actually, real ethics committees may include legal and administrative personnel.) The remaining committee members at James River are the "ethicist" Dr. Jameson and the chief of surgery. It is helpful that the show at least tells viewers that ethics committees exist to resolve difficult problems like this and that they include nurses; on most Hollywood shows, physicians simply make the decisions and overrule any objections by nurses, though it is rare for a nurse on such shows even to comment on a care decision.

Hawthorne starts with Paul, the chief of surgery, who knows about Hawthorne's relationship with Wakefield, but has also heard bad things about her from Gail. Hawthorne advocates for Valerie, arguing that she has no prior drug use, but became addicted from the first surgery. Paul is not convinced, and clearly doesn't think this is such a big deal. Hawthorne goes to Wakefield and urges him to persuade Paul about the heart valve. But Wakefield--possibly influenced by the fact that his relationship with Hawthorne is not going well at the moment--says he agrees with Paul that the treatment is too risky. Hawthorne later tells Bobbie that the hospital "seems hell bent on giving this woman a death sentence." But she has one more person to try.

Erin JamesonHawthorne visits the ethicist, whose door says "Erin L. Jameson, MD, PhD." Jameson (right) presents a cheery outlook and tells Hawthorne that the surgery has just been postponed, not denied. Hawthorne says she does not think Valerie will live long enough to do rehab first. They go back and forth about whether Valerie is too risky. Evidently looking for a way out that is easier than debating the merits, Jameson inquires about how Hawthorne can be director of nursing when Gail is still there. Hawthorne explains, and Jameson asks if the surgery would not be within Gail's jurisdiction. Hawthorne reiterates that Valerie will not complete her addiction treatment because her valve will give out first. Jameson assures her that all findings were weighed carefully. Hawthorne reminds Jameson of the patient's young daughters, who could end up in foster care. Rather than answer, Jameson asks what hospital Hawthorne came from. On learning the answer, Jameson says that at James River, they like to work through their issues: "And trust me, I have dedicated my life to ethics." Because Hawthorne has not, her opinion does not factor in, and in any case, Jameson notes, the patient can go elsewhere. Hawthorne says she has nowhere else to go. The physician's responses to Hawthorne are basically a smug series of non-arguments focused on platitudes, status, background, and irrelevant administrative factors. 

Still, Hawthorne will not give up. She does further research on Jameson and returns to the physician's office. Jameson admits Hawthorne is tenacious. Hawthorne looks around the office, which has wall photos of Cuba, Senegal, and Jakarta. Hawthorne, herself the mother of a teenaged girl, observes that she sees no family photos on Jameson's wall, then tries another tack.

Hawthorne:  Maybe it's the mother in me. And maybe I am too emotional. I just can't stop thinking about those two little girls who have only their mother to take care of them. You should come meet them.

ethics committeeJameson says it will not make a difference. But Hawthorne presses, asking whether Jameson doesn't "owe it to [her] patients to weigh all factors in their equation." Jameson says Valerie is not her patient. Hawthorne sees another opening: "You've never even met Valerie?" So Jameson actually accompanies Hawthorne to see Valerie. But Jameson excludes Hawthorne and Gail from this meeting, saying, "Sorry, this is doctor-patient only." We don't see the meeting, and when Jameson leaves she is clearly not interested in talking to Hawthorne.

Next we see Hawthorne barge into a meeting of the Ethics Committee.

Hawthorne:  Is this the ethics committee? Because I've got an ethics complaint. I want to put a complaint in against this committee. You see, it's my understanding that an ethics committee is a consult, a place where people with ethical dilemmas can come and get help. But see, you on the other hand have turned into a death panel. You got this woman out here who needs a new valve, and now you wanna play God? Well, I'm about to throw a flag on the play, or whatever you all throw, because it ain't right--

Jameson:  Christina. We are reversing our recommendation. Valerie will be treated for her addiction and have the valve replaced simultaneously, and I would like to thank you for making us take another look.

Hawthorne (shocked, then slowly withdrawing):  Sure…thank you.

Moving mountainsIt's a good thing Hawthorne has already prevailed before she enters the room, because her speech is likely to inflame rather than persuade, and in its almost comical swagger, it misses the real "ethical dilemma." It is not just that the committee is arbitrarily "playing God" and acting as a "death panel," but that in assessing the likelihood that the operation will be a good use of scarce resources, the committee seems to be undervaluing Valerie's desire to overcome her addiction and care for the children she loves. They are not giving her a fair chance. Still, Hawthorne's relentless and tactically astute advocacy for Valerie over the course of the episode up until that point is impressive. As the grateful Valerie suggests later, it seems like Hawthorne moved mountains for her. Hawthorne says she just got Valerie to the starting line.

The plotline involving Kelly begins when a 14-year-old named RJ arrives in the ED with priapism and his freaked out mother and grandfather. Bobbie asks RJ about possible causes. RJ confirms that the episodes have happened before. Upon learning that RJ is adopted, Bobby asks for the records from the adoption agency, to see the family history. The sensitive physician Steve Shaw tells RJ they will try ice packs. In pediatrics, Kelly greets RJ.

Kelly:  Hi, I'm Kelly, I'll be your nurse today. Has anyone explained to you what's going on with your body right now?

Mom:  Not exactly.

Kelly:  Priapism is a circulation issue. It's when blood flows in, but doesn't flow out. And it deprives the area of oxygen, which makes it rigid.

RJ:  And painful.

Kelly:  For some reason, your blood vessels aren't doing their job. But the ice pack is going to help with the swelling.

RJ:  How long do we leave the ice pack on for?

Kelly:  I'll handle that. You just relax.

Kelly, RJ and familyRJ is reluctant to have Kelly (an attractive young woman) working in this sensitive area, but his grandfather assures him it's OK, because she's a nurse. RJ's mother says maybe she, his mother, should do it. RJ is mortified. RJ's grandfather says they should let Kelly do her job. Kelly thanks him, and asks for a moment of privacy. The family leaves, and Kelly tells RJ that he will feel better. She warns him that she will be lifting his gown to examine him. To distract him, she asks if he likes baseball. He says yes, and wonders whether she likes it. She says not at all.

Later, we see Kelly telling RJ's mom and grandfather that a spinal tap is the only way to rule out meningitis. A cold, technical physician explains further. RJ's grandfather asks what will happen after that, and the physician says then they will try a "therapeutic aspiration to treat the priapism." The grandfather says, "A what?" Kelly explains: "That essentially means we drain the blood that's accumulated." The mother wonders how, and the physician says with a needle. The mother and grandfather hesitate over another needle, and the mother wonders whether medication or even just waiting might be better. But Kelly says RJ is in a lot of pain and this is the best way to alleviate it. The physician says that the worst case scenario is surgery to insert a shunt. The grandfather doesn't want that until they know what is going on. Kelly says they will take it one step at a time. The grandfather says he won't worry as long as Kelly is holding his grandson's hand; despite his gruffness, Kelly has clearly won him over. Kelly asks again about getting the adoption records, and RJ's mother claims there is no history of anything like this.

Unfortunately, it turns out to be too late for RJ to aspirate, and the physician says there are signs of vascular damage and that it is time to operate. The grandfather still doesn't want surgery till they know what's really wrong. Kelly says that once the immediate problem is treated and they have the full history, they'll know what the underlying problem is. RJ's mother insists that the adoption agency can't find the records. Kelly says OK, they will keep running tests, and she assures them that RJ needs the surgery. The mother and grandfather reluctantly agree.

Kelly, RJ and familyLater, as RJ is on his way to surgery, Kelly tells RJ's mother that the adoption agency found the medical records. Kelly says that the mother failed to note that RJ's birth father was African-American, and Kelly informs her that priapism is a symptom of sickle-cell anemia. Kelly says if this is a sickle-cell crisis, RJ may need surgery again. The mother wants to keep this information secret, and she notes that whites can get sickle-cell too. Kelly realizes that RJ doesn't know he's biracial. His mother says they are white, and she can't see why she should complicate RJ's life that way. She says RJ's grandfather is still upset over "the war of Northern aggression," and that he would "never forgive RJ" or her if he knew RJ's racial background. Kelly: "Are you sure your dad is the one with the problem?" Kelly gets away with that because her manner is so friendly and supportive. But RJ's mother reminds Kelly that RJ is her son, and she asks Kelly to say nothing. 

Kelly learns that RJ does have sickle-cell. She consults Hawthorne, as a mentor--a nursing mentor! Hawthorne says she is sorry, but by law it's the mother's choice whether to reveal RJ's race to him. When Kelly finds RJ's mother, the mother is upset, wondering how to help RJ with being biracial. Kelly advises that they try learning together, and take it as it comes. The mother says you make it sound simple. Kelly admits that it won't be, but "do it anyway." Later, Kelly reports that the "doctor said the surgery went great." This is not so great; PACU (recovery room) nurses could have told Kelly how the surgery went. RJ, in recovery, seeks assurance that the priapism will not happen again. RJ's mother tells him that he has sickle cell anemia, and she asks Kelly to give them a minute. She is going to tell RJ and his grandfather about RJ's biracial status.

On the whole, this plotline is an excellent illustration of nurses' physiological and psychosocial skills. Obviously Kelly handles all three interested persons (RJ, mom, and grandfather) perfectly in the middle of this awkward and fairly emergent situation, providing support and helping each to see the best way forward without pushing. She also displays an easy command of the technical aspects of RJ's condition. She educates the family and translates the physician's overly technical information into something lay people can understand. Some might consider Kelly's pushing of the mother to reveal RJ's biracial status as being over the line, but it's easy to see it as a critical intervention in RJ's long-term interest, to at least try to get him the truth about his background. 
 

Skyping Commando Barbie

Commando BarbieThe July 13 episode, titled "Afterglow" and written by Shelley Meals and Darin Goldberg, includes a plotline featuring nurse Ray and nurse Candy Sullivan (right), who has recently returned from a tour of duty in Afghanistan. Although Ray has been seeing the physician Marshall in Candy's absence, he has always been very attracted to Candy, and that has not changed. Although the Candy character never displayed a lot of clinical expertise before she left, she seems to have become energized by the work she did in the war zone. She tells Ray about the supply shortages she and her colleagues faced, explaining that they had to improvise, for instance by using a Foley catheter to get a foreign body out of a patient's esophagus. Candy says she loved her work, and she is thinking about getting certified as a trauma specialist. She inquires about Ray's own plans, referring to his past interest in medical school. Early in the first season, the show made much of the fact that Ray was stymied by his poor performance on the MCAT's, and at that time he seemed insecure and frustrated about being a nurse.

Candy:  And med school?

Ray:  Actually, I've been thinking about it since we spoke, and I'm seriously considering taking my MCATs again.

Candy:  Hey, that's great. Good for you.

The show leaves it there and does not really return to Ray's medical school aspirations, but even this passing reference, along with other conduct by Ray, will reinforce to some extent the stereotype that men in nursing want to become physicians but are not smart enough.

Brenda MarshallRay and Candy enter a patient's room, where they find Marshall (right). Marshall greets Candy with pointedly forced politeness; she pretty much abuses all nurses except Ray. The patient has a crushed arm and he is in pain. Ray explains that they will do conscious sedation while Marshall changes the dressing on his wound. Candy asks the patient if he could vacation anywhere, where would he go? The patient says Brazil, because the women wear so little. Candy asks him to close his eyes, think about it, and describe it. The patient begins, but almost immediately loses consciousness. Marshall says she is glad they did not need to hear more of that. Candy says the patient reminds her of IED injuries she saw overseas, and she extols the pain management they did there, noting that they treated each pain differently, rather than with just one narcotic. Marshall says she knows they don't all have the benefit of Candy's "transcendent experience," but asks her to give it a rest: "If I wanted a Commando Barbie I would have ordered one on eBay." Ray laughs a little, uncomfortably. Neither nurse can muster any response to Marshall's comment, which is not a bad example of physician abuse.

Soon afterwards, the nurses, including Kelly, are commiserating among themselves about what Candy describes as Marshall's "less than cheerful demeanor." One nurse jokingly suggests that Ray mellow Marshall out by having sex with her. Ray treats that as a total joke, but Kelly's reaction reveals to Candy that Ray and Marshall really are an item. Candy is, of course, shocked.

Later, we see Candy, Ray, and Marshall with the patient with the crush injury. The patient reports that the pain is still pretty bad.

Candy:  Dr. Marshall, I Skyped a doctor that I worked with overseas about this case. He suggested a local block that would help with the pain of the crushed arm, and he also suggested SSRIs for the tingling and burning.

Marshall:  You know what? If it's good enough for our troops, it's good enough for James River. Thank you, Nurse Sullivan, I will go write up the order.

She leaves. Candy says she's like a whole new woman, and wonders if Ray and Marshall actually did have sex. Ray denies that they would do that at work.

CandyLater, Ray visits Marshall and reports that the patient is doing great. Marshall actually says Candy (right) "hit it out of the ballpark" with her idea. Then Marshall begins probing Ray about some odd Skype activity on her computer. While Candy was in Afghanistan, Ray was foolish enough to Skype her repeatedly on Marshall's computer. Ray tries to evade Marshall, but Marshall says she sees the way Ray looks at the attractive Candy, and wonders how can she compete. Ray tries to reassure Marshall that she's the one he wants to be with, but it's not clear if she's convinced.

Arguably these personal interactions don't affect the show's nursing portrayal much, but they do add to its overall vision of Ray as a weak person, someone who can't face up to his real feelings, can't defend a colleague under attack, and who, frankly, is not very bright. Couldn't he have found any other computer on which to Skype Candy? Perhaps it's not so hard to see why he would have had trouble with the MCATs. On the upside, although Candy is no advocate for herself, she does a pretty good job advocating for the patient, pushing for better pain relief and even going around Marshall to another physician, despite Marshall's abuse. And Marshall actually accepts and praises Candy's advice, whether because she really agrees or for tactical reasons related to the romance triangle. Candy's care is slightly marred by the idea that she needs some physician to tell her about what an appropriate pain relief measure might be--a nurse with Candy's experience would presumably have known about this local block idea on her own rather than needing to ask a different physician--but on the whole, Candy is presented here as someone who has some technical knowledge. 
 

Who would keep all of you in check?

The August 24 season finale "No Exit" (written by Glen Mazzara and Adam E. Fierro) brings some of the show's management and clinical care concerns together in the context of the Joint Commission inspection. In the first scene, set just outside the hospital, we see a crane lifting a huge box. Looking on is a very-pleased-with-herself Jameson, who is telling Morrissey, Wakefield, and Hawthorne that they are finally installing the new advanced MRI machine. Morrissey says that they are just in time for the JCAHO inspection.

meetingLater, we see Hawthorne speaking with a group of nurses.

Hawthorne:  We also need to double-check that we're following our chest pain protocol. I found that we were not giving our patients aspirin as soon as they were admitted. And that's something we need to stay on top of, okay? All right, you guys, thank you for your time.

Shortly after, Morrissey approaches Hawthorne with a well-dressed man named Cecil McClinn and two others from the Joint Commission. They are there for the inspection--surprise! Hawthorne, recovering quickly, says doing the inspection today is not a problem. Morrissey leaves McClinn with her to inspect the ICU (though that is supposedly not her jurisdiction) and says he'll take the others to check out the ER and the other floors. For some reason, Morrissey does not seem to envision any role for Gail in this.  

explosionMorrissey is showing the other two JCAHO representatives the new MRI scanner, still on the crane. Commission member named Yih says that's an "impressive step forward," and Morrissey notes it's just the first phase of their 5-year capital plan. But as they lift the huge box up, the lines break and it tumbles back down to the loading area, landing on some barrels and setting off an explosion that creates a hospital-wide emergency. We see Morrissey telling Hawthorne and Jameson that the engineers can't guarantee the stability of the ICU, and it must be evacuated. He wants Hawthorne to coordinate that, and Jameson to coordinate with Gail in the ER. Hawthorne takes off, with McClinn following.

Later, we see Hawthorne clearing the ICU. She is piling people into an elevator. Meanwhile, Ray and Marshall (who are now on the outs because of Candy) are wheeling a cranky older male patient whose condition apparently causes him to use at least one Yiddish word every 10 seconds. Hawthorne consults a clipboard, confirming that only Wakefield and a patient of his are left. She finds Wakefield with Candy, who reports that the patient is tachycardic with dropping blood pressure. Wakefield asks if Hawthorne can get a dopamine drip from the nurses' station. As Hawthorne goes, she directs McClinn to tell those at the elevator to go and they'll get the next one. He's surprised to be asked to do anything, but he complies. Wakefield asks Candy for a portable ventilator. Hawthorne brings a crash cart, adjusts the patient's IVs, and takes over bagging.

Hawthorne (to Wakefield):  This reminds me of old times, when you were a hotshot cutter and I was a floor nurse. We spent a lot of time in the trenches together.

The contrast between "floor nurse" and "hotshot cutter" is a good example of nurses' self-devaluation, though it's not clear to what extent the show creators intended that. On the upside, these scenes do show Hawthorne as an authoritative decision-maker, and the nurses as important team members in the patient's care. Anyway, as Candy is getting some equipment, she unplugs a machine, and there is a spark and explosion, knocked her down and injuring her. We see Morrissey ordering a hospital-wide evacuation.

Stein, Marshall, patientMeanwhile, Ray and Marshall are stuck between floors on an elevator with the older male patient. Ray is on his cell phone, telling someone that their patient is claustrophobic, though that is not true. Ray explains that he said that so that those trying to get them out of the elevator would hurry. Although that tactic does not seem especially stupid, the obnoxious patient says he figures Ray says a lot of stupid things. Marshall tells the patient that he doesn't know the half of it. The patient wants to know about "the poofster." Ray asks if the patient thinks he's gay; clearly he does. So Ray reveals that he has been dating Marshall, which she confirms indirectly: "Oh, please, I only date men, not lying little boys who have Barbie fetishes." The patient is surprised they have dated, and Ray asks why. The patient says he's surprised because Marshall "needs a mensch, not a schlemiel." Later, still stuck in the elevator, Ray is telling Marshall that he regrets his contacts with Candy. Marshall explains to the patient that Ray was having sex with her while also harboring feelings for "this blonde, tarted-up nurse." The patient says Marshall should control her feelings for this kind of guy, because "that's meshuga." Ray thanks him for the input.

Candy being baggedIn general, these interactions are not that helpful to nursing. Of course the show is not endorsing the patient's apparent biases about male nurses, but it's not doing a great job of refuting them either. The show does make clear that Ray is not gay without suggesting there would be anything wrong with that; it's just a preconception people have. Unfortunately, Ray is not especially strong or clever in his responses to the patient's insults. Perhaps the fact that the patient is himself a comical Jewish stereotype is meant to signal the absurdity of stereotypes like those about men in nursing, but we're not confident that many viewers will see it that way.

Christina dragging patientMeanwhile, Hawthorne and Wakefield are working as a team in caring for Candy. Wakefield announces that Candy has 2nd degree burns, and Hawthorne promises to get her something for the pain. Hawthorne says her SATs are 92, and Wakefield asks Hawthorne to crank up the O2 and give 10mg of morphine. Hawthorne informs Wakefield that Candy is pregnant, so she'll give her an ultrasound. She does that as Wakefield rubs some white goo on the burn. The baby is fine.

Next, we see them dragging the two patients down the hall on a stretcher system that Hawthorne has apparently rigged up using mattresses. The Joint Commission representative McClinn, still with them, says that this is "very resourceful." Hawthorne: "Well, we're nurses, we have to be." Meanwhile, in the elevator, it's getting hot. Ray starts banging on the elevator to try to guide any rescuers, and just at that second, Hawthorne and her group pass by and hear. Ray says they are burning up, because there is no air.

Hawthorne:  OK, you know what, there's a panel underneath the buttons, open it and there's a switch. Flip it, and it'll open the vents and give you air.

It works. Marshall herself says she doesn't know how Hawthorne knew that, but if she, Marshall, can still get pregnant, she's naming her first-born after Hawthorne. Patient says, "Whoever you are, you're an angel." Wakefield wonders how Hawthorne did know that.

Hawthorne:  It's my job. I'm supposed to know everything about the hospital. Ray: In that same panel, there's another switch. Flip it to "inspection." You see it? OK, now you and Marshall should be able to pry the doors open, but be careful, because you might be in between two floors. You know what, Tom? We need something, we're going to have to pry this open on our end.

Christina pneumothoraxThey haul the patient out. Ray sees that Candy is hurt and he is pretty upset. Hawthorne tries to calm him. Hawthorne and Wakefield drag the other critical patient down a stairwell, but they find the doors at the bottom are blocked with a mountain of junk and they must go back.

Back upstairs, Hawthorne notes that Candy's SATs are dropping. Wakefield wants to intubate, but he can't see Candy's cords, because there is too much damage, so he wants to do a cricothyroidotomy. Marshall reports that her patient has a tension pneumo and needs help; she wants Ray to get a thorocostomy tray. He is not especially functional. Marshall's hand is hurt so she can't do the procedure. Wakefield wants Christina to do it, saying he can't because his hands are full with Candy, but he'll walk her through it. Hawthorne insists she can't do it. Wakefield insists she can. She agrees. Wakefield finally succeeds in intubating Candy. And Marshall shows Hawthorne how to insert the needle in her patient. Hawthorne succeeds.

Wakefield:  You know, when this is all said and done, you should consider medical school.

Hawthorne:  If I left, who would keep all of you in check?

QuoteThis isn't too bad as a response to Wakefield's idiotic comment, but we're not sure the show knows just how idiotic it is. Of course suggesting that being able to do one procedure like this makes a person a good candidate for medical school is silly, but for nursing, the problem is that an apparently smart, informed character would think this was a helpful thing to tell an expert senior nurse. In fact, going to medical school would seem to be a great waste of Hawthorne's nursing skills, something you might think Wakefield would know. Does the show really believe, despite everything, that medical school should be the ultimate goal of every able health worker? Hawthorne's response hints at nurses' roles as patient advocates and as a check on physician power, but we doubt many viewers will see how deep it goes and that's it's not just a throwaway line, maybe even one that says more about Hawthorne's personal qualities than her role as a senior nurse. And Hawthorne's performance of the procedure, while clearly meant to show how able she is, is yet another example of Hollywood's tendency--even on nurse-focused shows--to present nurses as achieving by doing things that physicians ordinarily do, as if those are more impressive than nursing tasks. They are not. We would rather see more of Hawthorne's inventiveness and authority in managing the care environment, monitoring and intervening with patients as a nurse, which the episode as a whole shows that the creators are capable of giving us.

Hawthorne, Wakefield, and the others provide further emergency care to Candy, who seems to have an intracranial bleed. They are soon rescued by the firefighters, and we see Hawthorne and the others shepherd patients out, on their way to another hospital. Outside, we see Morrissey arguing to the Joint Commission representative Yih that the hospital should not be judged on what happened today. But Yih has decided to shut them down. McClinn arrives with Hawthorne and Wakefield.

Yih:  This hospital is a disaster. You're lucky no one was killed.

Hawthorne:  OK, you know what, we're not perfect, I'll give you that, but we've risked so much trying to keep this hospital on its feet, you can't just shut us down.

Yih:  I'm sorry, I saw too many hazards here today, and considering your institution's history, we can't keep turning the other way.

Wakefield is incensed, and he gives a fairly long speech about the value of what they did and how shutting them down would mean "giving this entire community a death sentence."

McClinn:  Wait a minute, wait a minute. This staff went above and beyond the call. Sure, maybe all their T's aren't crossed. But I can't imagine a more dedicated group of people.

McClinn, who apparently has more authority than Yih, says the hospital will get a pass from the Joint Commission for now. Morrissey thanks Hawthorne.

On the whole, despite some glitches, the episode displays Hawthorne's leadership, advocacy, clinical skill, resourcefulness, and knowledge of the care environment--we did like the elevator scene, which suggests the breadth of nurses' holistic care model. We thank the show for its efforts to give viewers some sense of what nurses really do, and we look forward to season three.

Watch episodes of HawthoRNe here.

We have written a letter to HawthoRNe that reflects our analysis (below). If you would like to join us, please send us a letter to letters@truthaboutnursing.org and we will forward your letter to the show. Thank you!

 

Dear HawthoRNe creators:

I am writing to thank you for HawthoRNe, which generally tells viewers helpful things about nursing skill and how nurses affect patient outcomes.

As you know, in the second season, the strong nurse executive Christina Hawthorne and her nursing team fought through inept fellow nurses, resistant physicians, and resource shortages to provide expert care, including effective patient advocacy. The show was relatively good on nursing autonomy, at least in scenes involving Hawthorne; it showed a nursing chain of command, with Hawthorne presented basically as a peer of the chief of medicine.

Hawthorne’s team of staff nurses were also patient advocates, and in many scenes they excelled in both psychosocial and technical care. The young pediatric nurse Kelly Epson was especially impressive. Of course, some nurse characters on the show were better than others, but that was generally not a problem as it suggested that nursing is a serious profession at which not everyone can excel.

Sadly, the show has never been great on men in nursing or on the wannabe physician stereotype. Staff nurse Ray Stein is not a bad nurse, but last season he was still not very strong and he still dreamed of medical school, though he had failed the MCATs the first time. In addition, the show probably understated the threat to patients and nurses posed by abusive physicians like the Brenda Marshall character, and it did not really explore the options that nurses have to counter such abuse.

On the whole, though, HawthoRNe is helpful to the nursing profession. Thank you again for the show, and good luck with your third season.

 

 

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