Changing how the world thinks about nursing

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  Nursing Vision
203 Churchwardens Rd.
Baltimore, MD 21212-2937


Ms. Dee Johnson
Co-Executive Producer
Warner Brothers Studios
4000 Warner Blvd., Building 133, Rm. 107
Burbank, CA 91522

Dear Ms. Johnson:

We are writing to follow up on our November 21 discussion about "ER" and the nursing profession, especially with regard to how we might work together to make things better. We would like to thank you and Dr. Morocco again for taking the time to discuss your generally excellent show. Despite "ER"'s largely positive depiction of nurses, we have identified some areas that could be improved, including implications that nurses mainly perform menial tasks under physician supervision. Especially in the face of the current nursing shortage, we feel it is vital that these issues be addressed. Our suggestions include expanding and improving the accuracy of nurse characterizations, reviewing the short sample script we have sent, and using meaningful input from nurses in script development.

We would like to recap some of the points we made in the conference call. We salute "ER" for its relatively accurate portrayal of a public hospital emergency department. However, we feel that the show's current representation of ER nursing is less accurate and dynamic than it could be. We suggest that improving the show's portrayal of nurses could have positive effects beyond improved realism, including informing the public about the nursing shortage and helping to reverse it, as well as supplying a wealth of new plot ideas and perspectives. And of course, the nation's 2.7 million nurses, along with their friends and families, represent a significant portion of the consumers of television shows and other products.

The current nursing shortage is of great concern to us. Health and Human Services Secretary Thompson has called the shortage one of the nation's most serious health problems. Nurses today are short-staffed, overworked and undervalued. They are not entering or remaining in the profession in numbers sufficient to match the increasing need, resulting in an estimated 126,000 current nursing vacancies and a vacancy rate in some places as high as 20%. In the current climate of mass terrorism--and bearing in mind that nurses would provide the majority of care in the case of a major bioterror event--it is critical that we heed Senator Hutchinson's recent call for a spirited public awareness campaign to avert this potential public health catastrophe. As the nation's most popular television drama, "ER" can and should play a role in this effort.

We have expressed concern about recent "ER" episodes, which have implied that nurses lack independent authority. For instance, in the November 22 episode aired the day after our call, the Abby character spent most of her time injecting herself into Luka's personal relationship with Nicole. While Abby's suspicions about Nicole seem to have proved correct, her professional role in the episode consisted primarily of directing a medical student to a death kit and responding to Luka's request for Versed with questions about his love life. Luka lost patience and demanded that Abby give him the Versed to give to the patient himself. In our view, it would generally be very poor practice for an ER nurse to allow a physician to give Versed by himself. This is so not only because most doctors, for all their medical expertise, lack the skill and experience needed to give such drugs properly. It is also because if the doctor gave the drug by himself, the nurse would not be present to assess the patient's status during its administration and the ensuing period of conscious sedation--part of the nursing role that is often critical to the patient's survival. We assume "ER" did not mean to show Abby (generally a good nurse) casually approaching malpractice. We wonder if the conflict could have been highlighted in other ways, such as by having Abby insist on giving the drug herself, as a strong patient advocate would.

We have more general concerns about nurses on "ER," including our view that nursing is generally ignored as a profession on the show, while medicine is examined in great detail; that of the show’s major characters, ten are doctors and one is a nurse, when in a real teaching hospital ER the numbers of each profession are comparable; that some exciting aspects of the real ER nursing role are usurped on the show by doctor characters even when real doctors almost never do them (e.g. defibrillation); that the show regularly has nurses reporting to doctors, when in fact they do not; and that the show has suggested that nurses envy and wish to be doctors, when in fact most nurses who seek graduate education do so within the nursing field. In addition, the show does not seem to acknowledge the fact that in teaching hospitals, experienced nurses teach the medical students and residents—not only how things work at the hospital, but many technical skills such as starting intravenous lines, and how to begin to tell which patients are more "sick" than others. Though this role is informal and unacknowledged by many medical educators, it is important to the education of physicians. A more accurate portrayal of nursing could open up a new world of compelling drama, since the nursing roles of assessment, intervention and patient advocacy can entail intense challenges in nurses' relations with patients, doctors, and other nurses. We applaud the steps "ER" has taken to get input from real emergency departments and nurses, but feel that only significant nursing input on the scripts themselves can fully resolve these issues.

A couple of points that surfaced in our conference call justify further comment. One was whether the audience would care about the professional actions of characters who are not doctors. We think the success of shows like "Third Watch"--which focuses on emergency workers with less formal training than nurses have--shows that people are interested in characters who act autonomously to save lives. Nurses do this every day. And the renewed public appreciation for undervalued emergency workers in the wake of the September 11 attacks presents a great opportunity for "ER" to do well by doing good.

Another point made in the conference call was that an accurate portrayal of nursing would not help reduce the shortage, since a realistic view of how bad things are would not attract anyone. While this appears logical on its face, we still feel that the changes we suggest would help the profession and work to reduce the shortage. Even a "warts and all" portrayal of modern nursing would be more attractive than the view much of society now has of a class of poorly trained menial workers who are subservient to doctors. In fact, an honest treatment of the challenges nurses face would strengthen efforts to change the policies and attitudes that contribute to the shortage, as policy makers and the public became more aware of them. Surely a show that has courageously tackled as many controversial issues as "ER" has--and that continues to dominate other dramas in the ratings--would not shrink from addressing this issue on the basis that it was powerless to have an effect.

There are a number of ways in which we might work together to address these concerns. Among our suggestions are:

  1. that we arrange for the show's writers to follow real ER nurses at work for a few days at a major metropolitan hospital, such as Johns Hopkins or San Francisco General;

  2. that nurses be shown in their critical autonomous roles (such as triage, discharge planning, patient education and nursing research) and as advancing in their own field, rather than treating a medical degree as the goal of any serious health care provider;

  3. that the roles of existing nurse characters be expanded and/or new nurse characters be introduced, particularly nursing students, a clinical nurse specialist, an ER nurse manager and a director of nursing;

  4. that the Warner Bros. web site be modified: instead of stating that Abby has been "demoted to nurse," the site might say that she is an OB nurse who attended medical school for a time, but decided to resume her nursing career in the ER; as for the web site (in the "job description" section) that states nurses provide care based on "orders written by doctors," we attach an alternative job description that might also be of assistance to the show's writers;

  5. that "ER" help us to persuade NBC to air public service announcements to address the nursing shortage as part of its “The More You Know” program, which as you know has often enlisted “ER” actors for messages on other important health-related topics;

  6. that the show's producers and writers review the sample script we sent last week, which tries to illustrate some of our main points in a dramatic setting; and

  7. that "ER" regularly consult experienced nurses in its script development, since this would seem to be the only way to ensure that these issues are adequately addressed.

We attach a list of the areas of expertise of our advisory group members who would be pleased to provide this script input. Please contact Sandy Summers for help in coordinating such assistance on a timely and confidential basis.

Please let us know if you have any questions or comments. We'll be in touch soon to follow up on the above ideas. Thank you again for your time and consideration.


Professors of Nursing:

Jacquelyn Campbell, Ph.D., RN, FAAN, Associate Dean for Ph.D. Programs and Research, Professor of Nursing, Johns Hopkins University School of Nursing

Linda C. Pugh, Ph.D., R.N.C., Associate Professor of Nursing, Johns Hopkins University School of Nursing

Ruth E. Malone, Ph.D., RN, Assistant Professor of Nursing and Health Policy, University of California, San Francisco

Dan Sheridan, Ph.D., RN, CNS, Assistant Professor, Forensic Clinical Nurse Specialist, Johns Hopkins University School of Nursing

Emergency Nurses Association Representatives:

Mary Jagim, RN, BSN, CEN, 2001 President, Emergency Nurses Association

Benjamin Marett, RN, MSN, CEN COHN-S CNA, Immediate Past President, Emergency Nurses Association

Sherri-Lynne Almeida, DrPH, MSN, MEd, RN, CEN President-elect, Emergency Nurses Association

Graduate Nursing Students:

Richard Kimball, RN, MSN, MPH, Ph.D. student

Kelly Bower, RN, BSN, MSN/MPH student

Gina Pistulka, RN, BSN, MSN/MPH student

Bridget Roughneen, RN, BSN, MSN/MPH student

Christine Stainton, RN, BSN, BA, MSN student

Sandy Summers, RN, BSN, MSN/MPH student

Pat Woods, RN, BScN, Instructor, Emergency Nursing Specialty, British Columbia Institute of Technology, MScN student University of British Columbia


REGISTERED NURSE (RN): A Registered Nurse (RN) is a health care professional who has passed a state board examination after obtaining a 4-year Bachelor of Science in Nursing degree, a 3-year Diploma, or a 2-year Associate's degree. RN's are at the core of the health care delivery team. They independently assess and monitor patients, and taking a holistic approach, determine what patients need to attain and preserve their health. RN's then provide care and, if needed, alert other health care professionals. Emergency department RN's like ER's Abby Lockhart triage all incoming patients, deciding which are sickest and in what order they require the attention of other professionals. Thus, RN's coordinate care delivery by physicians, nurse practitioners, social workers, physical therapists and others. RN's assess whether care is successful. If not, they seek a different plan. RN's are patient advocates, who protect the interests of patients when the patients themselves cannot because of illness or inadequate health knowledge. RN's are patient educators, responsible for explaining procedures and treatments. For instance, RN's teach patients how to take medicines, change wound dressings, and use health care equipment like crutches. They empower patients, guiding them toward healthy behaviors and support them in time of need. Hospital RN's are responsible for discharge planning, deciding together with other professionals when a patient can go home, and helping the patient adapt to her condition and work toward full recovery. Some RN's are independent scholars whose work is at the forefront of health care research. Many RN's obtain Master's and/or Ph.D. degrees in nursing, then work as scholars, educators, policy makers, managers, or advanced practitioners such as Clinical Nurse Specialists or Nurse Practitioners.