Changing how the world thinks about nursing

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

October 10, 2001


Mr. John Wells
4000 Warner Blvd., Building 1
Burbank, CA 91522
Telephone 818-954-1687
Fax 818-954-3657

Dear Mr. Wells:

We are a group of nursing leaders and graduate students who are writing with regard to the portrayal of nurses on your excellent television series "ER." Specifically, we are graduate students at the Johns Hopkins University School of Nursing; deans and professors from the Johns Hopkins and University of California San Francisco nursing programs who have acted as their teachers or mentors; and past, current and future presidents and the Board of Directors of the 21,000-member Emergency Nurses Association. Among other things, we seek to promote accurate and balanced media portrayals of the central role nurses play in health care, in the hope that this may increase public understanding of the current health care system, help provide a platform for meaningful health care reform, and encourage nurses to remain in and young people to enter the nursing profession, at a time when the current shortage is reaching crisis proportions. We appreciate very much the depiction of nurses as responsible, caring professionals on a show as historically influential as "ER." However, we also believe that in this critical time our society and the show would benefit greatly from an approach that reflects the central and autonomous role nurses actually play in modern health care, including their vital missions of assessment, intervention, and patient advocacy, as well as the advanced state of nursing practice and research.

We applaud ER's portrayal since 1994 of nurses as responsible, caring professionals who work alongside doctors, whose actions reflect substantial training, and who play an important role in achieving superior results for patients under very difficult circumstances. Many of us have spent years as nurses in emergency rooms in major metropolitan public hospitals in the United States, and we can say that key characters like Carol Hathaway and Abby Lockhart, as well as the supporting nurse characters, are a quantum leap forward from prior and even some contemporaneous depictions of nurses on American television.

We also feel that the show and society might benefit from an even more robust depiction of the modern nursing role, one that clearly shows or at least is not inconsistent with the following facts:

  • while nurses may take an interdependent role in working with physicians, nursing is an autonomous profession that entails constant assessment, intervention, patient advocacy and care coordination that is independent of physician direction;

  • nursing is a distinct academic discipline in which advanced degrees are granted and which is at the forefront of health care research;

  • nurses are responsible for teaching patients how to care for themselves with their new illness and how to prevent a recurrence of the illness, and making sure patients are able to care for themselves once they are home;

  • clinical nursing is at the core of modern health care delivery and not on the periphery;

  • hospital nurses report to nurse managers and ultimately the director of nursing, not to other health care professionals, and physicians do not hire, fire or discipline hospital nurses; and

  • nurses, acting in their crucial role as patient advocates, regularly discuss with physicians the appropriate treatment for a patient, suggesting alternatives that may have been overlooked and explaining why those might lead to a better outcome, and many of these ideas are adopted; nurses have a professional obligation to resist treatment they view as inappropriate, and nurses can and do take the actions necessary to protect the patient in that situation; thus, nurses act as a vital check on acts or omissions by other health care workers that may pose grave threats to patients' well-being.

We’re sure you’ve heard about the growing nursing shortage in the United States, and the increasingly dire predictions about the devastating impact the shortage could have on the public’s health in the coming decades. Although there are currently about 2.7 million registered nurses in the United States, over 400,000 no longer practice nursing and application rates at nursing schools are declining at an alarming rate. Reasons commonly cited for the shortage include working conditions that have become increasingly untenable in the managed care era, particularly short staffing and the substitution of minimally trained unlicensed caregivers for nurses; the wide availability of better paying, lower stress alternatives for nurses; and a general perception among the young that nursing is not an attractive, worthwhile modern profession. Nurses today must negotiate between the increasingly technical and managerial demands of a system that seeks to standardize care and increase efficiency, and their moral and professional obligations to patients and families.

Mr. Wells, you and the other "ER" producers have an unusually large influence on the public’s perception of the nursing profession. Many people never see nurses function outside of your show. Most people don’t meet real nurses until they are older—well beyond the age when most make their career choices. If we are to encourage people to enter the profession, as we hope to, it is critical that the nursing role be depicted fairly and accurately. Once people see the independent role nurses have in health care and their responsibility for patient advocacy, they often find that nursing is a very attractive profession.

Unfortunately, as successful as "ER" has been in creating positive, nuanced portrayals of nurses, scenes in some recent "ER" episodes might leave viewers with the mistaken impressions that nurses do not act as autonomous professionals and that nurses are subservient workers who in fact wish they were physicians. Examples include the scene in one recent episode in which Dr. Carter asks Abby Lockhart whether she is reluctant to ask her boyfriend (a doctor) for time off, and the scene in another episode in which two nurses indicate to Abby that they envy her because she is thin, pretty and a medical student. Current entries on the Warner Bros. "ER" web site appear to confirm these impressions (e.g., "Abby Lockhart is a medical student who has been demoted to nurse" and an entire summation of the nursing profession as: "Registered nurses provide care to patients based on orders written by doctors". Moreover, though we have certainly not seen every episode of the show over the last few years, we have seen most and cannot say that we have seen nurses depicted as acting independently in the assessment, intervention and patient advocacy roles described above--which in fact comprise the core missions of modern nursing. While perhaps understandable in light of the relatively low level of understanding about nursing among even the best educated members of our society—including even some other health care professionals—such portrayals may have the unintended consequence of conveying negative impressions of nursing to current and potential nurses and the public.

In sum, because the vision of nursing presented every week on "ER" affects how tens of millions of people view nursing, we believe a constructive re-examination of that vision could have a substantial positive impact on the way nursing is viewed, and in so doing help to address the current nursing crisis, and ultimately the state of public health in our nation.

Incidentally, apart from the policy concerns we have in this regard, it has been our collective experience that the issues and conflicts that come with the "real life" nursing role can be dramatic and compelling—especially when nurses’ patient advocacy role may lead to disagreement or outright conflict with physicians or other health care workers.

We can imagine how busy you must be with your work on "ER," "Third Watch," and "The West Wing," your leadership of the W.G.A. and your many other projects. Nevertheless, because we feel so strongly about the matters discussed here, we urge you to consider opening a dialogue with us, to work together to explore ways in which our concerns might be addressed. A member of our group will contact your assistant in the next week with regard to the possibility of arranging a meeting or conference call with a small number of us, including professors and E.N.A. representatives. In addition, if you wish, members of our group would be pleased to provide ongoing technical assistance as to the role of nurses in emergency health care. In the interim, our group may be reached through Sandy Summers at phone (410) 547-8425, e-mail, or regular mail: 24 East Mount Vernon Pl. #3, Baltimore MD 21202.

Thank you for your time, and best wishes for the new seasons of all of your shows.

Sincerely yours,

Johns Hopkins Nursing Graduate 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

Sandra Summers, RN, BSN, MSN/MPH student

Professors of Nursing:

Martha N. Hill, Ph.D., RN, FAAN, Interim Dean, Professor and Director, Center for Nursing Research, Johns Hopkins University School 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 A. Lewandowski, Ph.D., RN, Associate 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

Ellen-Marie Whelan, Ph.D., NP, RN, Assistant Professor, Johns Hopkins University School of Nursing and Urban Health Institute

Rosemary Mortimer, E.S. - MS, MSEd, RN, Clinical Instructor, Johns Hopkins University School of Nursing

Emergency Nurses Association Representatives:

2001 Board of Directors, Emergency Nurses Association

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