Changing how the world thinks about nursing

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Sandy Summers
Executive Director
Nursing Vision
203 Churchwardens Rd.
Baltimore, MD 21212-2937

October 12, 2003

Richard Parsons, Chairman and CEO, AOL Time Warner
Barry Meyer, Chairman and CEO, Warner Bros.
Bob Wright, Chairman and CEO, NBC
John Wells, "ER" Executive Producer
R. Scott Gemmill, "ER" Co-Executive Producer
Dee Johnson, "ER" Co-Executive Producer
Mark Morocco, "ER" Medical Supervisor

Dear Mssrs. Parsons, Meyer, Wright, Wells, and Gemmill, Ms. Johnson and Dr. Morocco:

On behalf of the Center for Nursing Advocacy, I am writing about an issue of vital importance to the future of our nation: the state of the nursing profession. Media products under your influence, notably the NBC/Warner drama "ER," are harming the profession of 2.7 million American nurses by giving the public an inaccurate and inadequate account of what nurses really do to save and improve lives. Research suggests that "ER" strongly and negatively influences the way children view nursing. These products contribute to the nursing shortage, a public health crisis that threatens millions worldwide. One solution is to consult experienced nurses, but this is rarely done. Please let me know how you plan to improve your organizations' performance. We will be following up with the makers of "ER" shortly to discuss our concerns further.

The October 9, 2003 "ER" episode embodies many aspects of the media's ill treatment of the nursing profession. The show is about a bad day for nurse Abby Lockhart, whom the Warner Bros. web site still describes--despite our repeated protests--as having been " demoted to nurse." Despite a few positive elements, the episode sends a series of destructive, grossly inaccurate messages about nursing. Perhaps designed in part to show how hard it is to be a nurse, the episode in fact drops a half-smart bomb of disinformation. Here are some key inaccuracies and distortions that the episode presents to many millions of impressionable viewers:

  • Today, hospitals are cutting senior nurses back to part-time, so they can cut their benefits and hire cheaper traveling nurses and new nursing grads who will work for "minimum wage." In fact, there is now a critical nursing shortage. Hospitals are desperate for nurses--any nurses. Rampant short-staffing and forced overtime are driving many nurses from the profession they still love. This forces hospitals to hire agency and traveling nurses who are in reality far more expensive than staff nurses. As educated professionals who hold lives in their hands, nurses are paid far more than minimum wage.
  • Nurses report to physicians and serve at their will. This is false, despite what "ER" has told its viewers for many years. Nursing is neither peripheral nor subordinate to medicine, but is an autonomous profession with its own managers and its own professional and ethical responsibilities. Nurses collaborate with physicians but physicians do not supervise, hire or fire nurses. We made all this clear to the makers of "ER" in a conference call two years ago.
  • Nurses can excel by learning some medicine, but they should know their place. In fact, all U.S. Registered Nurses have at least two years of rigorous, college-level scientific education. Nurses who pursue graduate health degrees generally do so in nursing, as shown by the nation's 200,000 advanced practice nurses, virtually all of whom have at least a master's degree. Though media products like "ER" rarely show it, nursing expertise complements medicine but is independent of it. Indeed, nursing is the central function of hospitals, and nurses save or improve millions of lives every day. The nursing profession is second to none.
  • No one wants to be a nurse, and really, why would anyone want to? Today's short-staffed nurses obviously do face many challenges, not least of which is the continuing disrespect of the mass media. But the profession remains an extraordinarily important and often exciting pursuit. It is critical that the media let this be known if we are to resolve the shortage that has already claimed thousands of lives. Our families' lives depend on it.

I explain these problems in detail below, ending with a summary and urgent request for action.

Inaccuracy No. 1: Today, hospitals are cutting senior nurses back to part-time, so they can cut their benefits and hire cheaper traveling nurses and new nursing grads who will work for "minimum wage."

In the October 9 episode, many of the veteran ED nurses sign a petition and stage a walk-out when they learn the hospital has the plan outlined above for them. As a result, six nurses are summarily fired by chief of ER medicine Romano and a number of other nurses are given 90-day suspensions. Lockhart does not join the petition, at least in part because she is upset by a breakup letter from physician boyfriend Carter, and perhaps because the show has assigned her a supervisory position that the show itself does not seem to understand. Here she is called a "charge nurse," though last season she was forcibly made "nurse manager." The show clearly has little idea what either of these positions or any nurse management job entails. At one point a character says that some of the nurses will be speaking to "nursing administration" about the problem, but we never learn any more about that.

This story line seems mainly designed to show how the beleaguered Lockhart is caught in the middle, and that Romano lost none of his arbitrary cruelty when he lost his arm. But it also sends a message that there is such a glut of nurses eager to work for nothing that hospitals can jerk them around at will. Although real life nurses obviously were targeted for cuts some years ago and this has been a significant factor in the current shortage, this story line is a dangerous fantasy. "ER" has virtually never shown any awareness of or concern for the real nursing shortage, but blundering into a volatile situation like this is inexcusable. It's possible that the comment by nurse character Lydia that the new grad nurses will be paid "minimum wage" is not meant to be taken literally, but will viewers who know little of nursing understand that? Many viewers may assume that nurses really do earn something like minimum wage. And the traveling-nurses-are-cheaper element shows profound ignorance of the reality of nursing today.

In addition, the episode shows nurses casually abandoning their patients mid-shift, which would be a serious ethical violation and rarely if ever occurs. Of course, if you view nursing as largely peripheral work the patients can probably do without, such abandonment is not such a big deal. The med. students and clerks can pick up the slack. And they do: the episode shows medical students giving medications on their own, with no nurse present. Granted, they do run into some problems.

There is one bright spot. As part of their discussion, Lockhart does briefly tell Romano that cutting the RN-to-patient ratio will likely result in patient deaths, something that recent studies of RN-to-patient ratios have proven to be true. Of course, the show does little to show why that might be, but perhaps this comment will have some small positive effect for those who notice it.

Inaccuracy No. 2: Nurses report to physicians and serve at their will.

This is obviously nothing new for "ER," but the episode is an especially powerful example of this continuing, destructive inaccuracy. "ER" has always stressed that nurses work for physicians, who can fire them if they choose. Here, Lockhart tells Romano that he "can't fire nurses," though she does not say why. Romano responds that he can if they walk off the job. To this Lockhart has no real response, as is often the case. The makers of "ER" continue to be interested in showing nurses absorbing physician abuse, but they still have no clue what a real nurse might say in response, or how the nursing profession is actually governed, i.e., by nurses.

As in past episodes, the firings and disciplinary measures go through with no evident involvement from any nursing manager, despite the suggestion that the nurses were going to see "nursing administration." We suppose it is minimal progress that "ER" has finally realized that higher level nursing managers exist, but it is not clear what such managers actually do, since they never appear. And they never seem to have an impact on what happens on the show.

In one astonishing scene, ER physician Susan Lewis forbids Lockhart to tell a desperately ill teenage girl that she has a fatal heart/lung condition, out of respect for the wishes of the girl's parents. The girl is increasingly panicked because she is getting clues that something serious is wrong with her, but no one will tell her the truth. When Lockhart flatly tells Lewis that this is wrong, Lewis responds impatiently that Lockhart can't talk to Lewis' patient if Lewis asks her not to, because Lewis is the patient's physician, Lockhart is the patient's nurse, and Lockhart must do what Lewis says. Lockhart has--you guessed it--no response except to look hurt.

This is classic "ER"--a physician character inflicts a devastating, grossly inaccurate put-down on the basis of another character's status as a nurse. In this case, the implication that patients belong to physicians, and that nurses are merely physician appendages, is especially insidious. And because there is no response from Lockhart, most viewers are likely to conclude that while the physician may be stressed out or even a malicious jerk, what she says is essentially true. Of course, in reality, nurses have independent professional responsibilities to their patients which do not depend on what physicians think, nurses work with but do not report to physicians, and patients' concerns are as much the province of nursing as medicine. In this case, Lockhart--as a patient advocate--should have fought for what she believed was in her patient's best interest, taking this issue to the hospital's ethics committee, if necessary. Nor would it seem consistent with Lockhart's ethical responsibilities to simply ignore the parents' concerns and tell the minor patient anyway, as the episode's last scene seems to suggest Lockhart does.

Inaccuracy No. 3: Nurses can excel by learning some medicine, but they should know their place.

The episode begins by having Lockhart take charge of showing a new batch of medical students some things about the "ER," including actual health care procedures. Of course, as usual, the implication is that the nurse has only enough knowledge to help medical professionals who are somehow impaired, in this case by their inexperience.

At another point, a medical student accidentally gives a medical resident too much epinephrine for his asthma, sending him into V-tach. Lockhart comes by and saves the resident (and his hapless cohorts) by defibrillating him. We suppose that we should be gratified that the show has, after nine years, finally shown a nurse doing an exciting technique that real nurses do every day. But the fact that it occurred in such a unique situation, involving inexperienced medical students, takes a lot of our enthusiasm away--as does the fact that Lockhart does the procedure improperly and without the sedative the patient requests.

Other elements of the episode send more troubling messages about nurses' skills. In one scene, Lockhart urges the reluctant physicians to crack a crashing patient's chest. They resist, though Lockhart pushes so hard for the thoracotomy that she is, as Lewis notes with disapproval, practically ready to do it herself. This is consistent with this year's apparent theme of showing Lockhart to have significant technical knowledge and an increased willingness to push the physicians to consider her ideas for treatment, at times actually appearing to prevail in the resulting dispute. Here, Lockhart even mocks the physicians for their reluctance to do the procedure. And as it happens, cracking the patient's chest here is indeed an obvious call given the patient's condition.

However, it is pretty clear that the show feels Lockhart is being driven to insolently challenge physician care by her own frustrations, probably some anti-physician animus related to her problems with Carter. The show thinks she is being insubordinate. But another fundamental problem is that, as in the past, the show is suggesting that nurses excel by learning medicine, not nursing. Despite all the anonymous nurses who function as the show's human wallpaper, the show rarely focuses on actual nursing care. It appears to have little idea how one might show nursing expertise or professional development, to say nothing of the work of the nation's 200,000 graduate-prepared advanced practice nurses. Like serfs trying to show their worth to the higher classes, both Lockhart and her predecessor Carol Hathaway have demonstrated their real value only by showing interest in and aptitude for medicine. Higher nursing education does not exist.

Indeed, the show seems to think all nurses are basically interchangeable. At one point in the episode, veteran minor nurse character Malik tells Lockhart that he is not involved with the walkout because he is an LVN and so "it don't get no cheaper than me." This is truly bizarre. In all the years Malik has been on the show, apparently doing the same jobs as Lockhart and the other ED nurses, we have seen no hint that he is not an RN. In fact, LVN's generally do not even work in level I trauma center EDs, as they are not trained for many of the nursing tasks required.

Even within this dangerously flawed vision of nurse achievement through medical knowledge, the show wants us to know that there are limits. Lockhart is portrayed as overstepping her bounds. And Lewis is not the only attending physician to make clear that she is out of line. The highly respected surgeon Corday also peers across the thoracotomy patient at Lockhart, then explains why they won't do what Lockhart wants. In doing so, Corday seems more perplexed than annoyed--what is this nutty nurse on about? Only the relatively inexperienced resident Pratt seems to feel Lockhart had some justification for her actions, though he is hardly a poster boy for appropriate conduct himself.

Perhaps the most notable comment on nursing expertise in the episode comes from the hotshot surgeon Dorset, who is presented as the epitome of arrogant surgical brilliance, a swaggering, irresistible rogue. Medical students swoon over his mastery of sightless surgery, and Corday is soon getting intimate with him while on a coffee break. The show gives no indication that any character feels anything but justified awe for the man.

Into the mouth of this godlike character the show inserts an extraordinary line. At one point during Dorset 's virtuosic intervention into a patient's chest, he asks a medical question that two gawking medical students cannot answer. Lockhart tentatively does answer the question, prompting the surgeon to note that the students have been "nurse slapped." Lockhart seems to take this as a crude compliment, and at first glance it kind of sounds like one, since it suggests that she has contemptuously shown them her superior power (in the form of knowledge), as a pimp might in "bitch slapping" a prostitute.

But this does nursing no favors. First, as noted above, it suggests that nurses excel only to the extent they can absorb some medical knowledge. Second, the comment paints Lockhart as an abusive aggressor, which--the show's apparent view aside--is no model for professional conduct. In fact, Lockhart's actual demeanor in answering the question has the opposite problem--she is far too meek in offering her modest little view to the Great Man. Most fundamentally, Lockhart has a bachelor's degree in nursing, some medical school and many years of hospital experience. Is it a great compliment that she knows more than a couple fresh-faced medical students? What it does suggest is that for a medical professional to be upstaged by a lowly female nurse, no matter how much more experienced she is, is akin to being an oppressed woman dealt a dismissive physical blow. It is unmanly, and in the world of Mr. Testosterone, that is the worst you can be.

Inaccuracy No. 4. No one wants to be a nurse, and really, why would anyone want to?

Perhaps for the first time on "ER," the show actually shows a nurse, in this case Lockhart, acting as the triage nurse. Triage is a critical ED function in which nurses autonomously determine how sick people are and how quickly they need to be seen, life and death work that the show only recently even admitted that nurses do. Unfortunately, even this laudable effort is corrupted by the show's vision of the job as a kind of glorified baby-sitting, as Lockhart sees a succession of kooky people with fairly trivial complaints but an excessively demanding attitude. The idea is to show how this annoying parade helps to wear Lockhart down on her bad day.

Dealing with a range of distressed people is indeed a part of triage nursing. But we fear the average viewer will conclude that is all there is. The show gives no sense of the job's critical importance or the real nursing expertise it requires. Real triage nurses save lives all the time. But with only one exception, no patient Lockhart sees at triage appears to need urgent care, and a critical opportunity to educate the public is wasted. Even worse, in a bid to heighten the comic effect that actually serves to emphasize how mechanical and trivial the show thinks the work is, the show repeatedly has Lockhart punching the time stamp on patient charts, as if she had a simple, monotonous job on an assembly line.

As if the romantic jilting, tedious work, petty annoyances, staffing problems and physician abuse were not enough, did we mention that the public does not respect nurses? This reality is brought home to Lockhart when she escorts a gaggle of cute male and female school children to an upper floor of the hospital. Their teacher asks if any of them wants to be a nurse, and Lockhart helpfully adds that boys can be nurses too. The response from the kids is silence. Then one cute little girl says she want to be a physician, and other kids scream "me too!" Lockhart's response? We think you can guess, but we'll tell you anyway: hurt silence.

As for the children's views, well, yes. That is how many people think, and you can hardly fault a show for telling the truth. But would it have been too much to expect some stab at a response, some small effort to let America know why people think this way, or that it is a threat to our future, or that nurses do critical work saving lives and nursing can be very fulfilling despite the problems? Guess so. With no hint of any alternative vision, who could blame a viewer for concluding that the children are simply using good sense by rejecting nursing. As Lockhart herself says at one point, "I hate my job."

5. Summary and Urgent Request for Action.

Thus, an episode that the makers of "ER" may well have viewed as a hard-nosed but empathetic look at challenges nurses face amounts to one of the most damaging assaults on the nursing image that we have ever seen. In general, "ER" is so damaging because it strives so mightily to portray medical diagnosis and treatment as they really are that viewers may well believe it is equally dedicated to a realistic portrayal of nursing and the roles health care professionals play.

Why does this happen? For one thing, it seems clear that this show and many others continue to refuse to consult experienced nurses in developing scripts. This episode is consistent with a show that gets all its significant technical advice from people who may have worked with nurses, but have never understood what nurses actually do. Moreover, without impugning any motives or the fine work of any health care professionals, we cannot help but note that the media's inaccurate presentation of nursing as subordinate, peripheral work does no obvious harm to the standing of the medical profession.

In the end, while we appreciate "ER"'s apparent effort to empathize with nurses, we can only urge those responsible to honor one of the key tenets of the medical profession: first, do no harm.

We strongly urge the recipients of this letter who are responsible for "ER" or any comparable media productions to hire advanced practice registered nurses to review all scripts, to ensure that no further damage is done. Your health and the health of all people depend on it. If you cannot find a suitable person, we will be happy to help you. In addition, we believe it would be appropriate to make amends for the damage done by making tangible efforts to address the nursing shortage, as Johnson & Johnson has done in their recent "Campaign for Nursing's Future." Finally, we will be requesting a conference call with the makers of "ER" to discuss our concerns.

Thank you for your time.


Sandy Summers, MSN, MPH, RN
Executive Director
Center for Nursing Advocacy
203 Churchwardens Rd.
Baltimore, MD 21212-2937

cc:  Barbara Blakeney, RN, MS, ANP, President, American Nurses Association
       Diana J. Mason, RN, PhD, FAAN, Editor-in-Chief, American Journal of Nursing
       Kathy Robinson, RN, President, Emergency Nurses Association
       Gail Pisarcik Lenehan, RN, EdD, FAAN, Editor, Journal of Emergency Nursing