Changing how the world thinks about nursing

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

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 and Ms. Johnson:

In your Oct. 30, 2003 "ER" episode "Out of Africa," your television program effectively suggested that nurses advance by attending medical school, continuing your show's long tradition of virtually ignoring the nation's 200,000 advanced practice nurses, and the fact that recent data suggest nurses who obtain graduate education are at least 50 times more likely to do so in nursing than medicine. I strongly urge you to stop this destructive plot line and suggest that you make amends to the nursing profession by having Abby Lockhart enter into an MSN or PhD program to become an emergency/trauma Clinical Nurse Specialist.

In the October 30 episode, the Lockhart character returns to medical school years after her ex-husband's financial difficulties ended her studies. In the intervening time, Lockhart had appeared to embrace her role as a nurse. Registered nurses need not attend graduate school to provide excellent care and save lives, and recent episodes suggested that the show was making a few stabs, however flawed, at showing the character acting as a real patient advocate. Lockhart occasionally engaged physicians in discussions about care, pushed for more autonomy in dealing with patients, and actually treated physicians as if they were peers.

However, it now seems that the producers did not insert these elements to show that the talented Lockhart was becoming a stronger nurse, but as signs that she was chafing under the limits of what they appear to see as the peripheral, subordinate nursing role. Evidently Lockhart was destined to return to medicine, where, in the show's view, she could really make a difference for the patients. Lockhart's more formidable predecessor, Carol Hathaway, had also considered medical school. Of course, medicine is a noble profession, but it is far from the first or most logical choice for nurses seeking post-graduate training. Nursing is. Among the many exciting graduate nursing programs open to a nurse like Lockhart: emergency/trauma clinical nurse specialist.

To fill the show's traditional one-major-nurse-character quota, new character Samantha Taggart was also introduced in the October 30 episode. Unfortunately, she is of the gender and race that has traditionally dominated US nursing, which does nothing to help us recruit more men and minorities into nursing. And more than once she was referred to as the "new girl," despite being old enough to have a son perhaps 8 years old. I can't recall the show referring to experienced female physicians as "girls."

Will the Taggart character be able to illustrate much of the real life nursing role? In this episode she spent significant time at triage, a critical ED nursing role which "ER" has evidently now decided to show on a consistent basis. I applaud this move, even if it came over 200 episodes into the show's run. Commendably, the episode also suggests that triage matters, as a patient who left after not being seen for many hours later died as a result of a condition that could have been successfully treated. Unfortunately, this suggestion is undermined by the show's clear message that an inept resident physician was to blame. Taggart did ask this resident to see the patient, but a triage nurse is responsible not only for making the acuity judgement, but also for seeing to it that the patient receives attention from physicians--and nurses--consistent with that judgement. Triage is not just pestering physicians to work faster. The fact that the show did not even think to assign Taggart any responsibility for the patient's demise suggests that it does not fully understand the responsibilities of triage nurses. This is a key point: the Center has never asked that nurses always be shown in a positive light. Showing the deadly consequences when nurses err is also a key part of nursing getting recognition as the serious profession it is.

A few other troubling elements of Taggart's introduction deserve comment. Taggart reports to the ED looking for the "charge nurse," and clerk Frank responds flippantly, "we have a charge nurse?" Apparently unbeknownst to the producers and/or technical advisors of "ER," the charge nurse is a position assumed on a shift-by-shift basis by an experienced staff nurse who oversees patient care and coordinates the assignments of other staff nurses during that shift only. No shifts lack a charge nurse, and a clerk would be very aware of who the charge nurse is, since much of the ED's work revolves around that nurse. The show appears to (again) be confusing the charge nurse with the nurse manager, a long-term position which is rarely, if ever, vacant. The clerk would also be well aware as to the identity of the nurse manager.

At another point, veteran minor nurse character Chuny Marquez notes that no other nurse on the shift besides Taggart speaks English, an apparent reference--and not the show's first--to the language skills of the flood of new Filipina nurses the ED has hired in the wake of the mass firings and suspensions of the October 9 episode. This kind of comment--arguably racist and especially odd coming from the apparently Mexican-born Marquez character--implies that you don't need good English to be hired as a registered nurse at a Level One trauma center. That might be true if modern nursing was a menial job that did not involve constant, technical communication with patients and colleagues. But it isn't.

In a similar vein, Taggart asks Lockhart if she "used to" be a nurse, and Lockhart responds that she guesses she still is, since she will still be taking some shifts to earn money. The idea that nursing is like some part-time high school job that you "used to" do sends a harmful message about a serious, autonomous profession. Would anyone ask Senator Bill Frist or Presidential candidate Howard Dean if they "used to" be physicians? Of course not. No matter how far they get from a clinical setting, they will always be considered physicians, and will be happy to have people think of them that way. Here, Lockhart has not even left the clinical setting, but the show suggests that her identity as a nurse depends on what her last pay stub says.

Taggart, like her predecessors, will be limited by the need to share screen time with the 10 major medical characters. Actually, when I first heard about her, I thought that the producers might have decided to maintain two nurse major characters, perhaps as a small, belated nod to the fact that the nurse-physician ratio at real Level One trauma centers is about 1:1. Lockhart's return to medical school disabused me of that notion. In any case, the wildly unbalanced ratio of major characters continues to foster the false and damaging impression that physicians provide the great majority of important care in ED's.

I strongly urge you to rectify the problems with your depiction of nurses. As I have mentioned before, the only reliable way to consistently portray nursing in an accurate light is to hire an advanced practice nurse to advise on each script. We will be happy to supply you with a list of potential candidates.

We would also like to set up a conference call to discuss these issues with you in greater detail. 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