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Open letter to "ER" June 7, 2004

Dear "ER" Producers:

I was thrilled to hear about a special "ER" episode revealing that nurse character Abby Lockhart's return to medical school was just an illusion, and that she had instead become emergency services director of County General Hospital. Here is an excerpt from a June 7 item on The Center for Nursing Advocacy's web site about this:

In art-imitates-life shocker, NBC's "ER" follows example of nearby real-life hospital, naming nurse as emergency services director

A short item in the business section of today's News Press, a Southern California paper affiliated with the Los Angeles Times, reported that nurse Debra Brown had been named emergency services director of North Glendale's Verdugo Hills Hospital. In what appeared to be an astonishing coincidence, a nurse character is elevated to the same position on tonight's special episode of NBC's popular television show "ER"--which is filmed in nearby Burbank.

Debra Brown will reportedly "oversee all of [Verdugo Hills'] emergency operations." The hospital's emergency department has recently expanded to 12 beds, and the department apparently sees about 22,000 patients each year. ...

At the same time, tonight's special between-seasons episode of NBC's "ER" reveals that a significant plotline of the 2003-04 season had all been a Matrix-like delusion experienced by nurse character Abby Lockhart. The new episode opens the night after last month's season finale, in which it appeared that Lockhart had finally passed her medical board exam, after struggling through her final year of medical school for most of the season. But at the start of tonight's episode, Lockhart is shown waking up in an unfamiliar room, naked and surrounded by strange equipment, screaming at the thought of having returned to medical school and become a physician. Exactly what has happened to Lockhart is never made clear, but she is soon shown reporting for work on her first day as emergency services director of County General, the fictional Chicago hospital at which "ER" is set, with an air of relief and pride. Among the pragmatic, savvy Lockhart's first acts as director: the imposition of a moratorium on nurses fawning over physicians for having supposedly saved patient lives all by themselves, and new restrictions on physicians performing certain critical tasks, such as triage, patient education, and defibrillation, if better-qualified nurses are available to do them.

The surprise elevation of Lockhart shocked longtime "ER" watchers. Most had assumed that it was only a matter of time before "ER" lifer John Carter, an attending physician and former boyfriend of Lockhart, would join the ranks of physicians who would ascend to the director role on the show, on which nurses have never registered as much more than skilled but peripheral assistants to the dominant physicians. One senior "ER" producer noted that it was just a coincidence that the special episode appeared on the same day as news that Ms. Brown had been named ED director at Verdugo Hills, a hospital located within minutes of the Burbank location at the which the show is filmed, and to which the show's crew has occasionally traveled for care. "We honestly didn't know," she said, "but this just confirms what we've always said: you don't have to sacrifice realism to make compelling drama."

I was very disappointed to hear that, as the Center makes clear at the end of its item, the News Press story about Debra Brown's selection as head of emergency services at Verdugo Hills Hospital is real, but the "ER" episode described above is something the Center invented to make a point. Although nurses have had problems with "ER"'s portrayal of them as peripheral subordinates and love interests for the physician characters who dominate the show, we would be delighted if the show ever did decide to extend its well-known focus on "medical realism" to the nursing profession. We would be excited if "ER" ever showed its viewers that nurses can be health care leaders without becoming physicians. As you may know, in real life some nurses do direct emergency departments, and indeed, entire hospitals. Unfortunately, few people know this, just as few know that staff nurses are highly trained, autonomous professionals who save lives with cutting-edge technology, or that nursing is a distinct science whose scholars engage in ground-breaking research.

In the midst of the current nursing shortage and nurse short-staffing, which together are a public health crisis, it is critical that the public receive a more accurate account of nursing, so that it will demand that adequate resources and respect be allocated to the profession. We will never get the nursing we need until members of the public, including health care decision-makers, get a better understanding of just how important the profession is. The public needs to hear more stories about the role nurses can actually play, such as managing ED departments--or at least their own profession, as they have not usually been shown doing on "ER." I would like to be able to thank you for doing your part now to dispel years of harmful misinformation with plotlines showing the reality of modern emergency departments.

What might such realism look like?

It might entail hiring four additional major nursing characters, and eliminating five of the current major medical characters, in order to achieve a realistic 1:1 ratio of nurses to physicians, so the public would understand that physicians do not do 90% or more of the important work in modern ED's, as the show's set-up and plotting have always suggested. A 1:1 nurse-physician ratio would allow the nurse characters to start performing more of the work nurses really do, such as defibrillation and patient education, instead of having physician characters perform and take credit for such tasks. Realism would also entail showing the different levels of nurses who actually work in modern hospitals, from directors of nursing to nurse managers to clinical nurse specialists and other advanced practice nurses to staff nurses--and even to nursing students, who, to my knowledge, have never played any significant role in the show's decade on the air. The inclusion of nursing characters with varying levels of experience and authority would also allow the show to portray the reality of nurse training in the ED, as it has done so exhaustively and to such dramatic effect with medical characters over the years. And of course, the inclusion of a realistic number of major nurse characters would open up countless new dramatic options for the veteran show.

I know that North America's three million nurses and their families would be eager to tune in to an "ER" that showed how modern emergency departments--and emergency health care--really work. I hope you will consider making the new season the start of a new era in realism.



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