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Letter to "ER" from Kathy Robinson

Dear Mr. Wells:

I am writing on behalf of the members of the Emergency Nurses Association (ENA) and emergency nurses nationwide to express serious concern about the role of emergency nursing in ER. The October 9th episode of ER has elicited many responses from emergency nurses and others over the show and the messages sent by its depiction of emergency nursing. We realize that this show is first and foremost entertainment – a show about emergency physicians in a busy emergency department, but we are concerned that the significant inaccuracies about the nursing profession portrayed in this and other episodes are damaging the profession.

ER has encouraged the perception by its viewers and the public that it portrays emergency medicine as technically accurate as possible in the medium of television; what has been called "gritty realism." Why, then, is the portrayal of emergency nursing so grossly inaccurate? And what is the public to believe when the medical aspects of the show are so authentic? They will believe that the authenticity extends to the nursing on the show as well, reinforcing a serious negative perception about the nursing profession at a time when this country is in the grip of a critical nursing shortage.

As any of the more than 23,000 members of ENA could tell you, emergency nursing is exciting and dramatic enough without such fictional and inaccurate plot contrivances as new nursing graduates (or any nurses, for that matter) working for minimum wage, a walkout where nurses leave their patients in mid-shift, and the misconception that nurses work for physicians, who can fire them at will.

  • Nursing is a separate, autonomous health care profession, independent of medicine, with its own scope of practice, body of knowledge, licensing requirements, and independent professional responsibilities for patient care. A nurse can lose her or his license to practice for carrying out questionable or erroneous physicians’ medical orders. Nurses have an independent professional responsibility to their patients, and are obligated NOT to carry out such orders, but to catch and correct them, even if doing so requires reporting the physician’s orders to hospital management.

  • Physicians do not supervise, discipline, hire, or fire nurses. They do not have that type of authority within a hospital. Nurses are employed by the hospital to care for patients, while a physician only has "admitting privileges" at a hospital, and as such is not part of the hospital’s health care administration. In fact, emergency physicians do not even admit patients into the hospital – they must contact the patient’s own physician or a physician from the hospital’s referral bank in order to have a patient admitted. ENA’s 2001 National Benchmark Guide: Emergency Departments, found that 32.9% of the director of emergency services positions are held by nurses (35.4% are physicians), and 73.9% of emergency department managers and assistant managers are nurses, compared to fewer than 1% of physicians. Following the logic of your show’s emergency department structure, your physicians should be reporting to and taking orders from a nurse.
  • Nurses do not walk out in the middle of their shift in a work protest – an action that would cost them both their jobs and their licenses to practice nursing.
  • Given the current critical shortage in nursing, it is ludicrous to even think that a hospital would fire its senior staff to replace them with recent graduates, who also do not work for minimum wage. This situation would be even more ludicrous in the emergency department. Traveling, or agency nurses, are not a cheaper alternative to employing senior nurses. They are more expensive to use and command a higher hourly rate than in-house nursing staff.
  • Triage is one of the most critical areas in a hospital – and the registered nurse is identified by the Joint Commission on Accreditation of Healthcare Organization’s standards as the most appropriate person to perform patient assessment. A triage nurse must make independent health care decisions on the severity of illness or injury for each patient who enters the emergency department – hardly a position for a nurse to be assigned because she is "having a bad day."
  • The show’s nursing character, Abby Lockhart, is inaccurately described on the ER Web site as a medical student who is working as a nurse because she cannot afford her tuition payments. She would be more accurately described as a registered nurse who has returned to nursing after leaving medical school. Unless they already possess a nursing license, medical students are not qualified to work as nurses, and cannot legally do so.
  • In the emergency department, as in all areas of a hospital, nurses are the primary caregivers and advocates for patients. Without nurses, there is no health care. By not portraying nurses accurately in your show, you are missing out on countless dramatic storylines and doing nurses and the public a grave disservice.

We would be happy to work with your writers on technical nursing issues and to provide you with story suggestions based on real-world emergency nursing. We would also like to invite you and your writers to attend our upcoming Leadership Challenge 2004, February 26-29, in Salt Lake City, to meet with senior emergency nurses and nursing executives for a glimpse into the exciting real world of emergency nursing.


Kathy Robinson
2003 ENA President

cc: R. Scott Gemmill, Co-executive Producer
Dee Johnson, Co-executive Producer
Mark Morocco, Medical Supervisor
Barbara Blakeney, President, American Nurses Association
J. Brian Hancock, President, American College of Emergency Physicians
Sandy Summers, Executive Director, The Center for Nursing Advocacy



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