Starring Noah Wyle, Maura Tierney, Laura Innes, Anthony Edwards, George Clooney, Julianna Margulies, Eriq La Salle, Sherry Stringfield, Alex Kingston, Goran Visnjic, Ming-Na, Sharif Atkins, Mekhi Phifer, Paul McCrane, Linda Cardellini, Parminder Nagra, Shane West, Scott Grimes, John Stamos
Executive Producers: John Wells, Christopher Chulack, Michael Crichton, Jack Orman, Lydia Woodward, Dee Johnson, David Zabel, R. Scott Gemmill
Constant C Productions and Amblin Television/Warner Bros. Television
"ER" is arguably the best major health care-related television series since "M*A*S*H," and it is one of the most medically realistic dramatic series ever. When "ER" leaves prime time after well over a decade on the air, it will also have been one of the most popular shows in history. It will likely continue for years in syndication around the world. Accordingly, it will continue to have a tremendous influence on how the global public views health care, including nursing. "ER" has generally portrayed nurses as competent, caring health workers and avoided the most obvious stereotypes. But the show's physician-centric approach has led to a continuing failure to give viewers an accurate or complete picture of the vital role nursing actually plays in modern health care. Throughout the show's run, only one of its eight to ten major characters has been a nurse, with the rest physicians or medical students. The few nurses who do emerge from the wallpaper tend to be skilled, but fungible. With rare exceptions, they serve as subordinates and romantic foils for the heroic physicians, who consistently do key care tasks that nurses do in real life.Since its inception in 1994, "ER" has focused on the professional development and personal lives of a shifting cast of emergency department (ED) and surgical physicians, and the personal life of one ED nurse, at "County General," the main public hospital in Chicago. Keys to the show's success have been its adrenaline-happy depiction of emergency procedures, complete with whirling camera work and faster-than-the-speed-of-light technical dialogue, an addictive soap opera approach to the intersecting lives of the main characters, and an amazing ability to regenerate itself with new characters--by the start of the 12th season, none of the original major characters remained. In addition, unlike some popular hospital dramas, "ER" has grappled seriously with many of the thorny issues raised by modern health care. It has also featured some inventive plotting, strong characters, good direction and fine acting. In recent years the show has slowed down creatively, and some digressions into the characters' non-work lives have grown tiresome. But "ER" is still capable of engaging work, and it remains very popular.
In its early years, "ER" introduced the model that would prove so effective: dedicated, intelligent physicians staggering under the volume and complexity of cases seen in a public Level One Trauma Center, and trying to cope with the effects on their professional and personal lives. The show's plot is too intricate to summarize fully here, but major characters in the early years included: John Carter (Noah Wyle), a wide-eyed medical student from a wealthy family who would ultimately become chief ED resident, and who may end up as the most important character in the show's history; Mark Greene (Anthony Edwards), a sensitive, decent ED chief resident whose marriage to an attorney ultimately fell apart and who became, as an attending, the show's moral center; Kerry Weaver (Laura Innes), an insensitive, physically disabled ED senior resident who consistently put herself before her colleagues, and became chief of emergency medicine; Carol Hathaway (Julianna Margulies), whose suicide attempt was featured in the series premiere, a tough and committed ED nurse who became a nurse manager; Doug Ross (George Clooney), a hunky pediatric ED resident whose maverick ways would eventually lead to his departure from the hospital and the show, followed by long-time flame Hathaway; Peter Benton (Eriq La Salle), a coldly intense surgical resident who seemed to have a maximum allotment of one smile per season, which he didn't always use; Jeanie Boulet (Gloria Reuben), an earnest, HIV-positive physician's assistant; Susan Lewis (Sherry Stringfield), a down-to-earth ED resident who would leave the show for several seasons; Elizabeth Corday (Alex Kingston), a skilled English surgeon who would ultimately marry Greene; and the great Robert Romano (Paul McCrane), an acid-tongued, highly skilled surgical attending who would become the chief of medicine and who served, along with Weaver, as the show's enduring character-you-love-to-hate.
As the show got deeper into its first decade, these characters began to leave and be replaced, a process that has never stopped. Ross and later Hathaway departed for the Northwest to raise their twins, and Benton left for a job that would allow him to care for his young son. Perhaps most significantly, Greene succumbed to brain cancer, leaving Corday to raise their young daughter alone. Corday returned to County and stayed for some time. But she eventually quit and returned to England rather than accept a demotion for performing a noble but illegal organ donation between two HIV-positive people. Romano lost his arm to a helicopter rotor. Then he spiraled downward, unable to regain his surgical ability, until the show finally killed him off--by having a helicopter fall on him. Lewis returned and later became chief of emergency medicine. But she struggled to be taken seriously, and eventually left for Iowa with her flight nurse boyfriend and their baby, miffed at having been denied tenure. Weaver took advantage of Romano's decline to become chief of medicine, meanwhile coming out as a lesbian and having a baby with her firefighter partner, who soon died in the line of duty. Weaver carried on raising their baby, and eventually had a hip replacement that allowed her to walk unaided.
The show anointed Carter, now ED chief resident, to be Greene's successor as its moral and professional heart. In the middle years of the show, Carter thrived professionally, becoming an attending. But he did not do as well in his personal life, getting close to a marriage proposal to newcomer Abby Lockhart (right) (Maura Tierney) before pulling back, and making several soul-searching trips to provide care in war-torn Congo. Carter returned from one of these with new girlfriend Kem. Their baby was stillborn, and Kem fled, but Carter eventually realized his heart was no longer in Chicago. He left to join Kem at the end of the 11th season, though he returned in the 12th season for a few episodes set in Darfur (Sudan).
Lockhart became the show's most important character as Carter faded. At first, Lockhart was a somewhat confused, alcoholic OB nurse who was attending medical school. Then she settled in as the post-Hathaway major ED nurse character, and appeared committed to nursing. Then she reversed course again and went back to medical school. Lockhart stayed in the ED as an intern and then a resident, eventually becoming involved with newcomer Luka Kovac (Goran Visnjic). Kovac was a Croatian ED attending who replaced Ross as the show's designated hunk, but who had difficulty overcoming the death of his wife and children in the Balkans war. By the end of the 12th season, Lockhart and Kovac were expecting a baby, Lockhart was an increasingly assertive resident, and Kovac had replaced Lewis as chief of ED medicine.
The post-Lockhart major nurse character has been tough young single mother Sam Taggart (Linda Cardellini). Taggart is highly skilled. But most of her early plotlines focused on her romance with Kovac, and their joint efforts to raise her son Alex in spite of the negative influence of his father--a violent criminal who ultimately escaped from prison and kidnapped Taggart and their son, before Taggart herself executed him with his own gun. Taggart became assistant nurse manager in the early 12th season episodes with the highly skilled, aggressive ED nurse manager Eve Peyton. But Taggart's new role seemed to evaporate with Peyton's abrupt firing for decking an offensive patient on Christmas Eve.
Other new characters arrived, and some stayed. Jing-Mei Chen (Ming-Na), a contemporary of Carter's who had briefly appeared on the show near the start, returned as a resourceful but troubled senior resident. After a time she quit the ED to care for, and ultimately euthanize, her failing father. Michael Gallant (Sharif Atkins) was a bright, decent medical student whose education was funded by his commitment to the U.S. Army. He was ultimately sent to Iraq. Neela Rasgotra (Parminder Nagra) was a bright but bookish medical student who went through her last year of school alongside Lockhart. Rasgotra accepted a prestigious internship at the University of Michigan, but quickly bailed out and returned to County, slowly growing more confident in the ED. Rasgotra also maintained a tentative long-distance romance with Gallant. They actually married, but Gallant felt compelled to return to Iraq, where he was killed by a roadside bomb. Gregory Pratt (Mekhi Phifer), an often arrogant intern struggling to care for his mentally disabled brother, had a relationship with Chen. Pratt later showed signs of maturing, and he became far more skilled, but he refused to pursue the chief resident job. Ray Barnett (Shane West) was a brash young resident who struggled to balance his day job with his passion for playing in a rock band; he became more committed to medicine, and was fired from his band. And in the 12th season, borderline incompetent resident Archie Morris (Scott Grimes), who had been a minor character, became a major one. As the new chief resident, he generally remained an annoying, self-important weasel, though he also showed signs of greater skill and decency.Since the beginning, the show has also featured a diverse group of recurring minor nurse characters. They have included Chunie Marquez (Laura Ceron), Haleh Adams (right) (Yvette Freeman), Lily Jarvik (Lily Mariye), Malik McGrath (Deezer D), Lydia Wright (Ellen Crawford), Yoshi Takata (Gedde Watanabe), and Connie Oligario (Connie Marie Brazelton). These characters have been well drawn, though in contrast to the major characters, we have learned little about their non-work lives. They are often busy at the periphery of a clinical scene, and they have occasionally played notable roles in specific plotlines. For instance, in the 12th season premiere, Marquez and Adams were seen playing a key role in coping with "July syndrome," which occurs each year when new physician interns start work.
"ER" has generally depicted nurses as competent, caring professionals with technical training who contribute to patient outcomes. Unlike many shows, it has resisted portraying them as Nurse Ratcheds, sex objects, or mute ciphers who appear occasionally to execute physician commands. It has shown some nurses to be men and members of minority groups, though all three of the major nurse characters have been straight white females. It has even shown nurse managers, though these depictions have been problematic.
Unfortunately, the show's limited efforts to highlight the work of nurses have been overwhelmed by the physician-centric vision that has dominated its first 267 episodes. This includes the hopelessly lopsided nurse : physician major character ratio, the regular portrayal of physicians doing and getting credit for exciting, important work that nurses do in real life, the frequent suggestions that nurses are physician subordinates, the intense focus on physician training while nurses' professional development is virtually ignored, the disproportionate emphasis on the one major nurse character's personal life, and the mishandling of slurs against nursing.
The Carol Hathaway, Abby Lockhart, and Sam Taggart characters are, along with "M*A*S*H"'s Margaret Houlihan and "China Beach"'s Colleen McMurphy, among the most influential portrayals of nurses in television history. The "ER" nurses are capable, nuanced and generally positive. Hathaway in particular was a strong character, and a nurse manager who at a few points actually confronted some real-life nursing issues. Although Lockhart was fairly weak early on, in later seasons she began to show signs of an actual nursing identity, explaining why she chose to remain a nurse rather than continue with medical school, teaching resident Gallant the ropes, and questioning some physician treatment decisions. Unfortunately, Lockhart appeared to grow frustrated with nursing and abruptly reversed course, returning to medical school. That suggested, wrongly, that nurses who pursue graduate education typically do so in medicine rather than nursing. Current major nurse character Taggart is a stronger character with obvious skills and a willingness to advocate for patients, though at first her toughness arguably veered into inappropriate aggression. Early in the 12th season, Eve Peyton made Taggart assistant nurse manager, but there has been no real mention of this since Peyton's departure. The recurring minor nurse characters likewise have been shown as caring professionals with skills.
Over the years, a few episodes of the show have made some effort to highlight nursing skills or concerns. The Hathaway era included a plotline about a nursing labor dispute, and one episode in which Hathaway (right) had to provide solo care to a critical patient in a dangerous hostage situation. Indeed, as a nurse manager, Hathaway confronted nursing administration over the floating of nurses away from ED, she started an ED clinic and hired a nurse practitioner to work there (that did not last long), and she even quit briefly over the effects of insurance on the ED's practice. At one point, Lockhart gave a brief but spirited defense of her nursing abilities, and at times she also engaged the physicians in meaningful care discussions (though her return to medical school suggested that this may have been part of her outgrowing nursing). Taggart's plotlines have included one where she provided significant autonomous care to a critically injured rape victim, albeit with disastrous results, and another where she actually made an important catch that an intern had missed--and received credit for it.
In its 12th season, the show presented the formidable, doctorally-prepared ED nurse manager Eve Peyton (right). She was not a major character, and she appeared in only six episodes. But it was an unprecedented portrait of a mostly autonomous nursing leader who was more or less the clinical peer of the attending physicians. Indeed, Peyton may have been the most clinically expert nurse character ever to appear on a major prime time U.S. show. She took the nursing staff firmly in hand, doling out advice, holding staff meetings, and telling senior physicians how they were screwing up. The show stressed her autonomy and professionalism. She pushed for systemic change in everything from ordering new supplies for cutting edge procedures to encouraging more hand washing. She brushed back physicians on her autonomy over the nursing staff--and even embarrassed them with superior clinical knowledge. After recruiting Taggart as assistant nurse manager, she briefly seemed to become something of a mentor to the younger nurse.
However, these isolated plotlines have been swallowed by the hundreds of hours "ER" has spent telling viewers around the world that only physician care matters much. For all its medical realism, the show remains a victim of what Kalisch and Kalisch have called "Marcus Welby syndrome": the inaccurate depiction of all significant health care being provided by physicians. The show has frequently shown physicians performing critical nursing tasks, such as triage, patient teaching, giving medications, providing psycho-social support, minute-to-minute care of the critically ill, and preventative care such as vaccinations. Nurses are not the only ones affected by this; the show commonly has physicians doing the jobs of social workers and respiratory therapists as well. The show's physician nursing is a natural result of its consistent practice of having only one of the eight to ten major characters be a nurse, when in a real life Level One Trauma Center the nurse-physician ratio would likely be about 5:5. The show's character ratio would make it difficult to portray the two professions' roles accurately even if the show wanted to.
Of course, the show does have some recurring minor nurse characters. But they have been used mostly to deliver brief patient status updates to physicians ("BP is 88 over 40!"), to absorb physician commands, and to act as dramatic foils for the main characters. These nurses rarely have substantial interactions with patients, and are almost never seen providing care without a physician. To our knowledge, they have not played a major overall role in any episode.
Moreover, the show has consistently portrayed nurses as subordinate to the physicians who dominate it, rather than as members of an autonomous profession--as exemplified by its frequent depictions of physicians managing, disciplining, and even firing nurses. It's true that Hathaway actually acted as a nurse manager at times in the early years, though she was at times presented as being under the authority of the ED attendings. Lockhart too was dubbed a "nurse manager," though she was forced into it and did next to nothing with the title. Now, it's Taggart's turn to ostensibly be "assistant nurse manager," but since Peyton's departure, Taggart has done no "managing," and it's not clear if there has even been a "nurse manager." Not surprisingly, the show has filled this nursing management void with physicians. It frequently tells viewers that physicians direct all care and essentially manage nurses, even if they may have hired some unseen nurse administrator to handle the paperwork. Some might expect better from a show that was created by a physician, and that has counted physicians as some of its key writers.
Of course, there were the six Eve Peyton episodes in the 12th season. These made crystal clear that Peyton, as ED nurse manager, did not report to ED physicians. But for a show that airs more than 20 original episodes each year, they were obviously a drop in the bucket. Moreover, the episodes' depiction of nursing autonomy was itself problematic. It suggested that Peyton reported to chief of medicine Kerry Weaver. And although we were not too concerned at first that Peyton was seen as a rule-bound "bitch"--the show has had its share of physician managers in that mold--Peyton's final episode was a crude and implausible swerve into extreme battleaxe territory. In that episode, Peyton got dumped by her boyfriend; decked an offensive patient dressed as Santa Claus and poured his own urine on him, with no physical provocation and no regret; was fired in a matter of hours; and bid farewell to the ED staff with standard PhD-type phrases like "bite me," "screw yourselves," and "you all suck." Peyton was at least fired by a "nursing supervisor" rather than a physician. But the episode spoiled even that nod at nursing autonomy by having ED medical chief Kovac send three of Peyton's nurses home because he foresaw a light shift, and call them "support staff" as he did so, with no contradiction.
The show has also given viewers little sense of the independent, science-based assessment and intervention that is central to the nursing process. In recent seasons it has occasionally depicted nurses in their patient advocacy role, which can entail questioning physicians' care plans and catching their mistakes. But this has almost always been when the physician is somehow impaired, as by illness or inexperience; otherwise, the nurses tend to lose out in such discussions. "ER" has not often shown a nurse acting as a primary force in a patient's outcome. Instead, with rare exceptions, physicians tend to receive all the credit or blame for the results.
Apart from the Peyton episodes, the show has paid virtually no attention to the professional development of nurses, such as through advanced nursing degrees, research or scholarship. Nurse characters have limited opportunities to display their special knowledge and skills, especially since nursing students are never shown. This stands in stark contrast to the show's obsessive focus on each stage and feature of the physicians' professional development, from medical students through the chief of medicine. Tellingly, Lockhart finally chose a medical career and Hathaway flirted with one, as if to prove that they were worthy of the show's attention despite "only" being nurses. All three major nurse characters have also spent much of their time in romances with the show's physicians, and in a number of episodes, a key role of the minor nurse characters has been to comment idly on the lives of the physicians.
The show has also developed a pattern of mishandling slurs against nursing. Typically, it will have a character who is socially unskilled--perhaps an abrasive attending like Romano or Weaver, an unhappy patient, or a visiting schoolchild--express contempt for nursing. Perhaps the character will suggest that nursing is all about bedpans, or call a female physician a nurse as an insult, or suggest that nurses don't know anything about the prognosis of a major stroke victim, or express fear at the thought of being a nurse but joy at the prospect of being a physician. In response, a nurse character will look hurt, but she will not say anything. Or the remark will be made outside of any nurse's earshot, and no one will question it. The show may think it's helping viewers see how hard it is to be a nurse. But the persistent failure to have any character rebut such slurs will likely lead many viewers to conclude that while the speaker may be mean, what he or she says is essentially correct. It's just not the kind of thing nice people actually say. There was one notable slur reversal. At one point, Peyton failed to get Kovac to come help a resident with a critical patient. So Peyton did the required cutting-edge procedure herself, teaching the residents as she went, then advised the late-arriving Kovac that if he needed her, she'd be off changing a bedpan.
Finally, though the show prides itself on being on the cutting edge of social issues and has referred to the budget crisis in public hospitals, it has still paid no serious attention to the current nursing shortage or the short-staffing that drives it. This is a shortage that has for some years been a major threat to global health, but that "ER"'s generally inadequate portrayal of nursing has done little to address. The Abby Lockhart character did suggest in passing in 2003 that lower nurse staffing would likely cause patient deaths --in the context of an episode in which chief of ED medicine Romano had unilaterally fired a number of nurses. And one of the 2005 Eve Peyton episodes included a fleeting reference to the hospital's agreement to implement one-to-four nurse staffing ratios. But that seemed to be a quick way to set up new assistant nurse manager Taggart, whose first big task was to fire Haleh Adams for working excessive overtime. That plot also wrongly suggested that the big problem now is some nurses seeking to work too many extra shifts, rather than the reverse problem of mandation, in which hospitals force nurses to work excessive hours in order to cut costs. The real problem of short staffing has never been explored.
Over its 12 seasons, "ER" has shown some real appreciation for the role nurses play in modern emergency care. However, that recognition almost invariably gives way to its obsessive focus on the training and practice of physicians. In real life, nurses, physicians and other health professionals have complementary and interdependent work relationships. But on "ER," the bottom line has usually been that the physicians' role is unrealistically large and robust, and the nurses' role correspondingly small and flat. In dramatic terms, the physicians are the tragic heroes, while the nurses are essentially members of the chorus.
In its 12th season, "ER" seemed less inclined to die than to fade away. With all the NBC show's original characters gone, it seemed at times to struggle for ideas. Yet many characters and plots remained compelling, and the show was still popular by any fair measure. It was still the only network hospital drama with much dramatic depth or understanding of real issues in modern health care, including care in conflict zones like Iraq and Darfur. The big news for nursing was the six-episode arc of formidable nurse manager Eve Peyton, played by Kristen Johnston. Despite Peyton's bizarrely unconvincing exit (in which she attacked a patient), her episodes presented an unprecedented portrait of a mostly autonomous nursing leader who was more or less the clinical peer of the attending physicians. Because of that, and other efforts to show that nurses are skilled and integral to ED care, we have given the show's 12th season a "fair" rating for nursing--the highest we have ever given any serial television show. However, there was still only one major regular nurse character (Sam Taggart). And the show remained focused on the training and practice of its many physician characters. They provided the vast majority of the care the show portrayed as important, including tasks that nurses do in real life. Of course, the show is far better than the abysmal "House" and "Grey's Anatomy," which see nurses as petulant dimwits who are irrelevant to serious care. But "ER" still has a long way to go.
The 12th season introduced no completely new major characters. But much of the drama was driven by new recurring characters, principally attending Victor Clemente, and to a lesser degree Peyton. Clemente was a maverick, streetwise physician who was interim chief of ED medicine for a time. He clashed with attending Luka Kovac and others who were used to doing things their way, but he did appear to be on the cutting edge clinically. Clemente's troubled past followed him from New Jersey, in the person of a married nurse with whom he continued a torrid affair involving illegal drugs. Her vengeful police officer husband ultimately found them and shot the nurse. She survived, but the cop continued to stalk Clemente, and he ultimately crashed from the resulting stress and sleep deprivation. Clemente appears to be gone for good.
Nurse manager Peyton appeared in six episodes near the start of the season. She annoyed everyone, micromanaging and manipulating the nurses while questioning the decisions of the senior physicians, particularly Kovac. Yet Peyton was also a formidable clinical expert and leader. She acted as a mentor to Taggart, hiring her as assistant nurse manager. Sadly, the producers had Peyton deck a verbally abusive patient, get fired and exit the ED in a barrage of profanity, all on Christmas Eve. Peyton never did become a regular major character.
After Peyton's departure, Taggart and the other nurses continued to appear in various plotlines as sidekicks to the physicians, but nursing did not again enjoy the same level of attention. No new nurse manager appeared, and Taggart's supposed position as assistant nurse manager was ignored. Of course, Taggart got some attention for her personal life. She broke up with boyfriend Kovac. She continued to struggle to raise her son despite the influence of her jailed ex-husband Steve--efforts that took on greater urgency as the season ended with Steve and a fellow inmate escaping from the ED in a blaze of gunfire, with Sam and her son as hostages. Toward the season's end, Taggart also took a live-in job as a private duty nurse to a wealthy man to earn money for her son's education. Nurse Haleh Adams received attention in a couple episodes when Peyton and Taggart fired her for working excessive overtime, after Peyton reported that the hospital had agreed to one to four nurse : patient staffing ratios. But that was just a throwaway line, with no explanation. Taggart soon hired Adams back during a short-staffed crisis shift, a move Peyton later blessed.
Kovac got and held the chief of ED medicine position, though the hospital leadership seemed to believe he had failed to handle Clemente well enough, exposing the hospital to liability. After breaking up with Taggart, Kovac resumed his relationship with proficient resident Abby Lockhart, who remains the show's moral and dramatic center. Lockhart became pregnant, and by the season's end she and Kovac were both anticipating the baby's birth, though the finale left Lockhart hurt in the ED gun battle, with the future unclear.
In other management news, chief of medicine Kerry Weaver continued to be only an occasional presence, appearing mostly to represent central management, once in a while to fill in as an ED attending. She did have an operation to correct her hip problem, and for the first time on the show, confronted life without her crutch. Former chief of ED medicine Susan Lewis disappeared at the start of the season virtually without a trace; we learned that she had accepted a position in Iowa, presumably miffed at having been denied tenure last year. And new chief resident Archie Morris became a major character. He remained mostly a bogus weasel, but he did occasionally display other qualities, at one point actually standing up to the rusty Weaver on a key clinical issue, consummating a long-running feud with the surgical chief resident by having hot sex with her, and displaying his genuine singing talent in Adams's Christmas show.
The other residents, struggling at first in their new roles as intern teachers, were at the heart of the season. In addition to Lockhart, resident Neela Rasgotra continued to get substantial attention, particularly for her romance with one-time major character Michael Gallant, a military physician who spent most of the season in Iraq. Viewers did get some sense of military care there from a couple episodes. Gallant and Rasgotra married, but their joy was short-lived, as he felt compelled to return voluntarily to Iraq, where he was ultimately killed by a roadside bomb. Meanwhile, in Gallant's absence, Rasgotra began to develop a largely unexpressed thing with rapidly maturing, hunky resident Ray Barnett, her roommate. A major development for Barnett was the apparent end of his budding rock music career. His band dumped him just as they got a potential big break, evidently because he was too committed to medicine. Finally, resident Greg Pratt struggled to determine his ultimate place in the scheme of things. He largely rejected his estranged father's efforts to reconcile. But Kovac ordered Pratt to join former central character John Carter doing relief work in Darfur (Sudan), and Pratt seemed to return a changed man.The season actually included several commendable, if oddly uninspired, Darfur episodes. These focused mainly on the noble Carter and physician colleague Stephen Dakarai, with a few skilled sidekick-type appearances from minor nurse characters. We can't think of another network drama that would have focused multiple episodes on the health problems in Darfur.
Even without the Eve Peyton episodes, there were obvious differences between the way "ER" portrayed nursing and the treatment the profession got on "House" and "Grey's Anatomy." While nurses on the new hospital dramas are mute or disagreeable ciphers who pop in to perform menial tasks for physician gods, "ER" nurses are generally skilled, three-dimensional members of the health care team. They can display knowledge and expertise. This season the show seemed to make a greater effort than usual to show that the nurses make substantive contributions to care, for instance, in managing the effects of July syndrome. The Eve Peyton episodes showed viewers a doctorally-prepared, clinically expert nurse manager who yielded nothing to her physician colleagues. They also told viewers that nurses manage nurses, and that some nurses are more skilled than others--a critical element for any profession that wants respect.
Of course, the show's vision of care remained highly physician-centric. There was only one major nurse character to balance the seven or eight physicians. The show often portrayed physicians doing and getting credit for exciting, important work that nurses do in real life (e.g., triage). The show continued to focus heavily on physician training while nurse training was largely ignored. And--despite the Peyton episodes--the show continued to suggest that hospital nurses report to physicians.
Peyton appeared in six episodes originally aired in late 2005. She was the first real manager the show had portrayed since the Carol Hathaway days in the 1990's. And she may have been the most clinically expert nurse character ever to appear on a major prime time U.S. show. The show presented Peyton as a kind of nurse manager / clinical nurse specialist hybrid. She took the nursing staff firmly in hand, doling out advice, holding staff meetings, and telling senior physicians how they were screwing up. The show stressed her autonomy and professionalism. She pushed for systemic change in everything from ordering new supplies for cutting edge procedures to encouraging more hand washing. She brushed back both attending Kovac and chief resident Morris on her autonomy over the nursing staff--and even embarrassed them with superior clinical knowledge.
Peyton displayed wit. When Kovac became annoyed with her insistence that he come help a floundering resident save a patient, he made the mistake of calling her "Miss Peyton." She responded that she had a PhD, so if he wanted to get all formal, he could call her "Doctor." Then Peyton did the cutting-edge procedure herself, educating the residents as she went, and told the late-arriving Kovac that if he needed her she'd be off changing a bedpan.
Peyton's plotlines provided an unusual focus on different levels of nursing. Peyton made Taggart assistant nurse manager, a job that would include "staff education" and "implementing nursing policies," though the move did echo to some extent the show's past suggestions that nurse management is mostly a burden assumed for a modest pay hike. Peyton also seemed to become something of a mentor to Taggart. The Peyton episodes mixed in an occasional brief look at the struggles of new nurse Inez. Her problems gave Taggart a chance to display her skill and to teach her less experienced colleague. One episode even included a fleeting reference to the hospital's agreement to implement one-to-four staff ratios, which was presented in a way that suggested Peyton herself was pushing for it. Unfortunately, Taggart's first big task was to fire Haleh Adams for working excessive overtime. That plot wrongly suggested that the big problem now is some nurses seeking to work too many extra shifts, rather than the reverse problem of mandation, in which hospitals force nurses to work excessive hours in order to cut costs.
Indeed, the Peyton character did not erase the show's problems. Even the episodes in which she played a major role were dominated by the physicians; they did not suddenly feature a fair depiction of the place nursing really occupies in ED care. The show suggested that Peyton reported to chief of medicine Kerry Weaver.
Peyton's own management style was problematic. At first, we were not too concerned that she was seen as a rule-bound "bitch"--the show has had its share of physician managers in that mold, Weaver being one--though unlike with the physicians, there was no benevolent nurse manager to balance Peyton out.
However, we found Peyton's final episode to be such a crude and implausible swerve into extreme battleaxe territory that it was hard not to see it as a hit against any nurse uppity enough to challenge the physicians who dominate "ER." Peyton had been willing to modify unworkable decisions, and she had seemed the consummate professional. But in this episode, she got dumped by her boyfriend; decked an offensive patient dressed as Santa Claus and poured his own urine on him, with no physical provocation and no regret; was fired in a matter of hours; and bid farewell to the ED staff with standard PhD-type phrases like "bite me," "screw yourselves," and "you all suck." One possible message: any ambitious, aggressive woman who chooses nursing (rather than, say, medicine) must be a bitter, deranged kook who deserves to be treated with the same patronizing contempt with which all women were once treated.
Peyton was at least fired by a "nursing supervisor" rather than a physician. But the episode spoiled even that nod at nursing autonomy by having ED medical chief Kovac send three of Peyton's nurses home because he foresaw a light shift, and call them "support staff" as he did so, with no contradiction.
The rest of the season was somewhat better than usual, featuring a number of clear and specific (if limited) portrayals of nursing skill. Sadly, these were often undermined to some extent by suggestions that the nurses reported to the physicians.
The season premiere went out of its way to show that veteran nurses play a role in coping with "July syndrome," which occurs when new physicians arrive in U.S. hospitals to begin their internships. The episode included nurse Chunie Marquez acting to prevent several dangerous intern errors, and Haleh Adams critiquing a new second year resident's intern teaching, both extraordinary plot elements for a U.S. network show. Unfortunately, the episode seemed to present the nurses mostly as assistants to the senior physicians. Rather than directly teaching the junior physicians and giving them a chance to improve, as real nurses generally would, the nurse characters simply reported the problems to the senior physicians, who then came down hard. (Ironically, an episode of the sitcom "Scrubs" this season actually outdid "ER" on this point, showing nurse Carla Espinosa teaching clueless interns directly and even protecting them from unjustified senior physician wrath.)
The season finale also combined good portrayals of nursing skill with suggestions that physicians were ultimately in charge of the clinical setting. In this one, Sam Taggart was charged with training an imposter EMT trainee who would later help Taggart's inmate husband escape. The trainee's cluelessness gave Taggart a chance to display her technical knowledge and ability to multi-task complex procedures in high stress situations. The episode showed Taggart managing to intubate the paralyzed Kovac with a gun pointed at her, and subtly working to defeat the violent plans of the prison escapees. But the episode also had chief resident Morris doing a lot of nurse-free triage. And several scenes suggested that Taggart reported to Kovac even with regard to her nursing functions.
On the whole, "ER"'s efforts to show that nurses play a meaningful role in care were still swallowed up by its physician-centric approach. All but one of the many major characters were still physicians, so there was no way the show could provide a realistic vision of the professional roles in a real level one trauma center, where the nurse:physician ratio is roughly 1:1.
Physician training remained a major focus all season. Viewers were frequently invited to consider different aspects of the residents' professional development. Nurse training was again ignored, apart from the few minutes of screen time given to inexperienced nurse Inez.
Physician characters regularly did most or all of the triage, giving of medications, histories and assessments, receiving patients from onrushing EMTs, defibrillation, psycho-social care of patients and families, education about care decisions and treatments, and discharge planning. Of course, real physicians also do some of these things, but the point is they do somewhere between some and none of each--not virtually all of each. It is evident that shows like "ER" do find nursing exciting and important. They just don't seem to know that what they're showing actually is nursing, or perhaps simply find it more convenient to reinforce the prevailing misconceptions.
"ER"'s 12th season was a small step forward for nursing. But whether the improvement will continue is far from clear.
Reviewed by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Last updated: September 29, 2006
This is the 2005-2006 (season 12) review. Also see archives of our "ER" season reviews for:
The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.