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The scrubbed nurse

April 17, 2005 -- Tonight's episode of ABC's "Grey's Anatomy" actually presented a significant nurse character, dying pancreatic cancer patient Elizabeth Fallon. We have to give the show credit for a nurse character who was not a huge problem at first glance. Indeed, the bedridden Fallon was formidable and savvy, and the show suggested that she was an excellent nurse, though it has never offered viewers any hint as to what excellent nursing might consist of. The bad news is that Fallon was also seen as a career physician appendage, and her main professional focus seemed to be gruffly charting the progress of the physicians around her. Otherwise, the show's physician nursing continued unabated. Surgeon characters provided all monitoring, emotional support and advocacy for patients, practiced hospice nursing, and even handled deceptively difficult nursing tasks like enemas and colostomies. The episode was written by James Parriott, and the medical advisor was Karen Lisa Pike, MD.

The Fallon character has two main functions in the episode, "No Man's Land." First, since she had worked with intern Meredith's mother Ellis--a famous surgeon--for many years, she is there to give Meredith some perspective on her mother, who now has Alzheimer's and resides in a nursing home. Fallon bonds with Meredith about her mother's self-centered focus, even calling her a "bitch." Ellis, who has difficulty recognizing her daughter or husband, instantly remembers Fallon when Meredith brings her up, noting that Fallon was "excellent"--presumably a reference to her professional skill, since neither Ellis nor Fallon would seem to be excellent at much else.

Second, Fallon is there to help intern Cristina learn something about the limits of medicine, and her own naked ambition. Fallon and the attending physicians dangle the possibility that Fallon might need a sexy surgical procedure and that Cristina would have the inside track on participating, when in fact Fallon has only come back to her old hospital to die. (The surgical service certainly is a novel hospice choice.) This somewhat sadistic gambit could be seen as the nurse engaging in a kind of informal teaching of the overeager intern, something we have argued such dramas should show. Indeed, in playing these roles from her deathbed, Fallon projects a brusque, no-nonsense persona not unlike a drill sergeant interacting with some green officers-in-training, a la "An Officer and a Gentleman." She cackles at Cristina's transparent competitiveness. Fallon seems to have no friends or family outside the hospital staff, and some might see her as a bit of a lonely battleaxe figure; her last words explain the lesson to Cristina: "Think of it as a hazing ritual." But the show sets Fallon up as an "institution" in the way that Ellis herself was, a demanding surgical obsessive who has sacrificed everything for the job, and it's hard to say that this is bad for the nursing image, given prevailing attitudes. In addition, the show gets points because Fallon is played by a black actress; U.S. nursing desperately needs greater racial and gender diversity. And the actress playing her, Anna Maria Hosford, does a fine job of conveying a weary humanity under the character's harsh, incisive exterior.

The problem is that nurses are not sergeants who train physicians to be commissioned officers. (Virtually all U.S. military nurses are commissioned officers.) Fallon's remark that she was "Ellis' scrub nurse for 18 years" is a slap in the face to perioperative nurses, who are highly trained, autonomous professionals with their own science-based scope of practice. They work with surgeons, not for them. Fallon tells Cristina that she will call her "Cristina" and that the intern should address her as "Nurse Fallon," which sounds like a crude but pro-nurse reversal of the usual portrayal of nurse-physician naming--except that it's done mainly to be provocative, and to underline Cristina's rank newcomer status. To our knowledge, no other nurse has ever named or been named by a physician on "Grey's Anatomy." On the whole, the Fallon character is likely to give many viewers the impression that nurses are focused mainly on watching and perhaps assisting in the training of physicians, as if that is all that matters. In fact, nurses are focused on nursing, a complex science which like medicine entails a lifetime of learning, and experienced nurses also spend significant time training more junior nurses. Nurses' time is consumed with nursing, not observing and monitoring physician interactions and physician development.

Otherwise the show reverts to form, suggesting that only physician care matters, and having physicians spend a lot of time doing tasks that nurses do in real life, effectively giving them credit for the work of nurses. In general, nurses are completely absent from patient scenes. The physicians keep critical patients calm and provide all emotional support. Intern Izzie and resident Bailey are the only ones who interact with a patient confronting prostate cancer, and only physicians actually interact with Fallon about her care--an extraordinary distortion of the final hours of a slowly dying hospital patient, which would consist largely of skilled nursing care. Cristina, expressing her disagreement with Fallon's decision to have no heroic measures delay her death, says she would want the "doctors to do everything they could." Clearly, the show thinks that only physicians have a significant role in saving lives.

The show again suggests that the interns perform specific care tasks that nurses do in real life. An attending appears to direct Cristina to give an enema, Meredith suggests that she has dealt with patients' colostomies every "15 minutes," and Cristina transports Fallon around for tests. Of course, you might ask why we would object to the show assigning the interns nursing tasks that most people would not regard as attractive. Cristina refers to her time moving Fallon around as being a "cruise director." The reason is that, whatever the show or its characters may think, these tasks are important to patients' health and wellbeing. Nurses coordinate care by various members of the health care team and monitor patients as they undergo that care; you could regard that as being a cruise director, or you could see it as being the captain. Nurses are the ones who manage things like enemas and colostomies. It takes professional skill and great strength to perform these procedures properly, including educating and monitoring the patient during the procedures, while at the same time protecting the patient's dignity by not laughing, expressing disgust or embarrassment, or gagging (a great challenge for many pregnant nurses). Moreover, some of the tasks are clinically complex. For instance, certified ostomy nurses train extensively to manage colostomies. Physicians are not trained to provide such care, and they would not be qualified to do it. Of course, viewers will not immediately think less of nurses because the show assigns physicians what everyone thinks is scut work. But nurses will never be able to explain the importance of such care tasks if they can't get credit for doing the tasks at all. In the end, this type of physician nursing forms part of the show's overall vision of physicians as the providers of all meaningful care.

The physician characters on "Grey's Anatomy" also handle virtually all the patient advocacy. Meredith pushes a young couple to weigh carefully the choice between two treatment options for the husband's brain tumor. Izzie and Bailey advocate for the prostate patient to retain enough nerves for a chance at a good sex life. And attending Burke pulls Cristina away from her attempt to do a full code on Fallon, despite the patient's do-not-resuscitate status. And this brings us to the fleeting instance of patient advocacy by an actual nurse. The one nurse who has been permitted to emerge from the wallpaper as an actual caregiver on "Grey's Anatomy"--though he still has no name--is a young black man who had a few lines in the premiere. Here, he shows up at Fallon's code, and argues briefly that they should not code her, given her DNR status. But Cristina continues, and the nurse seems to just give in and join the code--it's hard to say, since he and the other nurses abruptly disappear from the scene so the camera can focus solely on Cristina. Only Burke, when he finally arrives, has the juice to pull Cristina off the patient so she can die. Needless to say, this is not exactly a shining example of patient advocacy by the nurses. That, as ever, is for the physicians.

We are pleased with one thing about the episode: for the first time on "Grey's Anatomy," a nurse character (Fallon) has actually been given a name! We wonder if the show will ever recognize any other nurse character in that way. Or does a nurse basically have to die on screen to receive such an honor?

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