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A Lump of Coal

December 8, 2005 -- Tonight's episode of NBC's "ER" seemed to mark the final exit of ED nurse manager Eve Peyton, the only significant nurse character ever presented as the clinical peer of the attending physicians. Her departure after six episodes marked such a crude and implausible swerve into extreme battleaxe territory that it's hard not to see it as a dramatic hit against any nurse uppity enough to challenge the senior physicians who dominate "ER." In fact, it could even be seen as a message to any nurse presumptuous enough to challenge the show's own physician-centric vision. Peyton was always a rule-bound micromanager who was considered a "bitch." But she was also a formidable, doctorally-prepared clinical expert who acted as a mentor to lone major nurse character Sam Taggart. She modified decisions that proved unworkable, displayed a sharp wit, and seemed to be a consummate professional. But tonight, Peyton got dumped by her boyfriend; decked an offensive patient dressed as Santa Claus and poured urine on him, with no physical provocation and no regret; was fired on Christmas Eve; and bid farewell to the ED staff with standard PhD-type phrases like "bite me," "screw yourselves," and "you all suck." The episode did at least have Peyton fired by the "nursing supervisor" rather than a physician. But it also began with new chief of ED medicine Luka Kovac sending three of Peyton's ED nurses home because he foresaw a light shift, and calling them "support staff" as he did so, showing once again that even on "ER," you just can't keep a good handmaiden stereotype down. The episode, "All About Christmas Eve," was written by Janine Sherman Barrois, and seen by 15.4 million U.S. viewers.

As the Christmas Eve episode starts, Kovac seems to be so thrilled about his renewed romance with resident Abby Lockhart that he arrives at work doling out gifts. Because he expects a light shift, one of his gifts is to send one resident and three "support staff" home. The show cares only about which resident that will be; Neela Rasgotra prevails in a rock-paper-scissors contest.

Later, while several staff are working on a patient, Kovac asks nurse Haleh Adams to get something from the drug lockup. Adams replies that she can't leave the patient because she's "the only nurse." That line, standing alone, is an excellent indication of the importance of nursing care, as it suggests that Adams is so important that she must be there constantly. Never mind that we've just caught a glimpse of one of the show's anonymous wallpaper nurses who never speak; we agree that they do not count for anything.

Then Peyton enters and asks if they need help. Kovac asks her where the other nurses are. Peyton notes that they're "a little light, it seems Santa Claus sent half of them home." This is a good line, but it makes clear that the "support staff" Kovac referred to earlier were nurses, and wrongly indicates that he would have anything to do with whether they are sent home are not. As the show itself has recently stated, nurses are autonomous professionals, and this staffing decision would be solely for Peyton or another nurse manager. Evidently the importance of showing the beleaguered nursing profession to be autonomous must give way if it would be too much trouble to think of some other trivial plot device to underline Kovac's Christmas spirit and get Peyton to the bedside so she can later flip out on a patient. But we can't stress enough how damaging it is for a life-saving profession that requires years of college-level science training to be dismissed as "support staff." Consistent with the support staff theme, Adams--who has been at the ED longer than any physician character on the show--persistently addresses the attendings as "Dr.____" in the episode. And no, the interactions are not in front of patients.

Another small plotline concerns new attending Victor Clemente's effort to elude an old flame, a New Jersey ICU nurse named Jody with whom he evidently had a torrid affair, though she was and is married to a police officer. In this episode, Jody actually shows up in the ED. ED clerk Frank describes her as "kind of a looker, in an interstate off-ramp kind of way." It's hard to escape the prostitution overtones of that comment. Clemente tries to get rid of Jody by telling her he's with a patient, though there's actually nothing wrong with the patient. When Jody says she's never heard of the condition Clemente invents to persuade her he's busy, he says she hasn't "because you're an ICU nurse and this is a toxicology problem." That remark is as silly as the apparently fake condition, but few viewers will know that; they'll assume ICU nurses know nothing of toxicology. Later, even though Clemente clearly fears her police officer husband, the two have "Grey's Anatomy"-type sex right in the hospital. We have some concerns about the nurse-as-sex-maniac implications of this plotline, though it does at least reverse the naughty-nurse-with-married-physician convention, and Jody is hardly passive or deferential.

The plotline that leads to Peyton's downfall involves several patients who have gotten into an altercation with each other at work. Their employer, responding to a complaint that the company celebrated only Christmas, threw a "PC holiday party" in which the employees all dressed up according to their respective holiday traditions. One patient, dressed as Santa, is still antagonizing a colleague who celebrates Kwanzaa, who has the bed next to his. It's clear right away that Santa is determinedly obnoxious and culturally insensitive. Peyton, providing bedside care presumably in the absence of her "support staff" nurses, is annoyed with Santa's mockery of other patients for their physical disabilities, and she demands a "urine sample now." She seems impatient, but not in danger of losing control.

Later, however, Peyton sees Santa harassing a group of blind black Christmas carolers who are doing their thing in the middle of the ED. Santa compares them to Ray Charles, Stevie Wonder, and Roy Orbison, though he notes that Orbison was not actually blind, but just wore dark glasses. Peyton tells Santa: "You sit down. I'm not going to tell you again." One of the singers tells Santa he's ruining their performance. Taggart assures them they sound great and should keep going. Santa tells the singer who objected: "Yeah, and don't yell at me again or you won't see any gifts under the tree. Oops, my bad, you won't see them anyway!" Peyton, who is quite a physical presence, punches Santa hard in the face, knocking him flat on his back and bloodying his nose. Then she pours his urine specimen on his belly, and wishes him the joy of the holiday season: "Ho, ho, ho, you piece of crap."

Shockingly, Santa wants Peyton fired. Taggart tries to soothe him, to no avail. Later, Kovac finds Peyton busy providing sensitive, autonomous care, including discharge teaching, to a boy with a broken bone, as if nothing has happened. We give the show points for this fleeting care interlude, at least. Kovac notes that Peyton punched Santa, and that she could get suspended. Peyton says the guy is lucky she did not have a gun. Kovac notes that the guy wants to call his lawyer. Peyton says she'll "punch him too" (not exactly a gender-sensitive comment from a female Ph.D., but then, nothing Peyton does in this episode says "Ph.D."). Kovak asks Peyton to apologize to Santa so they can "salvage" the situation. Peyton refuses to apologize to "some jerk who's teasing blind kids." Kovac notes that she could lose her job. Peyton retorts that Kovac may have gotten "a gold star and become chief of the department," but that "only the nursing supervisor can fire me." Actually, firing an ED manager would likely be a decision for the chief of nursing, not the nursing supervisor, but at least the show did not give Kovac the authority to do it.

Later, we see Taggart being questioned by a woman in business clothes, presumably the nursing supervisor. Kovac is present. Taggart, who is uncomfortable discussing Peyton's altercation, is evasive at first. The supervisor assures her they do "360 evaluation from supervisors, peers, and subordinates," and she asks what Peyton did after punching Santa and pouring urine on him. Taggart says Peyton "went to lunch." The nursing supervisor, who is never named, says that it's "grounds for immediate termination."

Soon after, Taggart sees Peyton crying in the locker room. She assumes it's about the firing, and tries to comfort Peyton, telling Peyton that she will find another job. But it turns out Peyton was crying because her boyfriend has dumped her. Peyton, the truth dawning on her, demands to know if she's being fired, and rushes off.

Later, Peyton approaches Kovac. She asks if he got her fired. Kovac says that he has nothing to do with that, and advises her to "[c]heck with the nursing supervisor." Peyton says the supervisor told her to "clear out" within two hours, and adds: "You know it's Christmas?" Kovac pauses, then observes dryly: "You'll be missed." Peyton responds: "Bite me." Kovac: "Don't make me call security." More ED staff have now gathered. Peyton assures Kovac she is leaving on her own, but adds:

I tried to do something good here, I tried to elevate this stupid ER, and instead of getting praised, I get fired on Christmas Eve? Screw yourselves, you all suck.

Taggart asks her to calm down, and Peyton turns on her: "Oh, you, behind my back, trying to get my job, Merry Christmas, Judas."

Later, at the end of Kovac's shift--his first as chief of ED medicine--chief of medicine Kerry Weaver congratulates him: "You cleared the board, and an employee." Kovac responds: "I had no choice." Weaver's apparent indifference to Peyton's fate is curious, if not another glaring example of the episode's discontinuity, since the harsh, manipulative Weaver was Peyton's best buddy in her first episodes; they seemed like two peas in a pod.

The entire Peyton departure plotline seems surreal. It asks us to believe that a doctorally-prepared ED nurse manager would instantly descend into aggressive violence, attacking a patient with no physical provocation, and fail to see any problem with her conduct, as if she had no clue that beating up patients might be frowned upon. On the contrary, she follows up with talk of further assaults, including gun violence. Of course, an experienced urban ED professional does not hit patients just because they are insensitive or bigoted. In addition to being bad care, unethical, and grounds for termination, it could add greatly to the workload. The show then asks us to believe that the best Peyton can do is to lash out at her colleagues with phrases like "bite me," "screw yourselves," and "you all suck." All of this seems more consistent with someone who has just wandered in from a chain gang than an experienced nurse manager at a level one trauma center.

We see the irony that Peyton, who has lived by the sword of summary workplace discipline, now falls victim to that sword. And we get the presumed allusion to actress Kristen Johnston's martial alien character on her old sitcom, "Third Rock from the Sun."

But this plotline would suggest that Peyton really is some kind of alien. There has been no real sign here or in prior episodes that Peyton is burned out, or suffering an undue patient load, despite Kovac having sent nurses home. Indeed, we see her care for the boy later in an exemplary way, the model of a pleasant, focused care giver. The most obvious stressor in this episode is her boyfriend distancing himself and then dumping her. Maybe we're meant to see that this evokes a past tragedy in Peyton's life, as we learned in an earlier episode that her fiance, a police officer, had been killed. And she has occasionally done quirky things, like poking idiot chief resident Archie Morris when he insulted her. But at the time she decks the patient, all her boyfriend has done is choose to spend the holidays with his family and without her. That's not a good sign, but Peyton does not seem that upset until well after she assaults the patient, when her boyfriend actually breaks up with her. Indeed, Peyton cannot even see that she has done anything wrong. Perhaps the show really is suggesting that psychological issues are responsible for her conduct. But it seems more like she's just a thug, albeit one who defends the blind.

We note another irony here. "ER" seems to delight in having nurses physically attack people--the Taggart character also had a violence problem when she was introduced two years ago, though she at least had been physically provoked. Maybe this seems funny because many still consider nurses to be harmless "angels." In reality, nurses are the health professionals most likely to be the victims of workplace violence, which is a factor in nursing burnout and the nursing shortage. Rather than doling out excessive violence, nurses tend to absorb it. To balance the Peyton plotline, "ER" would have to show many unprovoked assaults against nurses. We're sure those are coming right up.

Because "ER" has always overflowed with senior physician characters, its depictions of harsh physician managers like Weaver and Robert Romano have been countered with many portraits of wise, humane ones, like Mark Greene, Doug Ross, Elizabeth Corday, John Carter, and now Luka Kovac. But in a show that has never seen a significant nurse character anywhere near Peyton's level, who will balance this depiction? The young Taggart may nominally be given the nurse manager position, but even if she is, she seems unlikely to blow anyone away with her clinical prowess or management authority.

The film to which this episode's title refers is "All About Eve," the 1950 Joseph Mankiewicz classic. That was a vicious satire about a conniving backstabber who used people to rise to the top of the theater world, and it was seen as Hollywood's revenge on the theater that had long mocked it. We actually wondered if this episode could be "ER"'s revenge on know-it-all nurses who have criticized it for failing to portray nursing fairly and accurately. Peyton, despite her poor management style, presented many elements the Center itself has pushed the show to include. She was an assertive, highly educated clinical leader and a genuine peer to the senior physicians. Her episodes made some of our points in unnervingly familiar ways, such as the reference to nurses as "autonomous professionals." And her irreverence reminded us of some of our own analyses. Are we supposed to take a lesson from this--shut up or the show will take revenge on a fictional surrogate of nursing advocacy in front of 15 million people, suggesting that assertive nurses are just romantically frustrated loose cannons, clinging to their credentials and obsessing on their professional dignity because they have nothing else? Shall we take Peyton's bizarre decay into schoolyard violence and name-calling as a comment on our own tactics in trying to get "ER" to tell the truth about nursing?

On reflection, we believe that responsible Hollywood producers would never knowingly present such a damaging portrayal of a profession whose current crisis threatens global health, simply to fulfill some narrow vendetta. And of course, if such elite writers did ever try to capture the Center's well-supported analyses and finely calibrated advocacy tactics in dramatic form, we're sure they could do better than juvenile taunts like "bite me" and "you all suck." We conclude that the episode is probably just a more general punishment for nurses uppity enough to push against their "ER"-assigned roles as peripheral physician subordinates. It may simply reflect the view that it's fine for women to be assertive in traditionally male professions like medicine, but that aggressive nurses are too much of a threat to the natural order, and perhaps to the "feminist" doctrine that able women who choose health care careers must become physicians. Any ambitious, aggressive woman who chooses nursing must be a bitter, deranged kook. And she should be treated with the same patronizing contempt with which all women were once treated. It's always been easier to suggest that a woman who challenges the existing order is really motivated by some unrelated frustration. Of course, it would be easy to prove us wrong: simply introduce a positive, senior, major nurse character to balance Peyton.

We still believe that "ER" did some good with the earlier episodes featuring Peyton, particularly the first two from October. We doubt any other current Hollywood show would have introduced such a clinically expert nurse character at all. But Peyton's Christmas Eve departure, lightly spiced with the same old "support staff" theme, was a lump of coal for anyone who would like to see nursing get the real respect it needs.

Please send our instant letter, or one of your own, to "ER" and let them know what you think of their portrayal of nursing. Thank you.

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