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"OK, folks, the good news is the hospital has approved four-to-one ratios."

November 17, 2005 -- In a plotline begun in the November 3 episode and resolved tonight, NBC's ER" again showed nurses managing nurses, contrary to years of "ER" practice in which physicians did that. The show also made an unprecedented, if brief and unclear, statement about nurse short-staffing, overtime and the shortage. We applaud those efforts. In the first episode, ED nurse manager Eve Peyton abruptly hired major nurse character Sam Taggart as her lieutenant, and together they abruptly fired veteran nurse Haleh Adams for working excessive overtime. Adams was later rehired, but as you may have guessed, some elements of the plotline left something to be desired. They suggested that hiring nurse managers and firing veteran nurses were fairly casual affairs, and that the big OT 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 Nov. 3 episode was "Dream House" by David Zabel, and the Nov. 17 episode was "Two Ships" by Joe Sachs, MD, and Virgil Williams.

Near the start of the Nov. 3 episode, Peyton is holding a staff meeting. She delivers the following statement to the ED nurses and more than 14 million show viewers:

Okay, folks, the good news is the hospital has approved four-to-one ratios. That means extra full-time equivalents, and zero--zero--tolerance for excessive OT.

After the statement on ratios, Taggart interjects: "Finally!" After Peyton finishes, Adams seems to try to lay the groundwork for an exception: "Let's hope we have enough people to fill all those shifts." Later in this episode, Peyton tells Adams she is unhappy with the extra shifts Adams has been working in ICU; evidently, Peyton previously told her she could no longer do that in the ED. Adams notes that Peyton never told her she could not work the ICU shifts, but she promises Peyton that it won't happen again. Adams even later tells Taggart that although Peyton is "tough," her "energy" will be good for all the nurses in the long run, presumably because she's such a serious professional. Of course, we don't know who Peyton's predecessor was, if there even was one.

Meanwhile, Peyton has taken Taggart aside and praised her for having "fantastic interpersonal skills" and enjoying the respect of fellow nurses. Peyton says it's time for Taggart to "move[] up the ladder." Peyton offers her a "nursing administration" position that would include helping with "staff education," "implementing nursing policies and procedures," and a "big pay hike." Taggart hesitates, but when Peyton assures her that it will mean enough extra money to shop on Michigan Avenue, Taggart is in.

However, Taggart is distressed to learn that her first management task is to fire Adams (right) because of the excessive overtime, which Peyton says Adams has been warned about several times. Taggart resists, saying she does not need the job that badly. Peyton offers to join her in firing Adams. Peyton rejects Taggart's proposal that they simply counsel Adams (noting that she's not Oprah), and she notes that the firing will "send a message" to the other nurses, presumably about respecting the rules. It seems that Peyton is firing Adams at least as much to send this message as for the OT offenses, and we are invited to consider her a heartless, Machiavellian "bitch"--a word Taggart herself seems to assign to Peyton in an under-the-breath comment (a slightly unorthodox way to say "thanks for the promotion"). Taggart also tells resident Neela Rasgotra that Peyton is a "terrorist." But together Peyton and Taggart actually do fire Adams, with Peyton delivering the hard news, and the very reluctant Taggart making efforts to soften it with kind words. The distraught Taggart apologizes and pursues Adams outside the hospital. Adams reminds Taggart of all the times she covered for Taggart when the latter was having problems with her son, and suggests that Taggart has turned her back on her fellow nurse for "a couple extra hundred bucks a month." However, Taggart's sympathy for Adams does not prevent the ED staff from looking at her funny for her role in the firing.

This bad feeling hangs over the show until the Nov. 17 episode, which features some of the big vehicle drama "ER" employs when it needs a jolt. Here, an airliner collides with a helicopter and crashes into the middle of Chicago. With Peyton on her way out of town, Taggart appears to be acting as nurse manager in her stead, and she seems to do well, managing various logistical systems apparent shortage of nurses to work the shift, though this is mentioned only in passing. Of course, with all the crash victims, the ED is even more short of nurses. To fill the gap, Taggart brings in Adams. When Peyton returns and learns about Adams, we imagine there will be trouble. Taggart notes that they were getting crushed and Adams is "one of the best nurses in town." Peyton simply says: "Good move." So was this something Peyton might have done herself? Sending her "message" but eventually relenting, thus arguably having things both ways?

The plotline shows nurses managing nurses, with no physician involvement whatsoever. It also illustrates that nurses are professionals who need skilled managers, managers who might actually need continuing education. Taggart is clearly doing a good job managing ED systems in Peyton's absence in the Nov. 17 episode. Likewise, Taggart's statement about Adams' skill suggests that nurses are not just the fungible subordinates the show has often suggested; some nurses are actually better than others. And Adams' own positive comment about Peyton (before the firing) may be a nod at the value of nursing professionalism, though it's probably there mostly to make the firing seem more unfair.

Peyton's decision to fire Adams and the nasty way she implements it will leave many unimpressed with her management ability. The final bit where she praises Taggart's decision to bring Adams back redeems her somewhat, but Adams and many of the other nurses are unlikely to forgive her. Of course, it may also show that Peyton can reconsider her decisions, and that she is mentoring Taggart, encouraging her to develop her own management skill. This is the second time Peyton has reversed a seemingly harsh decision (the first being barring Taggart from shifts with ex-boyfriend physician Luka Kovac). Perhaps she is too mercurial, or perhaps she uses the tactic of severe action followed by backing off as a management tool. However, we are not objecting to the simple fact that a nurse manager has been shown to be nasty and manipulative. The show has portrayed physician managers that way, and we think the key is whether there is adequate context, and whether nursing is treated as a serious profession, which are not simple questions here. The battleaxe stereotype is a bad one, but nasty nurse managers do exist. Taggart herself provides some balance in that respect, though she is still finding her way as a manager.

Peyton's initial statements about nurse staffing are also praiseworthy, at least to some extent. They will suggest, at least to attentive viewers, that there has been a problem with short-staffing, and Taggart's reaction suggests that nurses have been pushing for reform. The nurse staffing crisis is something that the network hospital shows have, to our knowledge, so far ignored. Adams' statement that there may not be enough nurses, though motivated by her own economic goals, might at least indicate that there is a shortage of nurses, as would the apparent shortfall in the Nov. 17 episode. And the very fact that the nurses are having a staff meeting suggests that they are not physician subordinates, but members of a distinct profession with its own structure and concerns.

Unfortunately, the very brief and summary way the scene played out, right after a long commercial break and with no context in this episode or elsewhere, will likely mean that the points will blow right past many viewers. Without explanation, how many will even know what a four-to-one patient:nurse ratio means? And while Taggart's "finally" comment makes it sound like the show has often raised these issues, it has not. Moreover, even an attentive viewer will not get from this brief exchange the magnitude of the crisis, the key role short-staffing has played in it, or its devastating effects on patient care. And the idea that even a public hospital would agree to set staffing minimums without being forced to do so by legislation or collective bargaining may strike some as unlikely.

We also had some problems with the way Peyton hired Sam, and the way they fired Haleh. These decisions were shown as fairly casual ones, and they presented a somewhat distorted picture of actual nursing issues.

Taggart's hiring was certainly an improvement on the way "ER" nurse Abby Lockhart was supposedly made a nurse manager against her will by a physician several years ago; almost anything would be better than that. But there was still no indication of any of the elements that would likely be involved in a hiring process for a management job that anyone would actually want, such as group decision-making. We also doubt that many real managers are hired without even being told the name of the position they're taking. Kovac, though somewhat ambivalent about his new job as chief of ED medicine, did at least apply for it. And Taggart's new job comes wrapped in guilt; it looks like Peyton hired her partly so she could take the blame for firing Adams.

Moreover, both Taggart's and Adams's comments about the pay raise Taggart can expect suggest that professional advancement as a nurse pretty much means a bit more money. Indeed, that seems to be the only thing Taggart cares about. We can't say that no nurse would approach it that way, but it might have been nice to see a nurse character chosen for a management position express at least some interest in something beyond where she would be able to go shopping. Kovac, by contrast, applied for his job in order to keep new attending Victor Clemente from getting it, which at least related to care issues.

Haleh's firing also seems somewhat casual for such a senior nurse, though the show does at least make clear that she had received prior warnings. In addition, the rationale for her firing (leaving aside whether it was pretextual) sends a misleading message. The show seems to be saying that a staff nurse is being fired for working too many OT shifts. This does not seem to be a likely reason that a veteran staff nurse would be fired. All the hospital has to do is stop letting her work the OT shifts; it's not like the ICU can't check on her shifts. The plotline also may suggest that the big OT problem in nursing today is greedy nurses taking advantage of the shortage by working too many shifts and driving up costs. The reality is closer to the reverse, with some hospitals effectively forcing nurses to work excessive hours in an effort to compensate for the shortage, which has itself been fueled by hospital short-staffing. Indeed, forced overtime has been a factor in the shortage, driving nurses from the bedside, in addition to being a major threat to patient safety, as exhausted nurses are less likely to provide good care. (See the Ronnie Polanesczky pieces on mandatory overtime.) Thus, the Adams plotline fosters precisely the wrong impression about the overall relation of OT to the shortage. And of course, the brief comments near the start of the show do nothing to explain to viewers why there is a shortage in the first place.

On the whole, the plotline's depiction of nursing management was a mixed bag. But whatever its flaws, at least it showed nurses themselves doing the managing.

Please send a letter to "ER" and let them know what you think of their portrayal of nursing. Thank you.

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