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Peyton Place

October 20, 2005 -- The October 6 and 13 episodes of NBC's "ER" introduced hardcore ED nurse manager Eve Peyton (Kristen Johnston). Peyton is the first real nurse manager the show has portrayed in any depth since the 1990's, and perhaps the most clinically expert nurse character to ever appear on a major prime time U.S. show. These episodes present her as a kind of nurse manager / clinical nurse specialist (CNS) hybrid, a smoother, funnier Margaret Houlihan who takes the ED nursing staff firmly in hand and injects herself into their care, doling out advice, sending nurses here and there, stepping in when she feels needed, and not being shy about telling senior physicians how they're screwing up. The show stresses Peyton's professionalism and autonomy. It's funny to watch the other characters react, at times speechless, as "ER" tries to bring its audience somewhat up to speed with features of nursing that are common in the real world. However, the show still indicates that Peyton reports to chief of medicine Kerry Weaver, rather than upper level nurse managers. Peyton's management style does not seem ideal, and the other characters at first regard her as something of a "bitch." But given the show's tradition of annoying physician managers, we are not too concerned yet. Johnston does not appear in the show's credits, which would signal that Peyton was a major character. And we are concerned that in her absence, the show would likely revert to its overwhelmingly physician-centric depiction of care, as tonight's Peyton-free episode suggested. Indeed, even with Peyton, the physician characters still dominate. Even so, we thank episode writers David Zabel ("The Man With No Name") and R. Scott Gemmill ("Blame It on the Rain") for these serious efforts to address some of the nursing issues that the Center has been raising with the show for years.

Kristen Johnston is clearly qualified to convey Peyton's assertive and acerbic qualities, after playing a not dissimilar character (and alien) for years on the NBC sitcom "Third Rock from the Sun." Fittingly, Peyton initially alienates everyone in the ED except Weaver, who is filling in as chief of ED medicine during the search to replace the disappeared Susan Lewis. Peyton and Weaver are presented as two powerful female peas in a pod, and Peyton invites the same questions Weaver always has: Is she an insufferable "bitch" (as nurse Malik McGrath says he would call Peyton if he "wasn't a feminist")? Or are we sexists who have trouble with aggressive women? Or both?

Among the physicians, Peyton bugs chief resident Archie Morris by holding a nursing staff meeting (imagine!), and embarrassing him with her superior clinical knowledge when he tries to break it up. Morris tries to interest Weaver in stopping the staff meeting, asserting that only he and Weaver can allow such meetings. Weaver gives him a withering look, and he backs off to the view that only Weaver has that power. She says: "Exactly." Later, a chastised Morris tells fellow physicians that he now knows he can't interfere with the staff meetings because nurses are "autonomous professionals." (Love that phrase--wherever did the show get it?) The show does not try to reconcile that autonomy with Weaver's supposed authority over Peyton. Still later, when Peyton tries to push Morris to help clear some patients clinically, he tries to dismiss her, saying that's best left to the doctors. Peyton starts to say something about the five NEXUS criteria, and Morris asks what Peyton knows about those. Peyton says that as research coordinator at Emory she enrolled 2,000 patients in the initial study. The clearly outgunned Morris tells Peyton that maybe she can bring that up at her next "Nazi nurse rally." Peyton smiles and suggests that she knows so much about human anatomy, she could kill Morris with "this finger." When Morris doubts it, she pokes him in the chest. He yelps in pain, though he has recovered enough to be kissing up to Weaver about two seconds later. What is it with "ER" nurses and violence? Taggart had an anger management problem in her first season, at one point actually decking a threatening patient. Anyway, we would have preferred a verbal putdown from Peyton, but we'll let it go this once.

Peyton annoys attending Luka Kovac by persistently questioning his treatment decisions, his resident teaching, and his obviously compromised ability to handle working with his ex-girlfriend, lone major nurse character Sam Taggart. At one point Kovac asks Weaver to intervene because of how Peyton is managing the nurses. Weaver tells Kovac that if it's a "nursing issue," it's Peyton's "rice bowl" and he has to work it out with her.

As for the nurses, Peyton infuriates Taggart by pulling her off all shifts with Kovac, explaining that Taggart is the one whose work she can control (Peyton does offer Taggart the option of working elsewhere in the hospital). This seems unfair. Taggart says it will mean less money and make it harder to see her son. Yet Peyton has a clinical reason, as the Taggart-Kovac fallout has clearly threatened to compromise care. It might have been better for Peyton to have tried to negotiate with Weaver for some shared sacrifice on Kovac's part. But Peyton is new and it's a judgment call. Peyton annoys the rest of the nurses by watching them like a hawk, being picky, and interfering in their work, telling them what they need to be doing and how. She may go too far with this at times. But who knew a senior nurse could be as annoyingly authoritative as Weaver or the late surgeon Robert Romano, almost as if nursing was a real profession like medicine?

The major problem with the portrayal of Peyton as manager is that the show seems to believe that she reports to Weaver. It may not see her as under Weaver as chief of ED medicine--we'll have to see how Peyton relates to Victor Clemente (John Leguizamo), the maverick interim chief of ED medicine introduced in tonight's episode--but it seems to be saying she is subject to the authority of the chief of medicine. It's not just that Weaver says she served on the "emergency services committee" that hired Peyton. The interactions with Morris and Kovac leave little doubt that whatever authority Peyton has has been granted by Weaver. But the show has not suggested that Weaver serves as the hospital's chief executive officer, only as chief of medicine, which is not the same thing. In real life, Peyton's hiring would likely have been mainly the work of the chief of nursing--Weaver's nursing counterpart--and mid-level nursing managers. Of course, characters like that almost never appear on "ER." This point may seem picky, but it is fundamental. If even the most senior and powerful hospital nurses automatically report to physician managers, then nurses are not "autonomous professionals."

Peyton is the first nurse character in "ER"'s 11+ years on the air, and possibly the first in the history of U.S. television drama, to be portrayed--at least in these two episodes--as more or less the clinical peer of senior physician characters. Indeed, her clinical expertise leaves some of the "ER" characters practically speechless. After Morris tries to disrupt her staff meeting, she questions his apparent request for a nurse to administer IV antibiotics to treat a dental infection, and asks him to educate the nurses about "inferior alveolar dental blocks." Morris is baffled. In the October 13 episode, Weaver arrives in the midst of a rain storm at a backed-up ED. Morris and Peyton are there to greet her. Weaver practically dismisses Morris, listening to Peyton's assessment, and siding with her when she suggests that (contrary to what Morris has evidently been doing) not all the fender-bender cases require a C-spine film.

In another plotline, a busy Kovac brushes off Peyton's repeated requests that he come to the adjoining trauma room to help the flailing resident Pratt with a fiberoptic intubation for a hypoxic young accident victim with severe head trauma. Peyton picks up the difficult airway box and heads out of the room. Kovac, guessing that she is about to do something he won't like, says "Excuse me, Miss Peyton." She tells him she has a Ph.D., so if he wants to get formal he can call her "Doctor." When Kovac manages to get next door, Pratt and the rest of the code team are watching Peyton insert a laryngeal mask airway, educating as she goes. The patient improves immediately, and Peyton tells the late-arriving Kovac that he "might want to educate [his] residents about the LMA as a rescue device in can't-intubate / can't-ventilate patients." As Peyton heads out the door, the patient's mother tearfully thanks her, and she tells Kovac, "Take it from here, Doctor, I'm going to go find a bedpan that needs emptying." Kovac has no response. Unfortunately, Peyton does seem to call the physicians "Dr. ____" even though the physicians call her "Eve." This imbalance is a mark of nursing inferiority that we believe must end, on screen and off. If it's Eve and Sam, then it should be Kerry and Luka. And of course, ideally Peyton would shine not just by impressing physicians by doing work they typically do, as if that were the real sign of nursing expertise, but by impressing her nursing colleagues with her nursing.

Though Peyton behaves somewhat like a CNS, an expert clinical nursing resource, the show does not actually say she is one. To our knowledge, no recent prime time show has featured a CNS. But the apparent manager / CNS hybrid on display here, which appears to parallel the show's depiction of physician managers, may be a promising one.

Peyton seems to be something else the "ER" characters haven't seen in years--a true nursing professional. That means that, rather than simply punching in and out, she never stops thinking about how to do an excellent job. She thinks not only about patient X, but how to improve care at the system level. Some time after Peyton saves the hypoxic boy, Taggart tells her that she did not even know that the ED had the LMAs that Peyton used. Peyton says that before starting work, she reviewed the list of supplies and ordered them. Taggart says that sounds like something Weaver would have made her do. Peyton reports that it was her own idea. Taggart is amazed. In tonight's episode, Janine Sherman Barrois' "Wake Up," Peyton does not appear, but she still calls in to push Taggart to post flyers urging people to use hand sanitizer and distribute the product to the nursing staff. (Though the show does not say so, nosocomial infections are a growing threat to global health about which nurses are very concerned.) Taggart and colleague Chuny Marquez (right) marvel at a nurse actually calling in about work on her day off.

In the past, "ER" nurses have advocated for their patients by discussing care with physicians, at times even arguing with them. But the characters have rarely pushed for this kind of systemic change, nor taken it upon themselves to make authoritative suggestions about how the attending physicians were approaching their teaching and mentoring roles. We would probably have to go back to Carol Hathaway (right) and her free ED clinic, from the 1990's, for another example, and even then, she was not nearly as strong clinically. Of course, it's sad that the show's current nurse characters are so surprised to see a nurse act like a serious professional.

The episodes do not stop at showing the difference between Peyton and competent veterans like Taggart and Marquez. They actually do something else the Center for Nursing Advocacy has long urged by showing, albeit only briefly, how difficult it can be for an inexperienced nurse to cope with the stress and complexity of nursing at a level one trauma center. New nurse Inez, who is streetwise, but green as far as nursing goes, here gets in over her head on a couple patients. This gives Kovac and Taggart a chance to show Peyton they really can work together, but it also helps to illustrate more of the range of nursing expertise, to show that it can take time to gain real nursing skill. It suggests that nurses are not the fungible assistants they are generally shown to be on prime time television (and often, on "ER" itself). Here again, to our knowledge we would have to go back to the Hathaway years to find another real treatment of the problems associated with nursing inexperience.

Of course, the Inez plotline is not a major part of the episodes, and it isn't perfect. Peyton's management of the situation seems questionable. At times she sends Inez away from things she can't do, rather than teaching her to do them, an odd contrast to Peyton's hard line on the physician teaching. Taggart ultimately does move to help Inez, telling her to just ask if she has questions, and assuring her that it takes time to learn. Taggart also suggests to her that ED nursing just calls for "muscle memory," which seems like an iffy formulation. What Inez needed here was knowledge , critical thinking and problem solving ability, not just the practiced ability to do a physical task. Moreover, although we appreciate the limited effort to show that skilled nursing requires experience, it is of little significance compared to the literally hundreds of hours the show has spent examining physician training. A really fair portrayal would require the show to devote a substantial part of every episode to senior ED nurses teaching less experienced ones, as it does with physicians.

Some may have a negative reaction to the rule-bound "bitch" elements in Peyton's character, arguably a reflection of the "battleaxe" stereotype. But we are not especially troubled, at least so far. It's true that Peyton seems to be an organizational manager, focused on resources and costs, and arguably a micro-manager. She tells Taggart she can stay to help with a patient's family past the end of her shift but it will be "off the clock." (We'd be interested to see Peyton clash with the nurses over short-staffing, but so far the severe seven-year-old nursing shortage hasn't really made it to "ER.") These elements do support the Houlihan comparison.

But Peyton has not been shown to be pathetic (as Houlihan was) in her personal life, she is unusually witty for an "ER" character, and she has already displayed the ability to adapt and relent. Though she does go after Kovac pretty hard about his failure to help Pratt with the head trauma case and his apparent inability to work with Taggart, she then moves quickly to mend fences with Kovac; he is the one who seems slow to adapt to the new situation. In the October 13 episode, we see her work collaboratively with Kovac to clear some cases. In addition, Peyton patiently endures a short diatribe from Taggart, who argues that Peyton should treat the staff like professionals, that she can indeed work with Kovac, and that she deserves her old shifts back. Peyton merely responds with the gently mocking "feel better?" and advises Taggart that she has already changed the schedule back. If anything, Peyton is more reasonable and sensitive than Weaver. And we can't and don't expect to see perfect nurse characters, which would not be persuasive anyway.

Of course, the positive elements discussed above are very much subject to change, depending on whether Peyton has a significant role in the show, and whether the show continues to be interested in giving its nurse characters a more robust role in patient care. In this season's first few episodes, we believe there has been somewhat more of a focus on the show's minor nurse characters. And although the general assumption is still that physicians are the main ED players--by a long shot--sometimes nurse characters have spoken to each other, and even patients, rather than only to the physicians. But in tonight's episode, in which Peyton did not appear, not even Taggart got much attention. And not surprisingly, with every other major character a physician, viewers saw a lot of physician nursing. Residents did triage, physicians handled most patient monitoring and psychosocial care, and the vast majority of the drama ran through the physicians. Nurses might have been doing something, but as has been the case for 11 years, we did not see much of it, except to the extent they appeared as physician sidekicks.

But the October 6 and 13 "ER" episodes were two of the best for nursing on any U.S. prime time show in years. As such, they presented a bittersweet contrast to the utter contempt for nursing that is on display in ABC's "Grey's Anatomy" and Fox's "House," the new hits that seem to represent the immediate future of U.S. hospital dramas.

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

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