"Nurses don't need credit for saving lives! It's just what we do!"
August 11, 2009 -- Tonight's episode of TNT's HawthoRNe included several generally helpful plotlines exploring nursing autonomy, advocacy, and skill. The episode focuses on the intersection between the hospital CEO's efforts to get CNO Christina Hawthorne to cut her staff in order to reduce the hospital budget, on the one hand, and the tragic events that ensue after a woman brings her mother to the ED for treatment of a stroke, on the other. New nurse Kelly Epson manages, despite resistance from physician Brenda Marshall, to stop dangerous treatment of the stroke victim. But Kelly's advocacy also puts her job in peril. Nurse Ray Stein actually saves the life of his nemesis, Larry the accountant, who is choking on a donut. The plotlines have some problems, like nurse Candy's odd chastising of Ray for wanting it understood that the donut did not dislodge itself (as Larry claimed), and Ray's even more bizarre hookup with the awful Marshall after he confronts her for abusing Kelly. But on the whole the episode presents nurses as serious professionals saving or trying to save patients with advanced skills and tenacious advocacy. And the show's portrayal of the CNO as a clinical leader fighting for her staff? Some nurses may be skeptical, but we think there is room for at least one positive vision of a nurse executive from Hollywood, which has offered countless positive portrayals of senior physicians. The episode, "Mother's Day," was written by Glen Mazzara.
Early on, in the Richmond hospital's dining area, the accountant Larry is gabbing with friends about who might be laid off in the rumored budget cuts. He begins choking on his donut. Nurse Ray saves Larry with the Heimlich maneuver--not unlike Jackie Peyton did in the premiere episode of Showtime's Nurse Jackie in June--though Ray does hesitate slightly because he has a history with Larry, in part because both are vying for the affections of the lovely nurse Candy. This shows viewers that nurses save lives by themselves.
Later, we see Candy caring for Larry in the ER. Larry is trying to get her to do more tests or send him home, so he won't have to return to work. But at the same time, he is boasting that he was never scared of dying, and that the donut practically dislodged itself. Ray overhears this and, walking with Candy a moment later, tells her that is incorrect, and that Larry was actually turning pretty blue.
Candy (smiling at the silly guy): Ray! Nurses don't need credit for saving lives! It's just what we do!
She walks away; Ray looks abashed. We searched in vain for irony here, some sign that Candy really meant that of course it's a problem that nurses don't get credit for their important work, because that is a big part of why they don't have the power to do it right--a big part of the global nursing shortage, and incidentally, what helps physicians like Marshall get away with the abuse Ray can't tolerate. Maybe we're supposed to guess that the show creators do not agree with Candy, but viewers will likely take the scene as showing (again) that Ray is self-serving and insecure, and endorsing the traditional virtue script that has done so much to undermine nursing. When nurses are so self-effacing that no one appreciates what they do, they cannot attract the resources and respect they need to do it. Patients suffer and die, and nurses are driven from the bedside. Ironically, the show has itself included many scenes that do effectively credit nurses for their work.
Another plotline begins with Hawthorne and her friend Bobbie Jackson, who seems to be the ED nurse manager, in Hawthorne's office. Hawthorne is preparing for a big meeting with the hospital CEO Morrissey, who wants her to make more budget cuts. Bobbie says she has already cut the ED to the bone. Hawthorne basically appoints Bobbie as the acting CNO for the day so Hawthorne can deal with Morrissey and the budget, saying she has to "slay the dragon" in his lair. As Hawthorne explains some of Bobbie's temporary responsibilities, we get a little sense of the CNO's scheduling responsibilities (though in real life these would likely be duties of the house nursing supervisor).
Soon we see Morrissey in his office telling chief of surgery Tom Wakefield that he has to fire a surgeon who just isn't seeing enough patients any more. Wakefield protests, to no avail. Outside the office, we see Hawthorne ask Wakefield (a good friend of hers) for pointers on dealing with Morrissey. Wakefield says she could try to "drive a stake through his heart." Here it seems that these two are peers, both trying to protect their departments from the CEO's axe. That's good, because the show has at times suggested that Hawthorne reports to Wakefield.
In the dragon's lair, Morrissey and Hawthorne discuss the cuts. He tells her that the critical care head nurses don't need to attend continuing education conferences every year because "nursing doesn't change that much," and they can just check out the Internet. Hawthorne does not really challenge that, and maybe that makes sense tactically, but of course nursing is a dynamic modern health profession that changes plenty. Morrissey says if he does not convince the board they can reduce costs, it will outsource all administrative functions, and he claims that they already have three bids. He is trying to persuade them not to turn the hospital into a "Wal-Mart." He says she has to cut staff, and he wants six nurses she is "willing to fire" by the end of the day. Hawthorne resists.
In the episode's main clinical plotline, we see Bobbie and Kelly in the ED when a woman named Maureen comes in yelling for help. The nurses run outside, and the woman's mother, Shirley Riddle, is lying on the pavement in the parking lot, apparently having collapsed after exiting her daughter's minivan. Bobbie assesses the mother and asks basic questions. Maureen, who is very shaken, says her mother had just started slurring her words and shaking. Maureen says it did not happen before.
Inside, in the ED, Bobbie has to go attend to CNO duties. The ED physician on the case is Brenda Marshall, though past episodes have suggested that she is a surgeon. Marshall, acting very commanding, asks Maureen when she first noticed a change in her mother's behavior. Maureen says it was when she was driving her mother home, saying Maureen thought it was a seizure, and she drove immediately to the hospital. Marshall says it's a good thing she brought her mother in so quickly, because treatment of a stroke in the first three hours is critical. Marshall's diagnostic questions are intense and somewhat intimidating to the agitated Maureen. Marshall tells Kelly to get a scan and prepare for a tissue plasminogen activator (tPA), a clot-busting drug that is a common stroke treatment.
Later, after Marshall has moved on, Maureen asks Kelly to tell her more about her mother's prognosis, and whether her mother is responding to the medication. But Kelly can't tell her; she says every patient is different, and Maureen will have to ask Marshall.
Kelly: We just have to trust the doctors and just stay positive.
Of course, the first part of that formulation is a prescription for disaster, as the show itself will soon demonstrate. It's not encouraging to hear Kelly say this, even allowing for her inexperience, though it's possible the show is suggesting that Kelly will herself be getting an education in not blindly trusting physicians.
Maureen tells Kelly that she knew this was going to be a weird day as soon as she got up. Kelly, who is very alert to clues about patient conditions, asks what she means. Maureen says her mom just wasn't herself this morning and "hasn't been for days." Kelly asks for an example. Maureen says her mother dropped her coffee at breakfast, and then explained what happened in "gibberish." Kelly asks Maureen why she did not tell Dr. Marshall, who has to know everything so she can make the right diagnosis. Maureen says she just did not think of it. Maureen wonders why Kelly wants so many details.
Kelly: Well, the tPA can be dangerous if it's taken outside the 3-hour window. It can cause intracranial bleeding or even worse.
Maureen: But Dr. Marshall didn't say that.
Kelly: You didn't exactly tell Dr. Marshall everything that you told me. She was just going off of the information that you gave her.
Kelly asks when symptoms really began, and although Maureen says she does not know, Kelly has heard enough to know there is a problem. Clearly afraid to go to the nasty Marshall, Kelly calls Bobbie, presumably hoping Bobbie will do it. But Bobbie is very busy, and she flatly tells Kelly to tell Marshall what she has learned.
Kelly approaches Marshall, very apologetic for bothering her, and explains to the physician that there's a chance Maureen's mother might have had the stroke earlier than she thinks. Kelly gives her some details, but Marshall insists that that's not what Maureen told her, as if it would be surprising that a distraught relative's account would change. Kelly says Maureen did not remember these details when she spoke to Marshall. Marshall says she'll talk to Maureen, but Kelly can tell she's just humoring her. Kelly manages to pursue Marshall, saying that once Maureen found out about the 3-hour tPA window, she changed her story. Kelly asks whether getting tPA after the 3-hour window isn't dangerous, noting that Kelly's grandfather died of a stroke so she knows a lot about it.
Marshall (condescending): Oh, so maybe you should treat Shirley, huh?
Kelly: No, I just want you to know--
Marshall: And now I do, thank you. Anything else you want to pass along to me?
Kelly looks down, cowering like a frightened child.
Marshall: Are you sure? Is my breath bad? Are my roots showing? No? Good.
Later, we see Marshall leading a neurologist and Tom Wakefield to see Maureen's mother. A scared-looking Kelly is also there. Wakefield asks if there has been any improvement with the tPA. Marshall says not yet. But Kelly, making an effort to be brave, tells Wakefield that she wonders if the patient should be getting the tPA at all. Marshall tries to dismiss her, but Wakefield wants to see them privately. Kelly manages to tell Wakefield why she thinks Maureen's mother exhibited stroke symptoms long before the tPA window. Marshall says that's not what she was told during her initial examination. Kelly says she told Marshall why that was.
Marshall: But nurses second-guessing doctors in the ER has become an Olympic sport, and frankly, Tom, I'm sick of it.
Wakefield questions Marshall further on the diagnosis, and the three physicians discuss that in technical physician language, which Kelly plays no part in. Apparently the hospital's tests have shown no other signs of an earlier onset of symptoms. Marshall offers to run the tests again. Instead, Wakefield explains to Maureen that it's critical that they get the diagnosis right, because "if Kelly's right, we need to take your mother off this medication immediately." Maureen still wants to embrace the "miracle drug," but finally admits that the symptoms may have started the previous night. Wakefield asks that the drug be stopped, and that the patient be brought to the ICU so that the neurologist can figure things out. Marshall looks furious, and pursues Wakefield down the hall.
Marshall: Oh, Tom, that was a nice slap in the face, thank you.
Wakefield says that it's the neurologist's case now.
Marshall: I meant the ... mini-girl, don't ever cut me down in front of a nurse again, OK?
Wakefield: Don't even start with me today, Brenda, OK? I just we hope got that right. That is why we're here, isn't it?
Marshall: Oh, stop the fake drama, please. You're only protecting the nurses because of your girlfriend, Hawthorne, that's obvious.
Marshall backs off and leaves.
Back at the dragon fight, Hawthorne is trying to cut more costs, trying to juggle nurse schedules, but Morrissey is not satisfied. He wants staff cuts because of all the additional expenses that come with employees. He tells her to use per diems; she says that forces her "regulars" to work too hard showing them what to do, which is actually a good point.
Marshall appears outside the CEO's office, wanting a word with him. Morrissey speaks with her outside, then rejoins Hawthorne.
Morrissey: Dr. Marshall had a run-in with one of your nurses in the ER, one of the rookies, Nurse Epson? ... She refuted Dr. Marshall's treatment of a patient.
Hawthorne: You mean she challenged her. You do know nurses are allowed to do that?
Morrissey: Wasn't nurse Epson the one that killed Mrs. Lockman?
Hawthorne: Mrs. Lockman died of a coronary.
Next, Morrissey cites a complaint about Kelly by Mizaki, a foreign-born physician who can't speak clearly enough to be easily understood; an early episode showed Kelly breaking down after trying to communicate with him.
Morrissey: Mizaki's complained about her too.
Hawthorne: Really? How could you tell?
Morrissey: If she's that much trouble, you should consider cutting her.
Hawthorne: Not her.
Morrissey accuses Hawthorne of being soft, unable to make the hard decisions to help the hospital survive. He says he needs six nurses, and Hawthorne can't even give him one.
This plotline sends mixed messages about several aspects of nursing. First, the episode shows that Kelly has significant technical expertise, both in her familiarity with the tPA treatment and its potential drawbacks, and in her skilled questioning of Maureen, which elicits vital diagnostic information that the heedless, bullying Marshall failed to get. Unfortunately, the show undercuts this to some extent by suggesting that Kelly only has the technical information because her relative had a stroke, implying that nurses would not otherwise have such knowledge.
The plotline is also about patient advocacy. Kelly does ultimately manage to persuade a physician with enough authority to stop the tPA treatment and save the patient. Marshall may seem like a caricature of the abusive and incompetent physician, but real nurses know her conduct is quite possible given the power imbalance between the professions and their troubled history. The scenes with Marshall show the dysfunction of some nurse-physician relations. They point up the importance of listening to nurses, who may be able to elicit more information from patients since nurses are less intimidating and trained to interact with patients. And the scenes show that abusing nurses discourages them from providing key information to physicians. Of course, a nurse who acts as timidly as Kelly bears responsibility for the situation as well, even allowing for the fact that she is new. Still, though Wakefield did listen to Kelly and he did not suggest she had done anything wrong, his response to Marshall was inadequate. He had reason to believe Marshall had endangered her patient by resisting Kelly's input, but he said nothing about Marshall's toxic contempt for the professionals with whom his physicians work closely every day.
And lastly, the plotline is about nursing autonomy. Clearly Marshall has more power than Kelly, and she uses it by pressuring the CEO to get rid of the nurse. Of course, Marshall should have gone to Hawthorne, but she and the CNO have a history, and presumably Marshall knows she would get nowhere; Hawthorne does not cower. While Morrissey does seem to credit the complaints of the physicians, he does not force Hawthorne's hand. The show could have suggested that Marshall would have the power to fire Kelly directly, but it resists. No physician seems to be directly involved in these decisions. It is the CEO and the CNO. We might have wished for a stronger defense from Hawthorne. Kelly did not just "challenge" Marshall in a way that she is "allowed" to do, Kelly saved the patient's life by doing what her job requires that she do. But the plotline did at least suggest to viewers that good nursing can involve questioning physician care plans.
Later, Hawthorne comes to see the staff nurses. Kelly explains that she called Marshall out on her mistake, but Hawthorne does not exactly reassure Kelly about her future, and Kelly becomes convinced that she will be fired. Ray himself had a problem in an earlier episode when he tried to convince Marshall that she had made a prescription error with a diabetic patient. (Ray gave the dose anyway and the patient crashed.) Ray believes that Kelly is vulnerable since people are being laid off, and he actually goes to confront Marshall. He tells her she is an arrogant fraud who can't believe nurses know as much as she does. Then, he says, when she screws up, she hangs the nurses out to dry.
Marshall: You can't talk to me like that.
Ray: What are you going to do, you going to fire me? Go ahead, try it. Because then I will tell everybody what I know. You're not so tough.
This scene was basically OK up until this point, if you can ignore the implication that Marshall actually has the power to "fire" Ray, which the show itself just got done showing is not the case. But then Ray and Marshall leap on each other and engage in mad kissing. This trivializes the situation. And although it seems pretty clear that Kelly was right and Marshall wrong, as with earlier scenes in the plotline, no one ever quite states the obvious: This is not an anomalous situation in which we should choose to be tolerant of nurses for getting a little out of line and questioning physicians. Kelly has legal and ethical duties to protect her patients, to fix physician care plans that she knows to be wrong. When nurses do not do that, patients die. Nurses must always do what Kelly did, and any physician who acts like Marshall should be disciplined or lose her position.
Later, we see Hawthorne chastising her teenage daughter by cell phone. Maureen, the adult daughter of the stroke patient, overhears this interaction and is suddenly reminded of her own child--a baby that she has forgotten in her car on this extremely hot day while dealing with her mother's issues. The ED staff and Hawthorne rush outside. The decisive Hawthorne smashes open the car window. The nurses get the baby and rush back inside the hospital, again with no physician involvement, just as it would likely be in real life.
In the ED, the staff is agitated because the baby's condition is critical. Tom Wakefield shows up and asks for epinephrine, noting that they need to bring the baby's core temperature down. The nurses are doing most of the work here. Sadly, they can't save the baby. Everyone is devastated. In the aftermath, a shaken Larry actually thanks Ray for saving his life. True to his character, though, Larry quickly ruins the moment by saying Maureen is an "idiot" for leaving her baby in the car. Candy throws him out of the ER.
Later, we see Hawthorne holding what seems to be a debriefing of the nurses following the baby's death. She presses Bobbie to say a few words to the nurses, but Bobbie resists. So Hawthorne begins the meeting as if she will be the lead consoler--then quickly turns the job over to a shocked Bobbie. Bobby gives a tearful and heartfelt, if less than articulate, speech about how the day "sucked" and how "pissed" she is about the tragic death. Toward the end she goes a little off-message, before bringing it back to the baby.
Bobbie: The patients just thank the doctors. The doctors just ignore us, or talk down to us, or try to get us fired, or slap our ass. Let us be pissed because we can't save every one. And that is all we want...every damn one.
Wait--the patients just thank the doctors--so nurses actually do need credit for saving lives? Anyway, though not all of this speech works, it does point to real problems in nurses' relations with some physicians, specifically disrespect and sexual harassment.
That evening, we see Hawthorne back with Morrissey in his office. He is not satisfied with her proposed cuts, because there are no real cuts to personnel. He says that's their death warrant because the outside administrators will come in and cut staff anyway. Hawthorne says her staff has been through enough today. He again suggests firing Kelly, and Hawthorne again refuses. He suggests Bobbie Jackson, noting that with her seniority, the cut would be worth two regular staff positions, which is probably an exaggeration. Hawthorne refuses. She offers to resign--a move that makes her earlier pushing of Bobbie to assume more responsibility seem like an effort to train a replacement. But Morrissey says he needs a CNO, not a martyr. He says Kelly has to go, and he'll fire her himself. But now Hawthorne is crying.
Hawthorne: Don't make me fire anyone today. Please...not today.
Morrissey seems, finally, to be at a loss. He looks at his computer screen.
Morrissey: How about if I cut the cost of living increase for the year. It could buy us some time. Would they go for that, you think?
Hawthorne nods, thanks him, and leaves his office quickly. But she leaves the hospital slowly, looking at all the working nurses whose jobs she has, at least temporarily, saved. (Never mind asking why they did not think of this cost of living solution before.)
Some direct care nursing advocates might argue that a real CNO would be unlikely to stand up for her staff this way, just as a real CNO would not be involved in direct care, much less spend a significant amount of her time on it, as Hawthorne seems to. And the plotline is also odd because just three episodes ago, Morrissey was boasting that he had persuaded the hospital board to allocate more nursing staff, at least in the ED.
But nursing is not suffering because the public has too positive an impression of nurse managers. The public barely knows nurse managers exist, though HawthoRNe has already done more than any other show to change that. Nursing is suffering because the public believes that nurses, generally, do not possess the expertise and courage that Hawthorne displays. Certainly there is room for negative portrayals of nurse managers--Nurse Jackie's nursing manager Gloria Akalitus springs to mind. But there is also room for a show to present a CNO as someone who acts as a TV chief of medicine like Wakefield acts. To the extent some real CNOs do not provide clinical leadership or protect their staffs, it's not the worst thing in the world to offer a vision of what the job could be like if it attracted the resources and respect that chief of medicine positions do.
On the whole, despite problems here and there, the episode offered viewers some unusually helpful information about nursing, and we thank those responsible.
You can see the full episode by downloading it from iTunes.