From rock stars to activity logs
July 21, 2009 -- TNT's Hawthorne has some issues, but it deserves more credit for its efforts to show nurses as skilled patient advocates. The show often explores the limits of its lead character's authority as chief nursing officer of a Richmond, VA hospital. In the July 14 episode, Christina Hawthorne goes around a powerful surgeon to give a patient the option to get treatment from a more experienced surgeon at a different hospital. In doing so, Hawthorne violates rules related to the transfer of health records and gets in major trouble with the hospital CEO. In tonight's episode, Hawthorne tangles with the CEO over nurse under-staffing, though only in the context of a somewhat absurd plotline in which the hospital absorbs the entire emergency department patient load of a nearby hospital after its ED closes. Hawthorne also uncovers the cause of a teen's Adderall overdose: a prescription from his own physician father. These plotlines feature strong patient advocacy, though Hawthorne also tends to overstep and have her ultimately subordinate position made clear. Meanwhile, plotlines about the staff nurses--the real ones, though Hawthorne herself often plays that role--show that they too try hard to protect patients. In one, nurse Candy Sullivan shows an ED patient's contemptuous father that she actually does have expertise by catching his own hypertensive crisis. Another plotline conveys sympathy for the staff nurses who must log all of their daily activities for the benefit of hospital "efficiency experts." This task seems pointless and bad for patient care, until timid nurse Kelly Epson's log shows a patient's litigious wife that Kelly was actually nursing, rather than having sex in the closet, when the patient had an allergic reaction. Sadly, another plotline follows nurse Ray Stein on a deeply embarrassing ego trip as he plays source for a reporter who is supposedly going to expose the ED's overwhelmed condition--until the "reporter" turns out to be a delusional psychiatric patient. Ray is not a bad nurse, but he is also a hapless, self-absorbed physician wannabe--an unfortunate choice for the show's sole male nurse character. Tonight's episode was writer Jeff Rake's "Trust Me"; the July 14 episode was Anna C. Miller's "The Sense of Belonging."
The most important plotline in the July 14 episode centers on Amy Johnson, a teenaged patient who has a congenital heart defect and has been in and out of the hospital her whole life. She is a longtime patient of Hawthorne's, and they have a clear rapport. Amy is understandably distressed to be back in the hospital, with a specific condition the ED was unable to diagnose. Hawthorne herself examines Amy and asks questions, wondering if the ED ruled out pericardial effusion. As they discuss Amy's condition, it becomes clear that her mother is having trouble getting that her daughter is growing up and wants to play a bigger role in her own treatment. Hawthorne suggests the current health problem may be neurological, which turns out to be correct. Later, Hawthorne tells Amy privately that she knows her parents have always been overprotective, but "if you want to change that habit, stand up for yourself." Amy starts seizing. Hawthorne calls for Ativan, and a nurse gets it. The scene ends without a physician rushing in to save the day.
Amy's brain scan shows a problem. A hotshot neurosurgeon named Philips tells the family it is arterial venous malformation (AVM), a rare brain disorder which is a "lesion of the cerebral vasculature," and he says Amy needs corrective surgery as soon as possible. Hawthorne can see this is too much and too technical for the family to process, so she asks Philips to give them a lay explanation. He actually says he's not sure he can give one. Hawthorne asks if she can try, and she does.
Hawthorne (using her fingers to demonstrate): Basically, Amy's arteries and veins should be separate, like my fingers. Instead, they are tangled, in a clump. So now oxygen can't get to her brain.
This is a pretty good example of nurses translating the technical jargon patients often hear from physicians, which is a key nursing role. Philips can't challenge what Hawthorne has said. He does want to do the surgery immediately, noting that Amy's vessels could go "into active bleed," and he plainly sees no need for further discussion. But Hawthorne wants the distraught family to have more time and more information. After Philips leaves, she says she will do some research and talk to the hospital's chief of surgery about Philips. Amy's tearful mother responds: "You do anything you have to do."
Later, Christina arrives to see the chief of surgery, her friend Tom Wakefield, meeting with Philips about the case. Hawthorne urges them to put off the surgery until tomorrow, so the family can evaluate the AVM diagnosis. Philips actually says that it must be today because tomorrow he has another Today Show appearance, on tethered spinal cords.
Christina: Please tell me that we are not rushing Amy's surgery to accommodate your PR schedule.
Wakefield notes that Amy could have another seizure and bleed out at any time, so sooner is also better for her. Philips suggests that they do a video of Amy's surgery and use it as a promo. Christina says she was thinking that "we could focus on Amy Johnson instead of your TV career." Philips leaves. Wakefield says that the neurosurgeon is a "top gun," and that Amy is getting the best the hospital has to offer. Christina asks if Amy doesn't deserve "the very best." Seeing Wakefield's look, Christina deduces that the hospital can't give Amy the very best. She asks how many of these AVM procedures Philips has done. Under repeated questioning, Wakefield admits this will be Philips's first.
Later, Christina brings Philips a stack of research. He mocks her for Googling, and wonders if she has any surgical tips from WebMD. She is undeterred, noting that a Johns Hopkins surgeon named Ryan has performed more successful AVM surgeries than anyone in U.S. Philips says he isn't sure that surgeon, who is approaching 70, can still do it. Christina notes Philips has never done it. He brags about being a board-certified neurosurgeon that the hospital courted for a year and a half--as did Hopkins. She figures he came here to be top dog, which he presumably would not have been at Hopkins; he does not deny that. Christina wants Philips to refer Amy to Ryan, or at least tell the family he exists, so they can choose. Philips refuses, saying this is how health care works.
Philips: If she came yesterday, she would've got Bill the Butcher.
Hawthorne: Amy Johnson's not your lab rat.
Philips: And you're not my boss.
Of course, that is true, but it's not exactly addressing the merits either, and it is an example of how some physicians respond when nurses challenge them. When you have power, it's often easier to invoke or exercise that than it is to defend your views in a reasoned way, especially when there are time or other pressures.
Hawthorne simply contacts the Hopkins surgeon Ryan anyway, and actually sends him Amy's films. We see Christina making arrangements for Amy to travel to Baltimore, and we assume the family has decided to go with Ryan. Philips arrives at Amy's room, understandably angry. Outside, Hawthorne assures him that she said nothing "against" Philips to the family. Philips tells the family that he thinks it's a mistake. Amy is surprised that Philips did not know about the change. It turns out her parents told her Philips had referred her to Ryan, so she would not have doubts about the move. Amy says, correctly, that they were lying to her. When Hawthorne starts to explain why she referred her to Ryan, Amy tears into her, asking how one surgeon could really improve the quality of her life. Philips admits that it is possible, as she would be his first case. Amy says she doesn't care, she wants the surgery now, there. She even suggests maybe she can help Philips learn something, and the next set of parents won't have to torture themselves over whether he knows what he's doing. Her parents and Christina relent. Just before the surgery, Philips tells Christina that Ryan agrees that craniotomy with vascular clipping is the treatment of choice for Amy--he has consulted the Hopkins surgeon!
After the surgery, we see Philips telling Amy she'll be fine, and that she should watch him on The Today Show. Hawthorne approaches and tells Philips it looks like he's as good as he thinks he is. Philips says he knew she'd come around. She says she wouldn't take it that far. He says that doesn't sound like much of an apology. She says it's not; she would do it all again. Hawthorne tells Amy she's sorry if she did anything that made the process harder. But Amy says if it weren't for Hawthorne, she would not have been able to stick up for herself.
The patient advocacy here is generally good. Hawthorne advocates by pushing the surgeon to justify and explain his plans, by helping the family understand Amy's condition and options better, and by motivating Amy to stand up for herself, even in making a choice Hawthorne may not agree with.
Of course, Hawthorne's methods are bound to cause trouble, and they do. We see the hospital CEO Morrissey stop by the surgeon Wakefield's office, asking about the "flap" between Philips and Hawthorne. Wakefield says everything worked out, so it's "no harm no foul." Hawthorne arrives; Morrissey apparently paged her. She explains that she and Philips had a bit of a disagreement, but in the end it all worked out.
But this isn't enough for Morrissey. He notes that if it had not worked out, it would be a "real problem," and he asks about the Hopkins surgeon. Hawthorne says the family needed a second opinion. Morrissey suggests that's Wakefield's job, and Wakefield admits that he did advise the family that Philips was the right choice for the surgery.
Morrissey (to Hawthorne): Help me understand this. Despite advice from our two top surgeons, you sent medical records to a doctor at a different hospital.
Hawthorne: A world-renowned expert in AVM.
Morrissey: Did the parents request this?
Hawthorne: They gave their consent.
Morrissey: Written consent?
Hawthorne says they told her to do what she needed to do. Morrissey presses.
Hawthorne: I had a moral obligation--
Morrissey: --to commit a federal crime. You violated hospital protocol. You offended our rock star surgeon. And you deliberately broke the law, then said you'd do it all again tomorrow. If I report this, which I'm obligated to do, we open up this hospital to a huge liability. Should I report you to the authorities?
Hawthorne: I think you should do what you feel is best.
Morrissey (to Wakefield): How about you? You think I ought to turn her in?
Morrissey: So then I become the bad guy, I have to sweep it under the rug. And the three of us here makes it a conspiracy, which makes me feel dirty.
Hawthorne: Well, I wouldn't want that, so if you want me to turn in my resignation--
Morrissey: I considered it. But unlike you, I don't make decisions while I'm hot. Do me a favor. Stay home tomorrow. Consider what you did. And I'll consider my "moral obligation" to this hospital.
What can we say? This wasn't the right way for Hawthorne to go, and we can't fault the show for suggesting as much, though it seems pretty unlikely that a real CNO would do this. The show seems to be getting at the power dynamics here--nurses like Hawthorne should not be driven to measures like she resorted to in order to be heard on patient care. But maybe Hawthorne's just a loose cannon. The show could have had her simply persuade the parents to seek a second opinion and authorize the records transfer. Then the issue might have been sharper: Should nurses be excluded from discussing treatment options with patients and families, even against a physician's wishes? Of course, there is also a key group of missing players who might have weighed in here--Amy's staff nurses, who play no real role in the plotline.
The July 21 plotline on the ED overcrowding finds Hawthorne tangling with Morrissey again. We see all the major staff nurse characters struggling to cope with a huge influx of patients in the Richmond Trinity ED, apparently because Sacred Heart, another local hospital, suddenly closed its ED. The show has nurses Candy and Ray in the ED, even though we thought they usually worked on the floor. Of course, hospital shows have always had physicians practicing in all specialties, so whatever.
Hawthorne arrives and scrambles to find nurses to cover the ED. She learns that Morrissey called all the other nurses in early--without her knowledge. She confronts Morrissey, who says they only needed additional staff "on the early side" so he decided to let her sleep. He claims that they had no choice but to accept the patients: "It's called rising to the occasion." He explains that the city pulled the plug on Sacred Heart because it could not "meet its budget. So Morrissey "told the Mayor we'd take the inventory."
Hawthorne: Are we talking about people or washing machines?
Morrissey: Is that all? I imagine your services are needed downstairs.
Hawthorne: I imagine you're right, but if you're going to double my patient capacity, please double my staff.
Morrissey: Save your breath. I can hear the rest of the speech in my head. And you're not entirely wrong, we're treading water a little bit--
Hawthorne: We're drowning.
Morrissey: Fortunately, we have experienced care givers who will get through this when they accept the circumstances and focus on the work--starting with yourself.
Hawthorne: I'm gonna have to consult Dr. Wakefield on this one.
Morrissey: Be my guest. I've spoken to Tom and he's on board.
Hawthorne does take it to Wakefield (though it's not exactly clear why he would be involved in nurse staffing) and tells him that the ED overcrowding is ridiculous. He responds that "Sacred Heart got stuck, we fell on the grenade." She points out that the patients could have been spread out into every ER in the city--pretty clearly what would really have happened--and says this is just "Morrissey fueling his ego." Wakefield "is pretty sure his tank's already full."
The episode has Hawthorne refer to several measures to try to handle the influx, though it's not clear why any of them would do much good, since none involve more staff. Hawthorne tells the apparent ED charge nurse Bobbie that she's going to "work it out," maybe with a "satellite upstairs." Later, Hawthorne tells Bobbie to put some patients in the cafeteria, and she'll have "nurses and orderlies rotate through."
At one point, Morrissey appears in the ED with two men in suits, asking for Hawthorne's attention. However, as discussed in more detail below, Hawthorne is so overwhelmed dealing with various issues, including an ED patient who is a friend of Hawthorne's own teenaged daughter, that she never does get to Morrissey.
Still later, after Morrissey has again overruled Hawthorne's attempts to move patients out of the ED, and yet another wave of patients arrives, Hawthorne tells Wakefield she has had it and is going back to Morrissey. He tries to calm her, saying Morrissey would like an excuse to replace her. Later, though, Wakefield changes his mind. We see the three of them in the CEO's office.
Wakefield: A shootout in the ER is the last thing we need. John, you have got to trust your people on the ground. Focus on the big picture, and leave the day-to-day floor management to Christina. And trust that when she says the ER is overloaded, it's overloaded, period.
Morrissey: Here's a news flash. While Ms. Hawthorne was babysitting her daughter and caught up in whatever personal drama--
Hawthorne: Wait a minute, no, that was not how--
Morrissey: My turn. My floor management skills convinced the board's budget chairs--you saw them, two horrified men in expensive suits in the ER with me--that we needed more staff.
Hawthorne: You were putting on a show?
Morrissey: In a sense. I saw the Sacred Heart overflow as an opportunity and I took it.
Hawthorne: Why didn't you just tell me?
Morrissey: I don't trust you.
Wakefield: Why didn't you tell me?
Morrissey: You'd tell her. You're blinded by friendship, doctor, it's a weakness of yours.
Hawthorne (under her breath): Obviously not one of yours.
This plotline sort of makes the point that more patients require more nurses, though some of it seems to suggest they just need more space. The plotline does not convey that in many settings, short-staffing is endemic even under "normal" conditions, nor that it may be present even at the staffing levels for which many hospitals aim. Instead, the plotline suggests that short-staffing would be evident only in a once-in-a-generation overflow from another hospital. It does suggest that Morrissey knew they needed more nurses even in the absence of the overflow, and that he used the overflow as a pretext to get the board to go along. But it's pretty far-fetched to think that the board members would not realize this was a special situation caused by the other hospital's closure. Some might also question the suggestion that it is the hospital CNO who fights hardest for better nurse staffing. And of course, although the nurses here are overwhelmed and unhappy, this plotline does not bring out how patients can suffer and die when nurses are understaffed.
Another plotline in the July 21 episode pits Hawthorne against another arrogant physician. In this case, Hawthorne's high school-age daughter Camille arrives at the ED with her boyfriend and study partner Ryan, who is ill. Hawthorne examines Ryan. She tells Wakefield that Ryan has chest pains, is feverish, has a heart rate of 110, with pupils constricted. Ryan denies taking anything. Wakefield wants an EKG. Later, Ryan codes while sitting in the ED with Camille. Hawthorne, Bobbie, and Wakefield rush over and treat Ryan on the floor. Although Hawthorne's role in assessing Ryan up until now has been pretty good, it is Wakefield who does the defibrillation; with all the nurse characters on this show, there's really no excuse for that. Nurses generally do ED defibrillations.
The show creates a pile-up for Hawthorne in the ED. Ryan's snooty parents arrive. Dad is an arrogant ENT physician and mom is a psychologist. They ask Hawthorne for their son's chart. Meanwhile, Hawthorne's friend Isabel, recently homeless, also wants Hawthorne's attention. Isabel's baby Moses has been transferred from the NICU without her knowledge, and she demands to know where. And Morrissey, accompanied by the two suits, wants Hawthorne's attention as well. The ENT physician says that "they" probably told Hawthorne that Ryan had cardiac arrest, but he can tell by looking at "this place" that the "level of expertise is less than stellar." Hawthorne admits they are swamped, but assures him the level of care is excellent. Isabel wants her attention. Morrissey wants her attention. Hawthorne asks someone to go to the PICU and get Ryan's parents the chart. Camille wants Hawthorne's attention. Isabel wants her attention. Hawthorne tells Isabel the baby has been discharged to a foster home. Isabel is bereft, railing at Hawthorne while Morrissey continues to try to get her attention. Isabel ends up sobbing in Hawthorne's arms, as Morrissey and Camille look on.
This scene actually does capture some of the intensity of demands that may compete for a direct care nurse's time, and the show deserves credit for the scene, though in general only the Morrissey part is something a real CNO would be likely to encounter.
Later, Wakefield tells Ryan's parents that their son has electrical dysrhythmia, but that does not fully explain his condition. Ryan's dad wants to know why not. Hawthorne says teenagers don't just go into cardiac arrest, even those with abnormal heart rhythms. She says Ryan could be on a stimulant, like speed. The parents are contemptuous. Wakefield says they'll get the tox screen back soon, but in the meantime, to be safe, he wants to do a cardio-ablation, a procedure involving the insertion of a catheter and the short-circuiting of the damaged heart tissue. Ryan's father declares that to be nonsense and demands a second opinion. Wakefield says he'll get the electro-physiologist, but Dad can expect "the same nonsense" from him.
Later, Wakefield tells Hawthorne that the tox screen showed Adderall, a drug often used to treat ADHD, but which some kids also use as a brain stimulant to study. Ryan's parents don't question the diagnosis, but the mother goes on the attack against Camille, suggesting she must be responsible. Hawthorne denies that. Ryan's father says they are leaving, going to a different hospital, presumably the one at which he practices; they are not going to leave their son here in "Calcutta." Wakefield says there could be cardiac death without immediate ablation, but Ryan's father insists.
At Hawthorne's urging, Camille talks to Ryan, who confesses that he has been doing the drug for about a month. He tells her where he got the drugs, and Camille tells Hawthorne, but says she cannot disclose the source of the information. We see Hawthorne chase down the departing family. She says she called the pharmacy at the other hospital, and says Ryan has a prescription for the drug. Mom asks where he would get a prescription. Dad admits that Ryan got the prescription from him. Mom is shocked. Dad says Ryan needed help in his competitive academic environment. Mom is furious. She agrees to Hawthorne's plea to let them do the ablation, which they do successfully. Mom stops by to ask Christina not to report her husband, and let her "repair" her family. Hawthorne eventually agrees, though she says that the woman's husband should take a long leave of absence, and that the mother is lucky Hawthorne (who recently lost her husband) understands what it's like for a child to live without a father. Ryan's mother thanks her.
On the whole this plotline features strong advocacy and psychosocial skills from Hawthorne, who plays the central role in uncovering the truth about Ryan's condition, which is the key to getting him the treatment he needs. She pushes through the resistance and insults from Ryan's parents, yet ultimately manages to show them some compassion as well, declining to pursue the father for his misconduct (some nurses might question that decision, but we doubt many viewers will). Hawthorne even does an initial assessment of Ryan's condition, which shows viewers some technical skill. Of course, as is often the case, it's unlikely that real CNOs would do that. However, maybe they should--if a real chief of medicine would retain some clinical role, and be viewed as a clinical leader, why shouldn't a chief nursing officer?
Another July 21 plotline shows staff nurse Candy earning the grudging respect of a contemptuous ED patient. We see Candy caring for a girl who had a roller blade accident and has facial injuries. Candy sees that it hurts, and says she'll get the girl some painkillers. But the girl's impatient father has something else in mind.
Dad: I'd like you to get us a doctor.
Dad: Don't Dad me. I'd like some expertise... No offense.
Candy: Oh, I think a little.
Later, the girl's father complains that it's been 45 minutes, and still no physician. Candy apologizes. We see that Dad looks sweaty, and he complains about the heat, saying he could "poach an egg in my pants."
She looks at him, asks if he's OK.
Dad: I'll be OK when you get a doctor to see my kid.
Later, we see a resident examining the girl's cuts. He says she's lucky he just had his cosmetic surgery rotation, though it will take about 25 stitches. Candy assures the patient that they will use a local anesthetic and she won't even know it's happening. Candy sees that the father is still not looking so good.
Candy: Did you get a chance to eat something?
Dad: I had a big breakfast. Grand Slam.
Candy: And you're sure you don't feel light-headed at all, or--
Dad: Would you give it a rest? Can we get on with this, she's been sittin' here for three hours.
Resident: Um-hm, I'll be right back.
He leaves. Candy follows.
Candy: Doctor, could you take a look at the dad? He's all flushed and jittery.
Physician: Yeah, he's probably stressed out, give him some water and tell him to sit down.
Later, we see Candy assuring the father, who looks increasingly lousy, that she understands his frustration at the delay. But as she does so, she takes his pulse.
Candy: Mr. Deegan, are you experiencing blurred vision?
Dad: I told you--
Candy: Answer the question, is your vision blurred?
Dad: Maybe a little bit.
Candy pushes the emergency button, starts taking his blood pressure. The resident comes running.
Candy: Not just stress. Hypertensive crisis. 210 over 120.
Resident (examining his pupils): Sir, we need to get your pressure down right away. Are you allergic to any medications?
Dad: Could you just stitch up my daughter?
Candy: You know, we will; we gotta make sure you don't have a stroke first.
Later, with the crisis apparently under control, Candy asks the Dad if a nurse can draw his blood, "or shall we wait for a doctor?" The father says, in what appears to be his version of respect, "Knock yourself out."
Overall this plotline is great. Candy displays interpersonal and physiological expertise. As she is caring for the daughter, and providing emotional support, she is alert to an apparent problem with the father, though he expresses the widespread view that nurses lack "expertise." Candy catches the hypertensive crisis despite resistance from the resident, whose response actually conveys great disrespect--the words and tone seem neutral, but he is actually dismissing the input of a skilled professional without a second thought. The plotline illustrates the importance of physicians listening to what nurses think. Of course, Candy could have presented her suspicions to the physician in a more impressive way, and her initial request to him implied that she could not explore basic diagnostic tasks on her own, even though she did appear to be forming some ideas. But as we know, only physicians can diagnose! It is true that many nurses are reluctant to make direct suggestions about what is wrong with a patient for fear of treading on physician territory. But when one professional cannot speak plainly to another, it is a mark of dysfunction in the health care system, and an obvious threat to patient wellbeing. Another minor issue appeared in the final interaction about drawing blood, which might lead some viewers to believe that physicians would have anything to do with drawing blood, even if a patient did want that. Of course, nurses draw blood, and they have expertise in doing so.
The July 14 episode starts with Hawthorne holding what seems to be a staff meeting at a dining area outside the hospital. She begins, "Now, before you go off and save lives...", and goes on to harangue the nurses in a sympathetic way about filling out daily activity logs. Apparently, the nurses are supposed to record everything they do on activity logs, in sub-hour increments (later, Ray does it minute-by-minute, to mock the system).
Bobbie: And why can't Administration just stop pissing away money on efficiency experts and just hire more nurses?
We agree with Bobbie, but later, we see the logs are handy for something. In the ED, Bobbie tries to rein in new nurse Kelly's very conscientious efforts to record everything, which results in patients being kept waiting. But then they encounter the very pushy and stressed-out wife of an ED patient named Arthur Tanaka. He is in the ED for an infected ingrown toenail. But when Kelly gives him an antibiotic, he has an allergic reaction. Immediately, Bobbie recognizes it and gets oxygen, Kelly gets and gives epinephrine, and Bobbie asks for Solu-Medrol, respiratory therapy, and one Dr. Cadbury. But Tanaka's wife wants to know why Kelly was not in there with her husband. Bobbie glances at a log Kelly was filling out, suggesting at least to viewers that the logs may have kept her from the patient.
Mrs. Tanaka starts calling her lawyer, saying Kelly should have stayed by her husband's side while she gave the medicine: "She was probably on a coffee break or having sex in the closet like you people do. She was negligent!" But Kelly says she can prove otherwise, showing Mrs. Tanaka the detailed log of her activities, noting that it shows "all nursing, all the time." Bobbie smiles, adding, "And here's the medical history you filled out, indicating no known allergies. Is that correct, or did you make a mistake?"
Despite this interesting alternative use for the logs, the episode is not really suggesting they are generally a great idea, and many real direct care nurses would likely agree. Activity logs are apparently sometimes done for research purposes, but it would be critical that they not actually interfere with care, as seems to be the case here. In fact, the episode itself is kind of ambiguous--the logs seem to have saved Kelly and the hospital from a legal claim, but did the logs also interfere with Kelly's care for the patient? Of course, it's actually helpful that the plotline indicates that nursing errors could lead to malpractice liability, and does not imply this was ultimately a physician's responsibility. The show also gets in what may be a little poke at the naughty nurse image in Mrs. Tanaka's remarks about sex in closets, though that could also just be a tweak of ABC's Grey's Anatomy, in which major characters often have sex in closets.
A minor plotline in the July 21 episode features Ray, the show's only recurring male nurse character. Suffering from the ED overload, Ray meets a reporter from the Richmond Times-Dispatch who is doing an expose on the hospital carrying all the burden of the Sacred Heart shutdown. Ray becomes the reporter's "deep throat" in exposing the overwhelmed conditions--and goes on a major ego trip about it, boasting to Candy, who notes mildly that it might cost him his job, and mocks him ("good luck with that"). Ray does tell the reporter that the standard nurse:patient ratio in the ER is 1:4, but Ray is at 1:6 (though the overwhelming patient load the show depicts looks more like a 1:10 ratios). It's good that the show raises the issue of ratios, though it's a fleeting reference, and there is no follow-up to explain how poor ratios endanger patients.
At one point, the reporter asks how Ray got into nursing.
Ray: When did I know? Well, my mother breastfed me until I turned four, which I suppose is a long time. You know, maybe it's even a little bit creepy. But I can't help but feel that her instinct to nourish me, God bless her, to just let me suckle to my heart's content, that that instilled in me the desire to nurse. Not nursing in the breast sense, but nursing in the metaphysical--
Bobbie and Kelly overhear what Ray is telling the reporter and roll their eyes. Later, we see Ray telling the reporter that a "heterosexual male nurse" like him: "creates a palpable sensual energy in the ER. It's like it's my testosterone colliding with an avalanche of estrogen. Frankly, it's hot."
But the "reporter" turns out to be delusional psychiatric patient--and when the patient is exposed, he suggests that it's actually Ray who is delusional, with his pathetic egomania. Ray is totally embarrassed.
It's sad that the show's one male nurse character, while sometimes seen as a pretty good nurse, is also a foolish physician wannabe, who's always getting schooled by someone, from delusional patients to Larry in accounting. Of course the show is allowed to have a bogus nurse character, but it's unfortunate that it's the only man. Viewers know that Ray is not in nursing because his mother inspired him so much as he is because he has been unable to get into a decent medical school. Then there's the breastfeeding angle, an extremely unhelpful concept to mix with professional nursing, since it implies that "nursing" is something that does not require health care training and that only women do. Indeed, if any character is going to compare nursing with breastfeeding, it's unlikely to be a male nurse. And Ray's "heterosexual male nurse" comments are not exactly a mature or constructive take on the unfortunate reality that the vast majority of nurses are still female. Media images like Ray will do nothing to improve that situation.
On the whole, despite some problems, Hawthorne makes a fairly serious effort to show that nurses are skilled professionals who should and at least sometimes do push back at physicians and others when they believe it is in patients' interests.