Chief Nursing Officer
June 16, 2009 -- Tonight's series premiere of TNT's hospital drama HawthoRNe makes a serious effort to tell stories from a nursing perspective and to focus on nursing care, particularly the exploits of the dedicated, expert, and strong chief nursing officer Christina Hawthorne (Jada Pinkett Smith). Remarkably, the show has four diverse major nurse characters--including the black female lead and a man--with just one major physician character. This is an unheard-of TV ratio, though a good approximation of hospital reality. Indeed, the very fact that HawthoRNe shows that chief nursing officers exist is helpful. Nurses are not interchangeable widgets, and some here are clearly more skilled than others; to some extent they provide autonomous care. In several cases the pilot gives viewers a sense of the lack of respect nurses often receive from patients and physicians. And it suggests that nurses have the skill and perhaps even some obligation to resist physician "orders" in order to protect patients. One nurse questions but still gives an erroneous physician insulin prescription, then gets in trouble when the patient crashes. But sadly, the overall portrayal does not convey enough of nurses' real skill or autonomy, and elements of the episode reinforce harmful stereotypes. The nurse-physician conflicts do not really make clear that nurses are legally and ethically obligated to resist dangerous physician care plans. Many scenes suggest that the direct care nurses are, well, weak, and very much in need of rescuing by Hawthorne. As on other shows, the blistering contempt of some physician characters is not adequately refuted, except to some extent by Hawthorne herself. And surely nursing does not need an image of a frustrated nurse who really, really wants to be a physician but was unable to get into medical school, and so harbors a huge inferiority complex. Surely we don't need an image of a beautiful young nurse named Candy who thinks it's part of her job to grant sexual favors to Iraq War veterans as a "thank you" for their service, and who we see cheerfully provide manual sex to a soldier in the pilot. And at times, the show suggests that staff nurses tend to be frivolous physician helpers--physicians still do both defibrillations we see. HawthoRNe may not inspire a lot of critical respect, but its main character and basic structure could help nursing a great deal, so we hope future episodes will avoid stereotypes, and do more to convey what nurses do to save lives. The pilot was written by series creator John Masius. The first episode was seen by 3.8 million viewers.
Christina Hawthorne is an expert health care leader; the other nurses, not so much
The best thing about HawthoRNe is Hawthorne. The fact that a prime time show would even have a chief nursing officer as a major character, much less the main character, is unprecedented. Indeed, we doubt many people even know chief nursing officers exist--that is, few know that nursing is an autonomous profession with a scope of practice distinct from medicine, with a management hierarchy reaching to the executive level. HawthoRNe has the power to change that, at least to some extent. And of course, the lead character is a black female, not just the first such central nurse character on a major U.S. prime time show since Diahann Carroll starred in NBC's Julia (1968-1971), but possibly the first major black nurse character to appear at all since NBC's minor sitcom Nurses (1991-1994). The fact that Hawthorne even exists--and that Jada Pinkett Smith is an executive producer--is a television milestone and a significant vehicle to promote much-needed racial diversity in the nursing profession. Pinkett Smith's mother, incidentally, is often described on the Internet as "head nurse of an inner-city clinic in Baltimore."
In addition, however realistic it may be, the show does make some effort to place Hawthorne in executive situations, and to have her function as a real CNO might. At Richmond Trinity Hospital, she attends "executive committee" meetings, discusses budgets and events, and generally seems to carry the hospital on her shoulders. She also thinks broadly about health issues. In one brief scene, she sees a hospital worker using some new type of disinfectant to clean a hospital hallway. This stuff smells toxic to her; the worker agrees, but says he's been told to use it because it's cheaper. Hawthorne says it won't be cheaper when the worker's comp claims start. He asks Hawthorne if she could get him "the good stuff" again. She says she'll try, and it seems like she might actually have the power to do it. Perhaps the "worker's comp" reference was not the most sensitive way to describe potential injuries to this worker, but the point seems to be that Hawthorne has a broad view of public health, as well as the initiative and power to apply it.
The exact nature of Hawthorne's relation with physician managers is ambiguous. At times she seems to operate on the same level as the physician who seems to be her counterpart, Tom Wakefield, the chief of surgery who seems to function as the chief of medicine, as the chief of surgery does on ABC's Grey's Anatomy. At other times, it seems as if she reports to Wakefield. The episode at least suggests that there are separate lines of authority for nurses and physicians, something that seems to be beyond popular shows like Grey's and Fox's House. In any case, Hawthorne makes a serious effort to represent the interests of direct care nurses, and pushes back fairly strongly against physician aggression toward her nursing staff (or at least promises to, in some cases). Some nurses might be glad to have her as CNO.
And as for that staff, Hawthorne assumes the role of a demanding but supportive mentor, teaching, pushing, correcting, but also offering solidarity and even the occasional smile. In the pilot, Hawthorne holds what seems to be a kind of morning staff meeting with maybe 10 direct care nurses that brings out some of the good and less good elements of the show's portrayal of the nursing management structure. First, the very fact that Hawthorne is holding the meeting, and no other managers appear in this or other scenes, suggests that the entire nursing management team will be collapsed into one person, her. That's not necessarily a big deal for a TV show--recall how rare it is for nurse managers to appear at all--but the meeting also illustrates the unfortunate fact that, at least in the pilot, it's really only Hawthorne who could be called a strong, expert nurse.
Hawthorne starts the meeting by asking for a status report. One mousy nurse notes in a fragile tone, "Nobody died last night." When Hawthorne responds by noting that one particular patient obviously made it through the night, the fragile nurse notes that that patient is "too mean to die." Aww. Hawthorne also wants to know why "old man Fleming" was sleepwalking on the stairs the previous night. A nurse who evidently was caring for Fleming notes that he was in restraints, but that he is practically Houdini.
Hawthorne: I'm gonna say this for the last time. I don't care if we have to do bed checks every 5 minutes, we cannot have patients wandering around the building, unsupervised, putting themselves in danger, OK?
Hawthorne moves on, and the very new and tentative Nurse Kelly seems to be the one with the meeting agenda.
Kelly: Three of us complained about verbal abuse from doctors.
Hawthorne: Put it in writing.
Kelly: And six nurses think that Nick the paramedic is really hot.
Hawthorne: Make that seven.
Giggling. Hawthorne promises to raise all these issues with the executive committee (it's not clear if that will include Nick's hotness). Kelly wants volunteers to make centerpieces for the "Nurses Auxiliary Japanese Tea Ceremony thingee." Hawthorne volunteers.
To a great extent, this scene is emblematic of the episode. Hawthorne is strong and decisive, and some actual nursing issues are presented, but the other nurse characters are troubling. It's great that the show raises physician abuse, and there will be more on that later in the pilot, but the other two nurses who speak in the scene present so weakly that it's hard to imagine them standing up for themselves at all. Does only Hawthorne have any strength? It's also good that the show raises the very real practical concern of confused patients getting away from the nurses, though the way it's handled is somewhat absurd. No one in the current care environment is going to be able to do bed checks every five minutes, a comment that could be read to suggest nurses don't have a whole lot of other important things to do. And the comments about Nick's hotness are an obvious misstep. Even if you take Kelly's "six nurses" remark as ironic or self-mocking, and the line reading does not make that clear at all, the comment as so inane that even as a "joke" it degrades the profession. And the "Nurses Auxiliary" bit associates nursing with the classic image of peripheral female volunteer work--the Ladies Auxiliary--rather than the work of skilled professionals. Overall, this scene presents nurses more as low-skilled, mousy helpers (auxiliaries) and do-gooders, passively victimized by patients and physicians. Finding a date with hot guys is very much on their minds.
Hawthorne and the icky Dr. Mazaki
Other scenes show that Hawthorne protects the nurses, though again, some suggest that they may be a little too much in need of her protection. One minor plotline involves Dr. Mazaki, who evidently abuses the nurses when they cannot understand his very thick Japanese accent. This plotline involves Hawthorne's good friend Bobbie Jackson, the only significant nurse character besides Hawthorne who projects any real authority. But even she seems to need help. Bobbie mentions to Hawthorne that Mazaki is working that day and is likely to yell at her, but says that she can handle it. Hawthorne tells Bobbie says she knows Bobbie can handle it, "but let me, it's my job." Well, eventually it might be, but ideally nurses could at least try to deal with non-management physicians directly.
Later, we see poor meek nurse Kelly trying to make it through Mazaki's really very thick accent. The apologetic nurse struggles to understand, as the physician repeats himself, growing increasingly irate that she cannot understand simple English. Bobbie arrives.
Bobbie: Yes, sir, Dr. Mazaki, we'll get you a nurse who understands English, it'll just be a moment. Thanks for your patience.
Bobbie takes Kelly aside, and explains what Mazaki wants (the intake chart for patient 8). Bobbie says it took her three months to figure Mazaki's accent out. Hawthorne arrives. Bobbie says she handled Mazaki, because Kelly was starting to crumble.
Hawthorne: Where is that SOB?
Bobbie: He's in bay 8, saving someone's life. Probably not the best time to kill him.
Kelly (losing it and starting to cry): I got his icky saliva all over me... Am I gonna cry every day?
Hawthorne: Kelly, I promise, I'm gonna take care of this.
Here we see two experienced nurses protecting (rather than eating) their young, which seems good. But how good is it? Should Bobbie have told Mazaki, in essence, that he was right to be upset, and that the problem lay solely with the nurse? Of course colleagues should always work with newcomers to surmount language barriers, but Bobbie's obsequious "handling" of this essentially enabled a situation that not only threatens to derail Kelly's development--physician abuse is a factor in the high turnover rate among new nurses--but could also endanger patients directly. What if, before Hawthorne has time to "take care" of it, there is an emergency and Mazaki's colleagues have no idea what he is saying? What if Kelly's patient has a serious problem but she fears alerting Mazaki, because she knows she will have trouble understanding his response, leading to more conflicts? And of course, while it's understandable that a new nurse might have trouble dealing with abusive physicians, Kelly acts like she hasn't quite reached adulthood. Is it really in her interest that her mentors not even ask her to try to explain to Mazaki that she cannot understand him because his accent is very thick, and he at least shares the responsibility to find a way to communicate? Shouldn't Hawthorne be asking Kelly--and Bobbie, for that matter--to at least try to advocate for themselves and their patients?
Hawthorne finds baby Moses
Hawthorne is also presented as a clinical leader, though some of those scenes send mixed messages. One plotline involves a homeless woman named Isabel who knows Hawthorne, presumably from Hawthorne's years at the bedside. Isabel arrives at the hospital with a newborn baby she has named Moses. Hawthorne says she "need[s] to take him inside so the doctors can examine him." Just doctors? Hawthorne has made a very distorted statement of what will happen inside the hospital, especially since--to the show's credit--what we actually see is Hawthorne, Bobbie, and Kelly doing a skilled assessment!
Hawthorne: Temp's 103, let's get a blood panel and some cultures.
Bobbie: Pulse is elevated, 176.
Hawthorne: We gotta get that fever down, where the hell is Dr. Cadbury?
Bobbie: He's riding the porcelain bus, thinks it was the Mexican he ate last night. (To newer nurse.) How're you doing on that IV?
Kelly: He's too tiny, I can't even find a vein. Should I get a transluminator from the NICU?
Bobbie: Christina won't need one.
Hawthorne: You know what, it's OK Kelly, I see a big vessel right over the scalp.
Kelly: You're gonna put a needle in his head?
Hawthorne: Lasts longer, and we won't have to stick him so much. Can you two hold him tight please? (The baby is displeased, and Kelly is also getting upset.) Kelly...take deep breaths, keep reminding yourself, we are hurting him for a second to heal him for a lifetime. How about that BOA kit? (Kelly goes to get the kit.) I miss being a clinical nurse. (Hawthorne rolls the baby over.) Oh God...spina bifida.
The physician arrives, concurs with Hawthorne's assessment, and they head to the NICU. Later, Hawthorne tries to protect Isabel from a social worker who sees it as a case of endangerment and has called Protective Services. Hawthorne argues that Isabel rescued the baby. When Isabel stops by to see Moses in the NICU, it's clear that she has no idea what's going on, and blames Hawthorne and the hospital for making the baby sick. Hawthorne tries to console her, and to explain that they are helping the baby. Isabel, who veers very quickly from one mood to another, takes out a dollar bill and gives it to Hawthorne "for [the baby's] future." However, at that point the social worker shows up with the police. Isabel blames Hawthorne, but soon collapses, hemorrhaging. Hawthorne guesses that's because Isabel just gave birth; she is the real mother. From then on, Hawthorne gives both Isabel and the baby little bits of pretty good psychosocial care, stopping by to see them both, and taping Isabel's dollar to her son's NICU warmer.
The Isabel plotline presents Hawthorne as a clinical expert, especially placing the IV, but also in recognizing spina bifida. Bobbie and Kelly also display some knowledge. Hawthorne seems to be the main continuing force in Isabel's care, and acts as a strong advocate for her, even though as chief nursing officer she would not really play a major role. The average viewer might well see Hawthorne as a kind of overall care manager, and that is a role nurses actually play, or should play.
Hawthorne the renegade hospital intruder
Some plot elements seem designed to highlight Hawthorne's intense concern for patients and her willingness to disregard rules in order to help them, but they way the elements are handled at times strains credulity or reflects physician-centric assumptions. The pilot begins with Hawthorne lying in bed at 5:00 a.m., thinking about her deceased husband on the one year anniversary of his death, when she gets a call from a friend of her husband's, who is a cancer patient at the hospital. The despondent David is about to jump off the hospital roof. Hawthorne rushes to the hospital. But she forgets her ID in the car, and the new hospital security guard won't let her in--thinking she is homeless because she has just tumbled out of bed. She tells him she is the CNO. Rather than checking, he demands the ID, which is in her car. So she runs past him and heads for the roof, as he falls down in her wake, then sounds the alert for this major security breach. Running up the stairs, Hawthorne finds the confused "old man Fleming" and sends him back onto the floor, yelling "Incoming!"
Reaching the roof, Hawthorne tries to talk David out of jumping, but her method has an odd air of self-absorption--David should not do this to her today, because it is the anniversary of her husband's death. Losing patience, or taking a big gamble, she tells David to go on and jump, and turns away. He jumps. But since he is stopped on the way down by an overhang, he is not dead, and Hawthorne rushes down, blowing past the irate security guard on the stairwell. With help she manages to get the severely injured David into the ED--then tells the physician there that David has a DNR. He tells her to show it to him, "otherwise I'm saving his life." Hawthorne struggles to find the DNR on a laptop, but cannot. So the physician defibrillates. The police arrive to apprehend the intruder Hawthorne--still, no one has thought to check if she is really the CNO. Two officers drag her away, as she jumps up and down like a child having a tantrum, yelling "I'm a nurse!" It's not exactly a high point for the nursing image.
Later, we see David in the OR, and the surgeon Tom Wakefield also appears to be "saving his life." Wakefield was apparently the oncologist of Hawthorne's husband. Junior physicians wonder if it makes sense ethically to save someone who just tried to kill himself, but Wakefield wisely dismisses their concerns by noting that the patient is here now. Outside the OR, Wakefield tears into Hawthorne.
Wakefield: What the hell were you thinking up there? Last time I checked, my coat read chief of surgery. That man was my patient.
Hawthorne: Well, he was also my husband's friend. ... He called me, what was I supposed to do?
Tom: You should have called me.
Hawthorne: It would not have made a difference.
Tom: Are you kidding me? I'll tell you one thing, if I had been there he wouldn't have jumped.
Hawthorne: Well, excuse me for wanting to help Michael's friend on the anniversary of his death.
This stops Wakefield, and he softens and apologizes, asking how she is doing. She wonders why all his patients like him so much. He takes out a green lollipop, and gives it to her, noting it's because he gives patients candy. Later, Hawthorne follows up with the immobilized David, who seems to have no mental impairment. He tells her that his last thought as he jumped was that he wanted to live.
This plotline had some troubling elements. Aside from the unfortunate CNO-as-intruder bit and the incoherent treatment of the DNR, there are oddly physician-centric touches. First, there is the defibrillation; apparently, even on HawthoRNe, physicians must perform this dramatic life-saving act, though nurses generally do it in real life. Consider also the ED physician's "I'm saving his life." Oh, you alone are? The show gives no hint that it questions this statement. Then there are the interactions with Wakefield. Perhaps there are reasons to question how Hawthorne handled David on the roof, but what's all this about Wakefield being chief of surgery and guaranteeing a better result? Hawthorne does not really question any of that very strongly. Instead, she plays the grieving card. But why should his being chief of surgery bar Hawthorne from trying to save an old friend? Do powerful physicians own patients? Is it that the chief of surgery automatically has better psychosocial skills than the chief of nursing?
Some in Hawthorne's family seem to share Wakefield's doubts about her. In fact, both Hawthorne's rebellious daughter and her former mother-in-law--a hospital trustee--appear to dislike her intensely, and to blame her to some extent for her husband's death. It sounds like she may have made the decision to allow him to die because he was in great pain. But this--like Hawthorne's disregarding of security procedures--is pretty tame stuff compared to what Nurse Jackie has going on, and it seems unlikely that HawthoRNe will face criticism for presenting its main character as morally compromised.
I want Candy: The hot nurse with the hands of an artist
One small but remarkable plotline in the pilot presents Candy Sullivan, a very attractive nurse who is one of the major characters, as a patriotic version of a naughty nurse. Candy appears to regard it as part of her job to thank wounded veterans she cares for by providing them with sexual favors. In the pilot, we see a wounded Iraq War vet receive manual sex from her. The camera moves slowly down from his face as he has an orgasm, and we see Candy's gloved hands fixing the sheet.
Candy (brightly): ...And we're done! At ease, Corporal Sharp. And thanks again for serving your country.
After this, Candy arrives late to Hawthorne's morning staff meeting, saying she had to give a patient a little extra "TLC."
Later, Candy introduces Sharp to nurse Ray Stein, another major character, who will be taking over Sharp's care. Sharp--who finds the idea of a male nurse amusing--says he knows Ray will not be as good as "the perky little nurse in my dream last night. Oh my God...hands of an artist...even with the rubber gloves on."
Ray and other nurses seem to sense what Candy is doing and disapprove to some extent, but in the pilot no one goes beyond looks. Ray himself is plainly attracted to Candy, and near the end of the episode, he even asks her if he would have to go to war and be wounded to have a chance with her. Her reply is flirtatiously ambiguous.
So here we have a nurse named "Candy" who thinks it's part of her job to provide sexual favors to soldiers. We guess that does draw on the battlefield roots of modern nursing, but it also reinforce a pernicious stereotype: the naughty nurse. In fact, early nursing leaders emphasized nurses' purity precisely to assure society that women could do this vital professional work without raising questions of sexual immorality. Today, the ubiquitous nurse-as-sex-worker image infects a wide range of global media, particularly advertising and pornography, undermining real nurses' claims to adequate resources and respect. The presence of the image in HawthoRNe may be especially damaging because the show is a more credible dramatic portrayal, in contrast to the other types of media above. Perhaps Candy will eventually be corrected, but it's hard to imagine the show compensating for this plotline with anything short of a full-blown explanation of the naughty nurse stereotype itself--showing not just that Candy's conduct is unprofessional, but that it reinforces a damaging public misperception--which seems unlikely.
The male nurse as wannabe physician, and patient advocate--sort of
The plotline that sends the most complex messages about nursing--including nursing autonomy, patient advocacy, and the role of men in the profession--involves Ray Stein's care for this very patient, Cpl. Sharp. The plotline shows that Ray has the skills and some inclination to question a physician's dangerously wrong prescription of insulin for the diabetic patient, and it conveys something of how physician abuse can endanger patients and pollute nurses' work environments. Hawthorne advocates strongly for Stein. Unfortunately, the plotline also presents Stein as a desperate physician wannabe, a man who just wasn't good enough to get into a decent medical school, and is now chafing under nurses' supposed obligations to avoid diagnosing and to follow physician "orders."
When Candy introduces Ray to Sharp, the soldier assumes Ray must be "Dr. Marshall." Sharp laughs when Candy informs him that Ray will be taking over as his nurse. She says: "Ray is one of our best nurses, you'll be in really good hands." After Candy leaves, Sharp mentions to Ray that he has diabetes.
Ray: Your blood sugar's high, that's for sure. (Wistfully.) But I'm a nurse, so I can't give you a diagnosis.
Sharp says he would ask a doctor if he could find one. Ray says he'll see if he can get Marshall, and that he'll be back to give Sharp a sponge bath. Sharp: "I don't think so." This scene is OK in that it shows the problems male nurses may have with some patients, and Candy's comment about Ray is a good one--the message that some nurses are "best" at least suggests that the profession is something a person can excel at. But Ray's comments about diagnosis are unfortunate, suggesting that nurses lack the ability or the right to express a view on the patient's condition, even when it's well-established, as it is here.
At the nurses station, Ray asks another nurse about Dr. Marshall, who we gather does not exactly spend a lot of time at the hospital, as opposed to the golf course.
Ray: For patient Sharp, Marshall's ordered insulin on a sliding scale. Blood sugar's 225, 6 units seems high to me.
The other nurse looks at the chart and says the "order is very clear."
Ray: Oh, yeah. Surprisingly neat penmanship for a doctor. Look at the numbers, they're so pretty, they must be accurate! I just hope Sharp's insulin shock and seizures are equally as adorable. Give me a shout when Marshall answers the page.
Ray knows what he's talking about the diabetes, and he even has some sense of humor, but the "order is very clear" bit suggests that mindlessly following orders is really the accepted way to go, and Ray is flirting with trouble. Is it because he's a good nurse who fights a bad system? Or because he really should be a physician? In any case, Ray can't reach Marshall. The other nurse suggests Ray ask a young intern sleeping nearby.
Ray: He's 12.
Nurse: Walk me through it.
Ray: Sharp's diabetic, Marshall prescribes insulin. Nurse questions dosage.
Nurse: Nurse knows sliding scales can be tricky.
Ray: Nurse wants doctor to clarify.
Nurse: Nurse is being thorough.
Ray: Or is it nurse just being a bitter know-it-all who wants to catch the doctor in a mistake because nurse could have gone to med school...in Paraguay.
Nurse: Only nurse...knows for sure.
Um...nurse has real insecurity issues, and does not seem to respect or understand his own profession? In any case, Ray has more trouble reaching Marshall, partly because of bad cell phone reception. When Ray finally manages to connect with the physician, we hear only his end of the very brief conversation.
Ray: Yes doctor, understood. (Hanging up and relating to his fellow nurse what the physician said.) "You nurses have gotta stop calling for every little thing. If I wrote it, I meant it. Who do you think you are, questioning my orders?"
Nurse: Well, you're a nurse.
Ray: Yes, I am. But really, I could have gone to med school.
Nurse: In Paraguay. But in the real world, you're a nurse.
Ray (frustrated): And I follow doctor's orders. That's what nurses do.
Later, Ray still hesitates to give the insulin, but he does, repeating to himself: "I'm a nurse." Soon, the patient crashes. Ray sees the monitor, rushes into the room, sees the patient in shock, and calls a code. A physician does the defibrillation, while Ray watches from behind--apparently he plays no role in codes. Once again, in real life nurses generally do the defibrillation, and Ray would certainly be very busy if his patient coded. Anyway, the code team revives the patient, and he is taken to the CCU. Hawthorne arrives and asks what happened. Ray says Marshall made a mistake with the dosage.
Hawthorne: How did that get by you?
Ray: It didn't. I called the doctor.
Hawthorne does not really react, but tells Ray to go with the patient to the CCU. She tells the other nurse that Ray is "off his cases" and asks if that nurse can "cover" for him. The nurse says it will be tight, and she wants a favorable holiday work schedule in exchange. Hawthorne agrees. So, doubling a nurse's patient load? It just makes things a little tight. No worries about killing patients or anything, like those crazy studies have suggested.
Later, Ray is helping to settle the patient Sharp in the CCU. The physician Marshall finally arrives, looks at the chart, and goes right after Ray about the insulin.
Marshall: You didn't give him the shot until noon? How can you be so stupid?
Ray: It's genetic. My father wasn't a very bright man.
Marshall: Stupid and a smart aleck.
Ray: Oh, just in case you're wondering, this here is patient Sharp. You probably wouldn't recognize him because you were too busy when you blew through your rounds this morning.
Marshall: Interesting, giving me pointers on patient care. Remind me where you went to medical school?
Ray: I didn't. I gagged on my MCATs. Twice actually.
Marshall: Well, congratulations. Today makes it a hat trick for you, huh?
Ray: You think so? You know, maybe you should consider stepping up to a new cell carrier.
Marshall: Maybe you should consider shutting up, nurse, before I'm forced to file a complaint.
Ray: Be my guest.
Marshall: Oh, be careful what you wish for there, Stein.
Another nurse drags Ray away, as if he is way out of line, or risking a lightning bolt from the heavens. Next, we see Hawthorne meet with Wakefield and Sharp's angry father.
Wakefield: Mr. Sharp is the father of Corporal Sharp, who coded after one of our nurses gave him an insulin overdose.
Hawthorne: I'm sorry, Mr. Sharp. It's my understanding that our nurse was following doctor's orders.
Ouch! Hawthorne herself is hiding behind "doctor's orders?" Nurses will never get respect for their skills until people understand that they often bear just as much responsibility as physicians for such errors. In any case, the father asks where Marshall is, and upon learning that she is at the hospital, says he's glad she could find the time.
Wakefield: Mr. Sharp, I can assure you that Mrs. Hawthorne will discipline the offending nurse.
Hawthorne: And I'm sure that Dr. Wakefield will do the same to Dr. Marshall.
Wakefield looks somewhat shocked at Hawthorne's gall in contradicting him and/or suggesting that a physician could make a serious error. The father, who is furious, makes it clear he will be filing a lawsuit against the hospital. Hawthorne catches up with Ray, and tells him he should be glad Sharp is in stable condition. Ray says he doesn't feel glad.
Hawthorne: That's because you went against your instincts. Haven't I taught you anything? Or does it go in one ear and out the other?
Ray: I followed hospital protocol to the letter to protect my patient.
Hawthorne: How's that working out for you so far?
Hawthorne tells Ray that Marshall is now after her and the whole nursing staff, and that Hawthorne will likely catch hell in an upcoming executive committee meeting, so Ray should do "penance" and be glad he still has a job. The idea is plainly that Ray should have done something different, and presumably not have given the drugs, but Hawthorne does not spell out exactly what he should have done instead of follow "protocol." And what is this hospital "protocol"--mindless obedience to physician commands?
Later, at that executive committee meeting, which Marshall attends, Hawthorne is explaining how patients suffer when physician visits are shorter.
Marshall: Especially when nurses don't know how to follow doctors' orders.
Hawthorne: I thought this was a budget meeting.
Marshall: Oh, then why don't we discuss the cost-benefit of firing those reckless nurses who put the hospital at risk for litigation?
Hawthorne: Absolutely. If we're also prepared to talk about how doctors do the same thing. But I forgot--doctors don't get fired!
Wakefield: That's enough. Shall we move on?
Marshall: No, let's cut to the chase. Today, one of your nurses almost killed my patient and then had the balls to blame me for his mistake.
Hawthorne: I saw the chart, I saw your orders, and you were wrong. And he knew it. Now, he followed hospital protocol anyway. But if I were you, I would be thanking my lucky stars that Corporal Sharp only coded, and didn't end up in the morgue.
Marshall: Or up on the roof with you.
Hawthorne smiles. Wakefield wants to see Marshall outside. Hawthorne says it's OK.
Marshall: No, I'm going, I will not be lectured to by a nurse. I will file my report with Morrissey [presumably the CEO] and nurse what's-his-name can file his.
Hawthorne: Well, his name happens to be Ray Stein, and he's a damn good nurse.
Marshall laughs and leaves. This is not a bad example of a nursing leader giving it back to an abusive physician, and Hawthorne seems less rattled than Marshall does. Marshall is the one who retreats by leaving, and she has no answer to the key point about whether the dosage was correct. Perhaps she just assumes she can bluster her way through, regardless of the facts. And Wakefield's earlier eagerness to blame Stein suggests that this approach might have worked, without Hawthorne's advocacy.
Unfortunately, the overall portrayal of nursing autonomy remains confused. What Ray was actually supposed to have done remains unclear. He had some impulse to advocate for the patient, though he caved pretty easily. And the other nurse present expressed no real concern for the patient. No one really makes clear that Ray is legally and ethically obligated as a nurse to pursue the issue, despite Hawthorne's vague message that he should have acted differently. There seems to be no question that the excessive dose Marshall prescribed was the root of the problem, but Marshall and Wakefield never really confront that issue, and even Hawthorne herself seems to make contradictory suggestions about whether Ray should have followed "doctor's orders" or not. So which is it? Are nurses autonomous professionals who must not follow care plans that endanger patients?
Ray's responses to Marshall's contempt and abuse are inadequate. Simply making self-deprecating jokes does not tell viewers how and why she is dangerously incompetent. He can make jokes, but they ought to show that she knows nothing about nursing and not enough about medicine, and that her abusiveness is itself a huge threat to patients, since it deters nurses from raising critical care issues and drives them from the bedside.
Perhaps the most unfortunate thing about the plotline is the relentless portrayal of Ray as a self-loathing would-be physician. Nurses do occasionally go to medical school, but Hollywood's suggestions (notably in the first two thirds of ER's long run) that smart nurses aspire to medical school reinforces the wannabe physician stereotype, and of course suggests that nurses are not smart enough for medical school. In fact, nurses are 100 times more likely to pursue graduate education in nursing than medicine, something we hope HawthoRNe will at some point address. Hundreds of thousands of nurses have graduate degrees--in nursing. We wonder if Hawthorne herself has such a degree; the show does not tell us. It may be that Ray will eventually wake up and realize that nursing actually has something to offer him. But meanwhile, the character is reinforcing a stereotype that is especially damaging for men, who must often explain what they are doing in nursing, and why they are not physicians.
On the whole, it seems to us that some aspects of HawthoRNe are very helpful to nursing, while others are very unfortunate. The show has great potential as a vehicle to educate the public about the profession, and we hope it seizes the opportunity.
Please tell us--and the producers of the show--your thoughts on HawthoRNe!