Christina saved her life
"HawthoRNe"'s last season
August 2011 -- The third and last season of TNT's summer drama HawthoRNe, which featured a tough, expert nursing executive in Richmond (VA), was significantly weaker for nursing than the first two seasons. The last season focused less on clinical themes and more on Christina Hawthorne's personal issues, particularly her love triangle with her husband, surgeon Tom Wakefield, and police detective Nick Renata, who investigated the brutal attack that caused Hawthorne to lose her baby and her job at James River Hospital. There were still a few plotlines showing nursing skill and autonomy, many related to the shifting job descriptions of the main nurse characters. Hawthorne herself provided a range of great care to Renata's dying mother before finally returning as interim COO of the hospital, which affirmed that nurses can lead at high levels. Hawthorne's friend Bobbie Jackson took over as chief nursing officer and generally did well in a job the show portrayed as being mainly about public relations and fundraising, though Bobbie did also organize a health fair and boast to the press of improved nurse staffing ratios. The gifted young nurse Kelly Epson identified and acted courageously to counter a MRSA outbreak, even building an isolation ward, calling the CDC, and defibrillating a patient! But Kelly also moved from pediatrics to the OR in a long, excruciating plotline that reduced her to a silly neophyte begging crusty surgeon Brenda Marshall to hire and mentor her, a damaging misportrayal of nursing autonomy and skill. The tough nurse manager Gail Strummer appeared a few times, at one point giving a strong speech about the violence nurses face on the job. Nurses Candy and Ray were gone, which was fine, as they were weak characters who never added much and at times reinforced nursing stereotypes. A few minor characters simply acted like standard Hollywood nurses, that is, as deferential handmaidens. The show was canceled after the season ended, and in light of its wildly inconsistent treatment of nursing and its struggles with dramatic quality, that may be for the best. But HawthoRNe did present a strong, expert nursing leader and examples of nursing skill to millions of viewers from 2009 to 2011. We thank those responsible.
Nursing Guidance Required
The June 28 episode, "Parental Guidance Required" (written by Allison Robbins and John Romano), includes Christina's care for Nick Renata's mother, which ranges from defibrillation to subtle assessments to psychosocial care. But there are also awful elements for nursing autonomy and skill, with Kelly starting her pathetic efforts to persuade Marshall to let her be an OR nurse.
The tough detective Renata asks Hawthorne to join him outside the hospital, where he has his mother sitting in his car. Something is wrong with Mom, but she doesn't like hospitals. Hawthorne sits with Mom, talking and holding her hand, sending the unhelpful Nick for coffee. Hawthorne quickly establishes a rapport with Mom, who suggests Nick is concerned about her because he always carries the burdens of others. Hawthorne gently advises Mom that her pulse has Hawthorne herself a little concerned, so why not let her carry the burdens for Nick for a while. This is a minor but helpful mix of expert psychosocial and physiological care.
By the time Nick is back with the coffee, Mom is sweating, having trouble breathing, and finally coughing up blood. Christina takes charge, summoning nearby paramedics and getting Mom into the hospital. Hawthorne calls calmly to an ED physician as they roll in: "Steve, I got a 79-year-old diaphoretic woman, tachycardic at 140, coughing up blood." Steve suggests it could be a pulmonary embolism and asks for various tests. ED nurse manager Gail says she will start an IV, and Christina asks Gail to check the patient's airway. Steve gently notes that Christina no longer works at the hospital and says it's "illegal" for her to be there, meaning providing care.
Later, as Christina and Nick are reassuring Mom, Christina notes that there are "nurses here to take care of you." Tom Wakefield, the surgeon on the case, determines that one of Mom's major heart valves is ischemic and leading to blood clots, which could cause a heart attack. Surgery is the best option, but Mom refuses. Tom tells Nick they can try medication to dissolve the clots.
Tom, called to an unrelated emergency, asks his surgical resident Miles to take Mom up for a CT angioplasty to see if the medication is working. Christina joins them in the elevator and soon notices an issue on the monitor. She suggests that Miles check Mom's pupils. He complies, and a monitor starts beeping. Christina is already prepping derivation paddles! Miles asks what she's doing. Christina says the patient is "throwing multi-focal PVC's, she's about to code." Mom coughs up blood. Miles says Christina doesn't work there and "that's a liability." Christina says she's charging to 200 and she shocks the patient. Miles warns her not to do it again. Christina notes Mom is in V-tach. Miles again tells her to stop, but he's also pushing epinephrine. Christina shocks the patient again. Mom is back. Miles looks disgusted. But Nick, watching all this, looks relieved.
When the elevator doors open, the hospital CEO Morrissey is there, furious. In his office, he says he could have Christina arrested, and tells her that she cannot touch any patient. Hawthorne doesn't back down, saying the patient was going to do die, "and Miles should have had a nurse." Morrissey throws her out of the hospital.
These scenes have many good elements. Nurse Christina spots a critical issue a physician does not. And she acts quickly and expertly to save the patient's life, even defibrillating, a common marker of life-saving expertise that TV nurses rarely do, though real nurses do it all the time. And although we might have taken the show to task for having no practicing nurse to take an ICU patient to CT (a common Hollywood misportrayal), the show mostly removes that problem when Christina tells Morrissey that they should not have an ICU patient go to CT with no nurse. Of course, it was the patient who "should have had" a nurse, not Miles--even statements designed to show appreciation for nursing are often infected by the assumption that physicians are in charge of patient care and nurses just work for them. And the elevator scene isn't that persuasive dramatically; it's hard to believe Miles, otherwise portrayed as a skilled surgeon and good guy, would be quite so clueless, passive, and obsessed with liability rather than the patient.
The medication is not working and Tom wants Mom to reconsider surgery, but she refuses, saying that if the pills don't work, "I am at peace." She wants to go home, and wants Christina to help set her up there. Tom reluctantly says OK, noting that she's leaving "against medical advice," and that he'd rather it was someone else helping her (he does not like how close Christina is getting to Nick). But Mom trusts Christina. Tom tells Christina to give O2 if Mom's breathing gets labored and to keep an eye on her SATs, as if Christina would not know that. And Christina supervises Mom's transfer to home by Nick and his brothers, including taking what Christina calls a "defibulator." It's not clear why a "defibulator" is needed if Mom is really "at peace" with the likely outcome. At home, Christina seems to be providing skilled care to Mom. They bond, and Christina ends up revealing her own troubled background, which includes taking care of her mother, who had Crohn's disease, from the age of 5 to 17--perhaps we are meant to speculate that this led Christina to a nursing career. Mom invites Christina to climb up in bed with her, Nick climbs on the other side, everyone comforts everyone, and Christina falls asleep.
This episode also starts the multi-episode plotline charting Kelly Epson's transition from gifted if inexperienced pediatric nurse to clueless, juvenile OR nurse, complete with frequent suggestions that the surgeon Brenda Marshall directs OR nurse staffing, and no evidence of OR nurse managers or senior nurses. In its painful glibness, this is really more like a throwaway sitcom plotline. Yet here it is, consuming significant time in several episodes of an hourlong drama.
We see Kelly telling Marshall that she wants a transfer. She loves peds, she says, but maybe it's time for a change to the OR as a scrub nurse! Marshall says she would love the OR, but turns out to be joking, really Kelly would hate it because, Marshall confides, it is like "standing in the same place for 8 hours doing this." She makes motions like she is simply giving and receiving instruments, as if that is all a scrub nurse does. Kelly is unfazed because her aunt is a toll-taker--it's in her blood! Marshall remains dubious, but is amazingly gentle; in the first two seasons, she would have mocked Kelly unmercifully. Kelly says she "could at least try it out."
Later, we see Marshall performing an abdominoplasty. Kelly is there, but she gags the minute Marshall starts cutting. Kelly struggles for control, then seems to be on the verge of losing consciousness. Assisting surgeon Miles advises Kelly to sit before she passes out. Kelly says she just needs a second. Miles questions whether she really wants a transfer to the OR, and when he cauterizes a bleeder, the smell seems to make Kelly retch. Very emotional, Kelly says she is sorry. But the surgeons are preoccupied because they see that the patient has terminal liver cancer. Later, outside the OR, we see the ever-chipper Kelly telling Marshall that being in the OR is amazing and she doesn't "have the words for it," but unfortunately, doesn't think she has "the stomach for it either." Marshall notes that that is a "required skill," but she is gracious.
This plotline is inaccurate and degrading. Kelly was a skilled, if somewhat childlike, peds nurse. Now she is basically an idiot who thinks the OR is, like, so cool. And whereas before Kelly generally seemed to report to nurses, now we're told that surgeons direct OR nurse staffing. In fact, OR nurses hire, fire, and supervise OR nurses. Surgeons have nothing to do with it.
One other element in the episode worthy of note is the new CNO Bobbie Jackson's statement to the media in the wake of the attack on Hawthorne and the ensuing murder of her attacker.
Bobbie: Our hospital has been in the news as these stories have unfolded. And hearing that the man responsible for the vicious attack was found murdered yesterday leaves many angry, confused . . . If you'll allow me to stray from John Morrissey's statement, everyone at James River is outraged by what happened. This hospital is a place of healing, a place of care and compassion. And despite this horrific incident, we endeavor, no matter how difficult it may be, to put aside destructive emotions, to leave that at the door in the hope that this hospital remains a sanctuary. Thank you for coming out.
There's not much substance here, but it does present a nurse executive as fairly articulate and able to handle herself in a high-profile media interaction. Of course, it's ironic in an episode in which the show has repeatedly suggested that physicians direct OR nursing, but it is helpful.
"How much is a human life worth?"
The July 5 episode ("A Fair to Remember" by Shelley Meals and Darin Goldberg) is most notable for the plotline in which nurse Kelly acts boldly to contain a MRSA outbreak. The episode also includes ED nurse manager Gail lecturing a police office investigating the murder of Hawthorne's attacker about the violence nurses endure generally, as well as CNO Bobbie boasting to the press about the hospital's improved nurse-to-patient ratios and taking the lead in organizing a hospital health fair that appears to be a success--at least until CEO Morrissey interrupts with a drunken, though persuasive, rant about the sorry state of U.S. health care.
Kelly spends the episode in a clown outfit, apparently for her role in the health fair. Kelly is still a pediatric nurse here, but the outfit, in combination with her childlike personality, doesn't exactly suggest to viewers that nurses are serious professionals. On the other hand, she probably does save a number of lives in the episode. Early on, we see clown Kelly walking with Marshall, saying that the pediatric patient Kyle is still not responding. Kelly thinks they should try another antibiotic. Marshall asks if she wants to "write a prescription--in crayon?" Kelly explains she didn't want to waste time changing clothes. At Kyle's bedside, Marshall asks for the culture results, and Kelly says the lab has been slow. Marshall is remarkably civil about it--consistent with the June 28 episode, if not the first two seasons--and she even matches Kelly's typically good psychosocial care, telling Kyle they'll get him back at second base soon. Kelly corrects her, "Third--Kyle plays the hot corner," punctuating that comment by having her hat mock-explode. Marshall smiles and leaves. Kelly notices that Kyle is not responding much to their banter.
Later, Kelly is pleased to see Hawthorne, who is there to try to explain to her angry husband Tom why she was at Renata's apartment all night. Kelly tells Hawthorne that something is going on with Kyle but she can't prove it yet. Next we see Kelly meeting with CEO Morrissey and CNO Bobbie.
Kelly: And that's when I noticed this boy in peds had a secondary infection unrelated to his initial diagnosis.
Bobbie: Secondary infections are not uncommon to Methicillin-resistant staph, though, right?
Kelly: No, only other nurses are seeing similar cases on their floors too. All highly contagious staph infections.
Morrissey asks if anyone took a culture. Kelly says she did, but the results are not back yet, and she admits that the first culture from the boy in peds did come back negative. Morrissey thanks her, wrapping up. But she persists.
Kelly: MRSA test results come back false negative all the time. It's a highly contagious bacteria. It could cause blood infections, pneumonia, necrotizing fasciitis. I mean, there's a reason they call it flesh-eating bacteria.
Morrissey says they need more proof. Kelly thinks they are not taking her seriously. Morrissey mentions her clown outfit, but assures her he appreciates her diligence, they just need more proof before sounding the alarm. Bobbie asks to be kept posted on the cultures, and tells Kelly she did great work. Kelly is not satisfied: "I still think there's the potential for a serious outbreak."
Later, the troubled Kelly speaks with Christina. She says she wants to be like Christina, to get results. But Christina says Kelly can't "use her gut" without her head, she "can't have passion without thought, it will just spin you out of control." Instead, she suggests Kelly "follow your gut and use protocol when you can." Kelly has an idea. Next, we see she has dressed Christina in a clown outfit; presumably this will allow her to roam the hospital helping Kelly unrecognized. And the next time we see Kelly, she really is in Christina mode, talking to a group of nurses about MRSA response plans with no sign that she has cleared it with hospital management.
Kelly: We need to keep this threat contained, so we're going to quarantine all patients with suspicious secondary infections in an isolated area on 5 East, far away from the general population. OK, you guys? We can do this!
Kelly's trembling-little-doll persona is never more bizarre when, as here, she's being assertive and displaying technical knowledge.
Before long, we see Kelly surveying construction of the isolation ward, with Christina as her consultant. Kelly marvels at the "do-it-yourself clean room and airlock?! This is genius." Kelly tells Christina she got all the supplies she needed after using Christina's name. A montage shows all the patients being wheeled to the new ward, until Marshall spots Kelly and Christina moving Kyle. Kelly admits what they are up to. Marshall asks about the second culture. Kelly admits it is still not back from the lab, but says that if they wait, they risk an outbreak. Third season Marshall just smiles and says OK.
With Kyle in the elevator, they encounter CNO Bobbie, and Kelly admits what she is doing. Kelly assures Bobbie she followed all the protocols, including reverse ventilation. Bobbie, understandably amazed that they have built the ward, concludes that it's too late to shut it down, but wants it kept quiet, so it won't interfere with showing the hospital off "to those wealthy benefactors and the press." With a level voice, Bobbie notes that if Kelly is wrong, she'll be putting the patients and the hospital at "huge risk" and Bobbie will have to terminate Kelly. Maybe termination would be the result of Kelly's implausible venture, but it's not clear why putting some patients in isolation for a few hours would create so much risk.
Later, we see Kelly telling Christina that the next step is to contact the Centers for Disease Control about the potential outbreak, but Kelly is wavering. Christina tells her again to "trust your gut." Kelly makes the call. Later, ED manager Gail, who is supportive, warns Kelly that "somebody" called the CDC and if they're wrong it could mean "bad press, hospital inspections, the CDC could shut us down, and you could lose your job."
A moment later, Kyle's monitor alarm sounds. When Kelly and Marshall arrive, Kelly says Kyle's SATs are down to 85. Marshall says he's in respiratory arrest, and asks that Kelly bag while she intubates. Kyle enters v-tach. Kelly reports no pulse, full arrest. Marshall wants one amp of epi push and a crash cart ready. Kelly turns and asks a maintenance guy nearby for the cart (he's been building the ward). Kelly reassures other isolation patients, who are all watching. Marshall asks Kelly to charge the defibrillator to 100, but Kelly does the defibrillation! Marshall seems to be in charge, asking Kelly to charge and go again, twice, when there is no change. Finally, Kyle revives, and Kelly reports normal sinus. The patients clap and cheer. Kelly is actually broken up, and she tells Marshall she's seen this a hundred times, so she doesn't know why she's so emotional. Third season Marshall says maybe it's because Kelly's a good nurse!
Later, Kelly updates Bobbie on the possible MRSA outbreak.
Kelly: I've crunched all the morbidity and mortality numbers and secondary infection rates, and even though the CDC hasn't called me with confirmation, if we close the hospital doors overnight, and administer Vanco IVs to everyone exposed immediately, we can stop any potential MRSA outbreak.
Bobbie catches the word "potential," but she agrees. And apparently they take those steps. Later, Kelly gets a call, presumably from the CDC. It is MRSA. Bobbie says Kelly "did a great job."
Of course this is absurd--a staff nurse creates a functioning isolation ward for a dozen or more patients without the knowledge of management?--but suspending that awareness, consider all the good elements of the plotline. With Hawthorne's encouragement and despite the skepticism of the managers, Kelly spearheads an effort to contain a deadly MRSA outbreak, apparently saving many lives. She chirps and babbles, but she also displays technical expertise, tossing off comments about secondary infection rates, reverse ventilation, and Vanco IVs. She even defibrillates, playing a key role in saving Kyle, although that scene is undermined somewhat by the crying part. And however credible Kelly's interactions with the nurse managers may be, at least they are nurse managers; there's not too much here suggesting she reports to physicians.
Meanwhile, the Internal Affairs officer investigating the murder of Hawthorne's assailant has been interviewing all the main characters; it's pretty clear he suspects Renata and maybe Christina. All the characters react differently, but ED nurse manager Gail stands apart.
Gail: Detective Dupree, I don't know where you're trying to go with all this, or what you're looking for, but you're wasting your time. . . . You want to find the murderer, the person who put down the savage that killed Christina's baby? I know you have no idea the kind of violence committed against nurses every day by the people we try to help. But you do know that this attacker beat his wife and put her in our emergency room over and over until Christina talked her into leaving him. Now today, this woman would tell you that Christina saved her life. Now do you understand when I say you're wasting your time . .. . and mine? If you find the person who killed this animal, you should pin a medal on his chest.
OK then. Not all that politically correct, but certainly a forceful statement about what nurses face in the workplace, and a reminder of the difference nurses can make for patients, sometimes at their own peril.
Another plotline concerns the roles of CNO Bobbie and the CEO Morrissey in the James River health fair. As those two walk through the hospital, Morrissey observes that a day of free screenings and fun isn't going to placate the critical media or fix what's really wrong with health care. Though he is plainly on a cynical, downward path, Bobbie remains optimistic. And later, while fielding questions from the press about the murder investigation, she manages to work in a little advertisement about nurse staffing improvements at the hospital.
Bobbie: On a similar note, in the past year, James River has increased its nursing staff by 27. That's a ratio of one nurse to every three patients.
Presumably that is a hospital-wide average that can't be fully assessed without knowing the numbers on specific units, but it's probably very good. And the episode includes another effort by Bobbie to placate the critical media and the public, at the health fair, where we see her giving a speech to a large crowd:
Bobbie: Hi, Richmond! Thank you from the bottom of my heart for making the first James River Health Fair and Open House such a success. Yeah, give yourselves some applause. Today was inspired over a year ago by nurse Christina Hawthorne. It was her hope and dream that this would draw together our community. To help each of us realize our better selves, being in service to one another. But today is only one day, and just as every journey begins with a single step, I'm asking you to continue your support of James River Hospital tomorrow, and the next day, the day after that, and the day after that. We can never forget we're family, and in spite of the mistakes we've made and the hurts we've suffered, we remain a family. Together our future will be whatever we want. We all have something to offer--
Clapping halts this parade of platitudes, but then we see the CEO Morrissey off by himself.
Morrissey (drunkenly): Let's hear it for the future! Of course, the future won't include health care. Because it doesn't work! Did you know that initially, the ailing and the infirm were the responsibility of the church? Monasteries and convents. We are so far from that kind of care now, because we don't care! (Fending off efforts to shush him.) We should be ashamed of ourselves. (Pointing up at the hospital.) Those people up there, they are up there, the sick and the dying, while we are down here, pretending that everything is fine. This open house, this health fair . . . it's not fair. It's an illusion, a distraction from the real problem, all intended to make us feel better--while those people up there are the ones who need help! (He moves toward the stage, falls, recovers, and grabs the microphone.) It's my responsibility to protect the doctors and the nurses at James River Hospital. I do the best I can, so they can do the best they can. But when senseless attacks happen like the one involving Christina Hawthorne . . . how much is a human life worth? Why do we have to measure our existence in dollars and cents? (Hawthorne herself has arrived now, and she gently leads Morrissey away, telling him that is enough, though he keeps yelling.) You know where health care works . . . where they have nationalized health care. Cuba! And Canada too. Cuba! Yes, that's right, Cuba! Cuba and Canada!
This is a classic way of conveying dangerous views without real consequences--put them in the mouth of a drunk or a fool--but it does remind viewers of the conditions under which too many nurses work today, conditions that do in fact put the nurses and their patients at grave risk.
It's not real
The July 12 episode ("Let Freedom Sing" by Sibyl Gardner) makes clear that the show is committed to Kelly's hard-to-watch career transition. In essence, this plotline presents a promising young pediatric nurse as a caricature of nursing weakness and ignorance who has to be rescued by the smart, strong physician Marshall, who evidently hires and trains OR nurses, even though the show itself has been mainly about nurse managers.
Early on, we see Kelly begging Marshall to let her work in the OR. Marshall remains doubtful, mentioning Kelly's "OR nausea" as something that presumably disqualifies her. Kelly whines: "Why are you so mean?!" Marshall hauls her aside and asks what her problem is.
Kelly (speaking like an adultescent): What is your problem? Oh . . . sorry, that was too much. It's just, you're one of the smartest people I've ever met. Which means it's a crime, a sin, for you not to share what you know. And . . . I want you to teach me! Desperately! It's your responsibility.
Marshall says she has no obligation to Kelly, and starts to leave, then returns.
Marshall: I don't like you, Kelly. You're always happy, and it's not real. Moreover, it's annoying! But . . . if you want me to teach you, I will give you one more shot this afternoon. But if you think you're going to lose your lunch and duck out, don't bother showing up. Because the only thing I hate more than happy people is people who quit.
Marshall leaves, but looks back to see Kelly doing what looks like cheerleader moves in celebration. Yes, cheerleader moves.
Surely this is one of the worst scenes HawthoRNe has ever had about nursing autonomy. Of course, a nurse like Kelly would have things to learn from Marshall, but this really suggests physicians manage nurses. And the childlike way Kelly acts is pretty degrading for an alleged adult with a nursing degree.
Later, we see Kelly in surgery. The patient, a singer, has a tumor in her vocal cord area. Kelly claims not to be queasy, but she gags, and apologizes. Marshall says the "tumor has grown bilaterally into her vocal cords." Kelly, like a layperson: "That sounds even worse." The patient will lose her vocal cords. Marshall and the assisting Miles seem to be acting as the real nurses, calling vitals, e.g., that there are no breath sounds on the right side. Miles does ask for the blood pressure, and Kelly manages: "82 over 40." Miles cuts her chest to insert a chest tube and remove fluid. Only the physicians inform observers what's happening; the nurses don't seem to know or do anything important. Miles gets into the surgical area and Kelly barely manages not to be sick. The patient is saved, but apparently she will not sing again.
Afterwards, Kelly says to Marshall: "That was horrible." Marshall notes that the OR can be a horrible place where bad things happen and there's nothing you can do about it. Kelly asks, in her innocent way, if that's why Marshall is so unhappy. Marshall, irritated, tells "Epson" that they just saved a life in there, and a lot of "us" give up nights, weekends, and holidays "because what we do in there is more important than our own happiness." She tells Kelly she's blown her "shot" at being an OR nurse.
But later, Marshall approaches Kelly in the hospital cafeteria with reconciliation in mind. She says she hates people who quit. Kelly says Marshall "fired" her. Marshall responds that she quit once, Marshall fired her once, so they're even. Kelly says she accepts her apology, although Marshall won't admit that's what it was!
Marshall: I'm going to teach you everything I know. You're going to be the best OR scrub nurse in the state of Virginia, even West Virginia.
The beaming Kelly can't wait. And neither can we! Yay!
The August 2 episode (John Tinker's "Price of Admission") is notable for one short ED scene that embraces society's still-dominant handmaiden image of nursing so casually that few viewers are likely to notice, even in a show focused on nurses. The scene involves surgeon Tom Wakefield and an old wartime friend, Tony, who is now a local paramedic. Tony has been suffering temporary paralysis and is currently in the hospital's ED because he fell out of his rig and hit his head. Tony seems to want to avoid a diagnosis of his underlying problem.
Early in this scene, we see a mute ER nurse at the foot of Tony's bed. When Tom arrives, the nurse takes exam gloves and, without a word, puts them on Tom, as if this is what nurses always do for physicians. Tom jokes, "nice one," about his old friend's head gash. Tony snaps that Tom should just sew him up. Tom turns to the nurse and asks her to "give us a minute." She says nothing and leaves. The nurse has not said a word. Tony won't tell Tom what's really wrong. Tom calls back: "Jess, lidocaine." This gives the nurse a name, at least, and Jess is already returning with the drug. She gives it to Tom and he injects it in Tony's head. Tom notes Tony never liked needles or blood, apparently speaking to Jess. Tom asks for "3-0 prolene" suture material and Jess gets it. Tom notes that he never worked with a better corpsman. Now it's Tony's turn to ask the nurse to "give us another second." Again, she leaves without saying anything. Tony confesses to Tom that he has ALS, he's seen a neurologist, and now he just wants to go home.
The nurse in this scene does not say a word to her patient or to the physician. Nor does she take a single action that is not in service to the physician. It's not so out of line that she is asked to leave the room, because Tom and Tony are old friends and the subject is sensitive, but those two departures do dovetail nicely with her overall servile presentation. The nurse does at least have enough technical knowledge to fetch and prepare things. She just doesn't seem to do anything but silently serve the physician whose care really matters.
I've worked on my clinical skills
The August 16 series finale ("A Shot in the Dark" by Darin Goldberg and Shelley Meals) seems to resolve the main nurse characters' near-term professional issues, as Hawthorne becomes the hospital's interim chief operating officer; Bobbie seems to be staying as CNO; and Kelly gets "certified" as a scrub nurse, with Marshall still her only visible supervisor and mentor.
One plotline illustrates Kelly's growth as an OR nurse. Paramedic Tony, who has ALS, is wheeled in having impaled himself putting up a fence. Tony is typically uncooperative, refusing care, and in fact he seems to be embracing his life-threatening injury as a way for his family to collect life insurance without having to care for him in the end stages of his disease. His wife, unsurprisingly, is not on board with this plan. This all plays out with virtually no nursing care for Tony, except that at one point Tom, leaving Tony in a surgical unit, asks Kelly to "let [Tom] know if there are any changes," as if she would need to be told that.
Meanwhile, we see surgeon Marshall on a cell phone, saying that some people don't interview well. Kelly, following, asks Marshall if that call is about Kelly's "OR certification." Marshall denies that it is, and says they are due in the OR. As they exit the elevator, Kelly starts babbling.
Kelly: I've worked on my clinical skills, I completed my computer exam, I honed my knowledge of instruments, I learned about preps, procedures, and sterilization, specimen handling, pre-op and post-op . . . the only thing I'm not confident about is this interview with the nursing board. And I figured that since you're my mentor, you could just give me a little bit of--
Marshall again denies the call had anything to do with Kelly, and asks Kelly if she actually doubts her certification, with Marshall as a mentor. So Kelly is being interviewed by a "nursing board," but physician Marshall is her mentor? Nurses would mentor Kelly, not physicians. And if Kelly wanted to be certified, it would not be solely as a scrub nurse, as the show implies, but as a perioperative nurse, which encompasses a much broader range of care. That certification requires a great deal of nursing expertise. According to the Competency & Credentialing Institute, perioperative nursing certification requires a "minimum of 2 years and 2,400 hours of experience in perioperative nursing, with a minimum of 50% in the intraoperative setting" and "the average nurse spends two to three months preparing for the exam." And how much about that does the average physician know? Close to zero.
Tony's wife persuades him to have the surgery to repair the impalement. We see Kelly in the OR with Marshall and Wakefield. As they confront setbacks, Kelly has to hand Tom and Marshall a series of instruments in quick succession; she falters a bit but gets through it. Later, Kelly reports that Tony's BP and heart rate are good. Tom tells Kelly she's done a good job, and "if you don't get certified, I'll eat my hat." Kelly asks Tom when they'll know if Tom can come off the ventilator. Tom says maybe hours, days, weeks--clearly he is the only one who can say. Aside from Kelly, there is apparently no nurse for this patient, and Kelly reports to and consults the physicians alone. Tony's wife vows to keep fighting the ALS, and near the end of the episode, Marshall tell Tom that Tony is "doing great, O2 sats normal, and he's off the vent." Just like that! Virtually all nursing care and expertise has been scrubbed from this plotline, and what little there is--Kelly handling the instruments--will just look like her ably serving physicians.
Kelly gets her OR certification. Somewhat surprisingly, she chooses to tell Christina Hawthorne first that she is "a certified scrub nurse." Why not tell Marshall first? She is the OR nursing expert! We do see Kelly and Marshall bonding later. It's not clear if Kelly will ever stop calling her "Dr. Marshall," while Marshall continues to call Kelly "Kelly."
The episode also wraps up the other ongoing clinical plotlines, confirming both Hawthorne and Bobbie Jackson in positions of leadership at the hospital. Hawthorne stops by to tell Morrissey, who's in some kind of rehab facility, that she "did accept the interim COO position." He's thrilled because, he says, she has "all the right qualities to run James River." Hawthorne says she's just holding the position till he is ready to return, but he's not sure he wants to return. In full rehab mode, he wants to embrace the present, try other things in his life, and so on.
Meanwhile, CNO Bobbie has been leaning toward quitting, sick of all the mind games played by the interim COO Brice who has been the bridge between Morrissey and Hawthorne. Bobbie is never sure where she stands. But then the newly anointed Hawthorne stops by, saying she wants Bobbie to stay on as CNO because she's so good at it, citing some funding Bobbie has raised for a new cancer center. Christina and Bobbie have been somewhat estranged since Bobbie took over Christina's old CNO job, but they seem to reconcile here. And when Brice also warmly congratulates Bobbie for the cancer funding, we're left to conclude Bobbie will likely stay.
HawthoRNe had flaws, both in its portrayal of nursing and in its persuasiveness as dramatic television. At times it fell back into stereotypes of nursing or the still-dominant physician-centric narrative, and it suffered by comparison to its contemporary Nurse Jackie. But for three summers, the show presented millions of viewers with a hospital environment in which strong, expert nurses played critical roles, showing leadership and critical thinking, providing skilled care, talking to patients, nurses, and physicians, and in many cases saving lives. That is the vision we hope will stay with viewers, and that is why HawthoRNe's creators deserve our thanks.