Dr. Gregory House injects a patient with edrophonium chloride. The drug blocks acetylcholinesterase and can boost muscle strength in people with myasthenia gravis, so it is sometimes used to help confirm a diagnosis. The patient, who had been too weak to even sit up, suddenly stands. But the effect is temporary and after a moment, the patient crashes to the floor. Dr. House looks down at him.
“This is exactly why I created nurses. Clean up on aisle three!” Dr. House bellows.
This scene from the Fox TV show House is one reason the series is unlikely to win any awards from nurses. Indeed, when the Center for Nursing Advocacy announced its “Golden Lamp Awards” for media portrayals of nurses earlier this year, House was listed among the worst shows.
“Grey's Anatomy and House are the worst offenders,” Center Executive Director Sandy Summers stated in the awards announcement. “These globally popular shows portray nurses as brainless servants, while heroic physicians provide all important care—much of which nurses do in real life, like defibrillation, triage, and patient education. With a nursing crisis stemming in large part from undervaluation of the profession, this is unacceptable.”
Other popular shows on the center's “worst” list include episodes of NBC's ER and Heroes, and HBO's The Sopranos. There is one, just one, primetime show on US television that won praise from the nursing group: NBC's Scrubs. It's a comedy.
Scrubs, like all other entertainment shows set in hospitals, features a cast in which doctors far outnumber nurses; while of course in real hospitals the ratio is the other way around. But a nurse, Carla Espinosa, is featured among the leads. She's no mere bedpan-changer—as one retort to the hospital's Chief of Medicine makes clear:
“You're worried about what I can handle? Vascular surgery wants an update every two hours on bed one. I'm weaning Mrs. Jones's dopamine from 10 mics to 5. Mrs. Myers' abdominal wound is dehiscing. And Mr. Wilder's about to be turfed to psych because he thinks he's Flo from Alice,” Carla says.
One of the patients, Mr. Wilder, chimes in, “Kiss my grits!”
Carla responds, “Exactly, Flo, exactly.”
In another episode noted by the Golden Lamp Award judges, Nurse Espinosa catches an intern's error and takes charge of handling a patient's seizure. The lead writer of the episode, Angela Nissel, says that even though the show is a comedy, the scene echoes reality.
“Over and over we do hear doctors say that when they start, they are amazed that nurses know so much more than they do. You've just finished all these years of medical school, and to have a nurse step up and say, ‘No, that's not how you do it.’ Or to have a nurse actually save someone's life, it must really put you in your place really quickly and let you know how much of a newbie you really are,” says Nissel.
By the way, her mother is a nurse. (See sidebar)
“I just wanted my Mom to look at an episode and smile for once and say, ‘Thank you! After four years of writing on Scrubs, you actually showed what we do,’” Nissel says. “It was important to show a nurse as something other than a background character.
“Carla is supposed to be a head nurse. She's a Registered Nurse. She's been there a while. She obviously went to college. She knows a lot of stuff; and to have one or two episodes out of a hundred where she shows what she went to school for is important.”
So why don't other shows feature similar nurse characters?
“It's like asking why the ratio of female superheroes to male superheroes is so low. We just have this thing in our society about what the hero or the main character looks like, and it takes a long time to get over that. And also because the majority of nurses are women, but the overwhelming majority of writers are male. When it comes time to write the main characters, most of them tend to be male,” suggests Nissel.
It's not that writers and producers are unaware of the role of nurses, even at House. Bobbin Bergstrom, RN, has been helping shape episodes of House since its first season. (See sidebar) She hears and understands the criticisms from nursing groups, but says she works hard to help the writers be as realistic as possible.
“I'm trying to even out the fairness of the portrayals in ways that I can, while still keeping the drama in the show,” Bergstrom says. “It's a show that works. It's really a fantastic show. The writing is excellent and I love working on the show. I'm very proud of it.”
Bergstrom concedes that the physicians on House do a lot of nursing, as they do in other shows.
“The reason they do that on our show is that the way the show is written, the scenes are so intimate that to have an extra person in there, doing what a nurse would actually do, would take away from the drama of the scene.” She notes that the attending physicians also invade the turf of all sorts of specialties, such as radiology, pathology, and every type of surgery.
Accurate, But Not Dull
Bergstrom says the writers and others working on House want to be accurate, but they dare not be dull.
“A good example is that in order to take a pulse accurately in the real world, you have a minimum of 20 seconds to check it. Twenty seconds of checking a pulse on TV is death to the drama. So if you are watching a television show and you say, ‘No one could ever check a pulse that quickly,’ you are absolutely right, but nobody wants to watch somebody check a pulse for 20 seconds.”
And while she'd like to see more nurse characters doing more of the nursing on medical shows, she says the dominance of physicians merely reflects the attitudes of society in general.
“I'm not sure why, but physicians are still revered as next to godliness, and that makes them interesting to people. Many people think, ‘I could never be a doctor.’ It's a mystery to them. And so doctors are more glamorous than nurses,” Bergstrom says. “Being a nurse, I think it's very sad, but I don't think the general public finds nursing an interesting thing to hear about.”
Still, that means that physicians are seen performing nursing tasks, thus making nurses seem superfluous. But since physicians are the main characters on the show, Bergstrom points out that it'd be rather dull to have them just standing there, doing nothing, when they are talking with a patient. The scenes demand action, so the physician characters go around hanging IV bags, giving injections, drawing blood, and doing other things that real physicians rarely do after they finish their residencies.
From her perspective, some of the criticism misses a key point: Most of the negative comments about nurses come from the character of Dr. Gregory House, who is written as a flawed and unhappy person.
“He does act like nurses are stupid. That's part of his character, so I can't take that away in order to build nurses up. I can only do it in other areas of the show, where it's appropriate,” Bergstrom says. Viewers “love to hate” Dr. House, and that's part of the fun of the show; so viewers shouldn't think the show is trying to endorse or agree with what his character says or does.
The formula of the show demands that Dr. House charge ahead with his brand of extreme medicine.
“In a way it's better for the image of nurses for them not to be there, because if they allowed [those procedures] to happen, then that would destroy the credibility of what nurses do. We are patient advocates. I've gotten in between patients and physicians myself in my career,” Bergstrom notes.
Indeed, she says that given House's outrageous actions, if nurses were present, they'd constantly be put in untenable positions.
“The nurse would never allow him to put a needle in the heart and perform a cardiocentesis [as happened in a recent episode, without warning, in unsterile conditions]. We would put ourselves in the way. That's really a great example of why you can't always have a nurse present, when there would really be one there. Because they would stop the procedure, and the story would be gone.”
And ultimately, on TV, it's all about the story.
Scrubs Writer/Producer Angela Nissel: ‘I've Grown Up Hearing that Nurses are the Ones You Should Trust When You Go in the Hospital’
Angela Nissel has been on the “Scrubs” writing team since the show's second season. Over those five years she's grown up from being, as she puts it, a “baby writer” to a consulting producer.
She takes a personal interest in the character of Nurse Carla Espinosa.
“My Mom is an RN, so I grew up with the opposite ideas about nurses and doctors compared with what most people I work with have. I've grown up hearing that nurses are the ones you should trust when you go in the hospital,” Nissel says.
“My Mom always said the nurse will spend hours with you, and the doctors will run in and out. And I've always known there were different levels of nursing, LPNs and nursing assistants. Most people get most of their ideas about what nursing is from television, so they think that all nurses do is stand by doctors, listen to orders, and change bedpans or adult diapers.”
Nissel says she feels fortunate to have that familiarity with nursing in her background, but it can also stir conflict with her fellow Scrubs writers.
“It's supposed to be a show about our doctors, and so sometimes I come across as the super-nursing-advocate. I try not to push it too much, because it'll seem like I'm pushing for my Mom!”
Nissel says that as a writer she's really pushed by the great stories that flow from the experiences of nurses.
“I remember when I was growing up, after school I used to hang out in the changing room at my Mom's job, where all the nurses got changed. And I remember all the conversations about doctors, and their work, and patients. And I remember thinking, ‘This would make a great show!’”
Nissel says everyone involved with Scrubs is a bit surprised by its long network run. The show is still going strong in its sixth season, which means the underlying premise has had to adapt. After all, it started as a tale of young, inexperienced interns. Now, the interns have grown up. Those stories of fledgling doctors tackling their first cases have been told, so the writers are exploring other situations and fleshing out other characters.
“We get to do some of the stories that have been hanging on our story list for awhile, and there tend to be more and more Carla stories on there, about her nursing career, that I've been trying to pitch for the past five years. So hopefully we are finally getting around to them. And my Mom will get some of her pitches in as well.”
House Advisor Bobbin Bergstrom, RN, Aiming to Do What She Can for the Image of Nursing
Bobbin Bergstrom, RN, has been advising the House team on the technical aspects of medicine since the show, now in its third season, began its network run. She earned her RN almost two decades ago and began advising TV shows in the early 1990s.
Bergstrom has to balance her desire to boost the image of nurses with the recognition that the point of the show is to entertain, and if it doesn't, then ratings will fall and the show will die, accomplishing nothing.
“I do try to take my crusade to the limit in those areas where I can. And the writers and creators allow that, they want that. They definitely want to infuse reality where it's appropriate and where it won't take away from the drama,” she says.
“In the beginning I did say, ‘Well, there would be a nurse in here.’ And they would point out that if [Dr.] House is talking to the patient, why is the nurse just standing there, why isn't she or he imposing their opinion, like they would?”
And Bergstrom notes that the writer didn't invent common stereotypes about nurses and physicians.
“I had an experience in the emergency room where I was working with a female ER physician and I had a male nurse counterpart. When the patient was responding to questions asked by the female doctor, he answered to the nurse, because the prejudice in his mind was ‘male equals doctor, female equals nurse,’ even though it was exactly the opposite. That still happens in the real world.”
Within the constraints of the show's premise and the imperative to entertain, Bergstrom says she tries to do what she can for the image of her profession.
“I frequently will try to take away some of the business from Cameron. If the three of them [Dr. Cameron, Dr. Chase, and Dr. Foreman] are in a room and they have only one of the doctors doing something, I'll ask the directors to take it away from Cameron and give it to one of the male doctors, so she doesn't always look like she's a nurse, thus supporting that stereotype that all physicians are male and all physicians are female.”
Things would be different, if the main characters were nurses. So, does Bergstrom think such a series will someday glow on TV screens?
“It think that would be great and I hope it does happen.”