Gotta keep ‘em from killing people

Nurses show skill and some authority in early seasons of Chicago Med

The first two seasons of the NBC hospital drama (2015-2017) focus on physician characters who generally direct clinical care. But the show also has three skilled nurse characters: the wise hospital executive Sharon Goodwin, the authoritative ED charge nurse Maggie Lockwood, and the competent ED staff nurse April Sexton.

May 2017 – NBC’s Chicago Med is a television drama about dedicated public servants in the emergency department (ED) and operating room (OR) of a major city hospital (the show is a sibling of producer Dick Wolf’s Chicago P.D. and Chicago Fire). In its first two seasons, Chicago Med followed the traditional Hollywood model, in that it focused mainly on a half dozen expert physician characters who were generally portrayed as directing care. But the show broke with that tradition by also spending significant time on three skilled nurse characters. They were the competent young ED staff nurse April Sexton, who was typically seen providing direct care; the authoritative charge nurse Maggie Lockwood, who ran the ED logistically; and the “executive director of patient and medical services” Sharon Goodwin, who resolved policy issues and had authority over even the physicians in the ED and the OR. All three nurses at times provided good technical care, effective advocacy, and psychosocial care, including some patient education. In season 2 episode 1, Lockwood told Goodwin she was busy keeping the new residents from killing patients. Indeed, these nurses often discussed care with physicians, even pushing for different approaches. The nurses also did things that are not common on other shows, like meeting ambulances and being personal friends of physician characters. On the other hand, physicians were generally shown to be in command of clinical care, and they did the most exciting procedures, like defibrillations. When patients had urgent problems, nurses were there in an assistive capacity. But when the patients were more stable, nurses were rarely involved–physicians tended to manage care by themselves. In season 1 episode 17, Sexton told a patient that she, Sexton, could not pursue the care path she wanted because “the doctor’s in charge.” There were micro-self-aggressions in some throwaway lines. Lockwood advised family members to back off to “let the doctors” work. And nurses did at times respond to physician requests with an obsequious “yes, doctor!” Despite all that, the show is probably the best current U.S. prime time show for nursing (although the U.K.’s Call the Midwife is far superior). For that, we thank the Chicago Med producers.

Flexing nursing muscles

Insubordination

Flexing nursing muscles

In virtually every episode of Chicago Med, the nurse characters play a key role in care, although not as key as the physicians. And many episodes showcase real nursing skills, as well conveying something of what nurses experience in the clinical setting. For example, season 1 episode 15 features Maggie in her charge nurse role, directing patients on arrival, and April in her competent assistant role, calling out vital signs and absorbing seemingly complex physician directions to give drugs. At the same time, at some points in the episode Maggie seems like a bit of a secretary for the physicians, and nurse characters are also shown taking the kids of patients to the break room for a snack. Goodwin engages in her usual higher-level problem solving. For example, in episode 15 she advocates strongly to help a homeless surrogate mother with pre-eclampsia who does not want to deliver early because of her contract with the parents. It would be possible for a casual viewer not to realize that Goodwin is a nurse. But in season 1 episode 16, all three of the nurse characters are seen to have “RN” on their identification badges. That episode also includes the three of them playing what seems to be the main role in handling a hospital inspection by the Joint Commission. And in the season 1 finale (episode 18), an altered patient injures April, and she has some continuing pain. When her then-boyfriend later expresses surprise and concern, she tells him she has been hit many times: “Nursing is a dangerous profession.”

Season two episodes also consistently show the nurses as skilled players, although again there are suggestions that the physicians matter more. Episode 1 finds Goodwin discussing a new crop of resident physicians with Maggie.

Goodwin: “New residents settling in?”

Maggie: “Yeah. Now I just gotta keep ‘em from killing people.”

Goodwin: “July 1^st, it’s not a good day to need a hospital.”

Maggie jokingly tells the nearby physician Ethan Choi, who is becoming chief resident, that she is looking for his chief resident gavel. Ethan happily tells Maggie he has some ideas to improve patient care.

Maggie (privately to Goodwin): “I hate killing their dreams.”

Goodwin: “You like to let them hang themselves.”

Yet this same episode includes the intake of a pregnant car crash patient, during which Maggie tells a family member, “Why don’t you come with me and let the doctors do their work?” So which is it—do nurses matter or not?

April will at times educate patients. In season 2 episode 2, she notices that a baby has a neuromuscular issue and then gives a pretty good explanation to the mother in lay terms: “A baby’s natural position is to flex the legs. When straightened, there should be some resistance.”

Maggie can be a creative problem solver. In season 2 episode 6, as part of her work managing patient flow, she locates an ICU room that one patient needs. However, apparently the physicians superstitiously resist, because it is “the red room” in which patients are supposedly more likely to die. When rational argument seems futile, Maggie arranges for a Hawaiian friend of many ED staffers to perform a kind of shaman ritual, and that seems to resolve the issue.

Goodwin herself at times displays direct care skills. In season 2 episode 20, she visits the ailing father of Will Halstead, one of the main physician characters. Casually taking the patient’s pulse and noting his pale color, she quickly leaves and directs that the surgeon Connor Rhodes be paged. Goodwin tells Rhodes that the patient is “throwing runs of PVCs.” The patient needs surgery and despite some resistance from him, he gets it, ultimately surviving. Will later thanks Goodwin for “jumping in.” She says: “It’s good to flex nursing muscles every now and then.” Overall this is helpful, apart from the assumption that Goodwin is not nursing when she is acting as a health care executive, and the iffy suggestion that nursing is about “muscles” rather than brains. Nursing encompasses high-level health policy decisions, as well as skilled direct care.

A plotline in season 2 episode 10 provides a good snapshot of the roles and skills of all three nurses. In that one, a police officer arrives at the ED very badly injured. Maggie has a bad history with this officer, who actually arrested her in a first season episode for preventing a blood draw from a patient who was intoxicated and unable to consent, a plotline that seems to have eerily anticipated a similar real incident in Utah in July 2017. Even so, Maggie now directs the officer to an ED bay in her usual way. It soon becomes clear that the officer is brain dead and may be an organ donor. At one point, the physician Ethan introduces Maggie as “my charge nurse” who will coordinate the potential donations. But when the police, including the injured officer’s husband, realize who Maggie is, they object to her role. Ethan assures them that “Maggie’s a pro, she’ll do her job,” but they go over his head to Goodwin. As Maggie begins expertly coordinating organ donations, Goodwin arrives and says that April will take the lead. Maggie resists, but Goodwin is firm. April takes over the transplant process. She somewhat tentatively explains to the widower that his wife’s organs are being matched to people in need, that they will then schedule surgery, and that he is free to stay with her throughout. The husband asks how many lives might be saved. April says potentially 7-8, with caveats about the need for organ evaluation. When the police ask if some of them can be present in the OR, April says she will talk to the “surgical charge nurse” but is sure they can work something out. Later, we see Goodwin running a meeting in which otherwise only physicians attend, it seems. This must be an ethics committee, as they vote to deny the officer’s heart to one possible recipient because she used drugs just that morning. But when there is no other feasible option, Goodwin tells the physicians that this recipient will get the heart after all. Later, Maggie tells the widower that she will ensure that his wife’s treasured necklace will be in her hand during the surgery. Maggie finally persuades him and Goodwin to let her resume the transplant care. And she does, very sensitively.

This plotline effectively highlights the work of all three nurse characters. Goodwin is the wise, commanding executive with apparent authority over nurses and physicians; not exactly a nurse manager. Maggie is the logistically-oriented charge nurse whose passion for the work can lead to conflicts but whose commitment and skills ultimately win others over. And April is the least experienced, but an able and promising junior nurse, ready to step up when needed. All are serious and excel at psychosocial care. Of course, the plotline does still reflect the overall primacy of the physicians, who dominate high-level discussions like the one about who will get the organ, and who can make comments about “my charge nurse” without raising any eyebrows.

Insubordination

The show’s presentation of nursing autonomy is mixed at best. In season 1 episode 17, April and resident physician Will Halstead clash over how to treat a homeless patient named Chuck who is struggling with alcoholism. April knows Chuck, as he is what some ED staff call a frequent flyer. In this episode, he is going through withdrawal. Chuck asks April to help him get out.

April: “I’m sorry, Chuck, the doctor’s in charge.”

Chuck insists he is in charge. (Go, Chuck!) In any case, April is in charge of holding a pan for him to vomit into. She also helps him manage delirium tremens hallucinations (DTs), and tries to motivate him to beat the addiction. She increases his meds, but seems unhappy. Goodwin, who sometimes keeps in touch with clinical cases, recalls that when she was a “clinical nurse” she dreaded this process. Later, Will spots April taking alcohol to Chuck. Will objects, saying this is against protocol. April counters that a former supervisor of hers did it all the time. Will argues that giving Chuck a drink is just giving him a band-aid. April says Will is just standing around while the patient dies in front of them, and that they need to listen to the patient. Will says it’s not his job to listen, he’s a doctor who “decides what is best” for patient.

April: “That is exactly why I’m a nurse.”

She tosses Will the booze. Later, she calls Will back, noting that Chuck is vomiting blood. It is an esophageal rupture because of years of alcohol abuse and all the vomiting; they need to intubate. Chuck is bleeding out. Will says he’s doing all he can. But later, Chuck seems to have made it through. Will is suspicious about why symptoms subsided. April says that Goodwin gave Chuck a drink, observing, “I guess once a nurse, always a nurse.”

Will confronts Goodwin, against whom he is basically powerless. Goodwin calmly responds that Chuck “was likely going to die without one, I’ve seen it happen.” Goodwin adds that an addict has to want to quit and Chuck wasn’t ready. Will seems angry, but chastened.

This plotline does present a direct care nurse advocating strongly for a patient, and of course it is Goodwin, a nurse, who basically overrules the physician’s insistence that the patient be denied alcohol, even against the patient’s wishes and at serious risk to his life. But Goodwin has an executive role over the whole ED, and the plotline wrongly sends the message that staff nurses like April must obey physician commands. Some viewers may assume that April specifically asked a supervisor to intervene, that staff nurses generally have this recourse, but it seems at least as likely that it was just chance that a powerful administrator was involved and agreed with April.

Another season 2 plotline with problematic messaging about the autonomy of staff nurses came in episode 12. In that one, the senior surgeon Isodore Latham, confronting some setbacks in the OR, blows up at an apparent nurse named Beth about her “insubordination,” and he even violently shoves a tray of instruments. Beth in turn complains that she has had put up with “that ingrate for seven years, no more.” The surgeon Rhodes tries to mollify Beth, admitting that Latham treats staff badly, but noting that he has the patient’s best interests at heart. Later Latham concedes that he has autism, and asks Rhodes for help. He then treats Beth better in surgery. It’s good that Latham’s conduct is shown to be problematic, and that viewers are given the relevant context. But leaving aside where responsibility for the misconduct may reside, the plotline suggests that the solution is informal persuasion by another, more benevolent surgeon, rather than rules of workplace conduct to protect nurses and other staff. It’s not really questioning the standard Hollywood vision that physician authority over nurses is largely unchecked. And it’s not clear what steps may be taken to address Latham’s violent conduct, a serious threat to the workplace.

On the whole, because all three major nurse characters are sentient beings who display skills and play important roles in care, Chicago Med may well be the best current Hollywood show for nursing. But there is certainly substantial room for improvement, especially as to autonomy.