The Resident features a skilled nurse advocate
The Fox hospital drama’s first season highlighted some real problems in the U.S. health care system, including corruption and harmful errors. But the show also had nurse practitioner Nic Nevin, arguably the strongest, most expert nurse character on U.S. television. Sadly, the other nurses were mostly handmaidens.
May 2018 – The first season of Fox’s hospital drama The Resident followed the exploits of renegade senior resident Conrad Hawkins, an internist who broke rules in order to save lives, despite some high-level corruption at his Atlanta hospital. All the major characters were physicians, except for nurse practitioner Nicolette Nevin, arguably the strongest nurse character now on U.S. television. Nic was a love interest of Conrad’s. But she was also his chief clinical ally, displaying skill, autonomy, and strong patient advocacy. In episode 2, she advised a new resident not to rely on an EKG reading but to use a stethoscope, which led him to discover a heart murmur. In that same episode, two physicians discussed why the highly skilled Nic was not a physician. Supposedly her reasons included spending more time with patients and making more money than resident physicians. Nic was also, evidently, pursuing a doctorate in nursing! Yet her name tag read “BSN, NP,” when an NP today would likely need at least a master’s degree. A major season-long plotline involved Nic pursuing a powerful research oncologist who was committing insurance fraud through egregious overtreatment of her patients. On the other hand, Nic often seemed like a skilled assistant to Conrad. At times her practice included the kind of direct care that staff nurses provide. But her quasi-physician role also seemed to involve supervising staff nurses. Those nurses rarely spoke, and most were peripheral subordinates, suggesting that Nic had risen above other nurses by becoming more like a physician. There was a limited exception in episode 4, which showed that nursing triage skills matter by contrasting a respected veteran nurse with a clueless neophyte. The season addressed some real problems: unequal health financing, overtreatment, overworked residents, and health care errors. And it actually presented senior physicians as the main villains. Usually seen as the wise masters of care, here they represented the corruption and ego infecting the system, while gifted newcomers like Nic offered some hope for the future. In fact, the show’s somewhat iconoclastic approach sparked outrage among some real physicians for “eroding trust” in physicians. The Resident was created by Amy Holden Jones, physician Roshan Sethi, and Hayley Schore.
The best nurse and the best doctors
Except for Nic, all major characters on The Resident are physicians. And during the 14-episode first season, whenever Nic was not involved in a clinical plotline, the show was not much better than shows like The Good Doctor, with nurses generally appearing only as silent helpers. That was especially notable in episodes at the end of the season, after Nic’s crusade against the senior oncologist had ended in Nic’s firing. And despite the show’s focus on certain abuses by powerful physicians, it was certainly not above the kind of physician glorification seen on other shows. In an episode 3 plotline, the drama surrounding a sympathetic young patient was repeatedly amped up with statements about how she dreamed of becoming a physician. In episode 5, Nic followed one physician’s introduction of her as “the best nurse” in the hospital by assuring a worried patient that she would get care by “the best doctors in the hospital.” At times the show also reinforced the myth that abusive, arrogant physicians are good ones. In reality, such physicians would be killing patients through hubris and discouraging feedback.
There were a few somewhat positive elements in the season apart from Nic. A couple episodes included brief scenes with the respected senior ED nurse Ellen Hundley. Early in episode 4, the ED physician Irving Feldman complained to a novice nurse about her triaging. Feldman asked what happened to the competent Hundley; the new nurse said that Hundley was gone because of “budget cuts or something.” Feldman later reported to Conrad that Hundley was let go for being too experienced and expensive, and the new triage nurse was “a bubblehead.” When the ED got multiple traumas, the new nurse was overwhelmed. She mis-triaged an unidentified patient with a head injury, which led to his death. The physicians berated her about this, which is fair, although the lack of any senior nurse in the plotline is not. The new nurse cried, remorseful about her mistake, and she eventually disappeared from the show. Later, Conrad convinced hospital administrators to re-hire Hundley by pointing out the litigation risk. It is helpful to suggest that physicians would care and advocate about something like this. But doing so would really be the job of nurse managers. Of course, nurse managers often lack the power they should have. In any case, here there was no nurse manager to be seen.
Episode 5 had a morbidity and mortality (M&M) conference, and nurses participated, which we have rarely seen on a Hollywood show. At one point, in a discussion of how one patient had the wrong testicle operated on, a nurse actually appeared to take some responsibility, for having removed the incision mark when she sanitized the surgical area. As with the triage plotline above, this was helpful in showing that nursing matters enough that nursing errors matter.
Episode 6 had a problematic interaction related to autonomy. By this point, Nic had begun to persuade physician colleagues that the prominent oncologist Lane Hunter might be committing insurance fraud by overtreating patients. A focus was the fragile young patient Lily, who was growing concerned about the bone marrow transplant Hunter had planned for her. So physician intern Devon Pravesh asked a staff nurse to do some tests on Lily to assess her condition. A nurse curtly reminded Devon that Hunter centralized tests at her clinic. Devon responded that he was the doctor, she was the nurse, so she had to do the tests, or he would take it up with her supervisor. The nurse caved. Later, the lab work came back and Devon noted that Lily was in renal failure, inviting the nurse to look at the results. At first the nurse sniped, “I thought you were the doctor.” But then she did look, saw the problem, and said, “How did we miss that?”—as if she was a skilled colleague. Devon ordered measures to stop the potentially deadly transplant. Overall the nurse came off as more of a disagreeable bureaucrat than a professional, more interested in protocols than helping the patient. And despite the reference to a nursing supervisor, the plotline suggested that the intern was functionally in charge of the nurse’s care.
A few late season episodes included brief appearances by a “nursing supervisor,” but these too were mixed. The supervisor, Alexis Stevens, BSN, MSN, seemed to have some good judgment and commitment to her staff. However, she still acted more as a mid-level bureaucrat than a clinical leader. In episode 10, Stevens paged Nic to her office and asked her to go coordinate the care of a Chinese billionaire in the VIP wing. Evidently the patient had been more than lesser nurses could handle. Nic resisted, noting that she was an NP “with my own patients” and the VIP wing was about “coddling rich people.” Even so, Nic masterfully managed the difficult patient, giving him just the right amount of pushback about his aggressive security detail, adapting to his need for a lucky room number, and intervening effectively when he crashed post-op.
No gamers, no slackers, no doctors
But of course, most of the show’s nursing portrayal was about Nic. One of the first things she did in the premiere was tell the new intern Devon what he needed to know about Nic’s then-ex-boyfriend Conrad. She compared Conrad to a “jerk” mechanic who instantly fixes your car, as opposed to a really nice but ineffective and expensive one—an example of what we might call the show’s jerk-physician glorification. On a personal level, viewers learned that Nic’s Tinder profile reflected her past experience with Conrad (“no gamers, no slackers, no doctors”). But she was far from a naughty nurse. It took almost the entire season for her to relent and get back together with Conrad. And in episode 7 she stopped a star baseball player patient from sexually harassing her by threatening to forward the explicit selfie he had sent her to gossip websites.
The season repeatedly touched on Nic’s status as a nurse. In episode 1 she told Devon that errors are the third leading cause of death in the US—Nic’s mother was the victim of one—and that Nic wanted to be one of the “doctors and nurses” who was not causing such harm. Part of that work appeared to involve monitoring and guiding Devon’s work. In episode 2, Nic advised Devon not to rely on an EKG reading but to use a stethoscope. Doing so, he found a murmur. But in pushing for Devon to use this practice, she stressed that Conrad would “ream” him otherwise, as if she was channeling Conrad instead of herself, and serving Conrad rather than the patient. On the other hand, Nic didn’t need a physician to tell her to look out for Lily. And Nic regularly showed expertise in providing direct care to Lily. For example, in episode 1 Nic reported that Lily’s systolic pressure was fluctuating, and she requested that 12 leads be kept on her, to allow clinicians to more closely and quickly monitor the unstable patient.
In episode 2, Devon told Feldman that Nic was really good, so why didn’t she want to be a physician? Feldman said that was because she is smart: the nurses get to spend more time with patients (except on Hollywood shows, he failed to add); the nurses have a strong union (less likely in a “right-to-work” state like Georgia); and the nurses make more money than residents do (as if all that matters is the first three years of practice, before physicians begin earning far more for the rest of their careers). Feldman added that Nic was working on her doctorate – in nursing. But we heard no more about that, so it’s not clear what it will mean to viewers. Indeed, Nic’s white coat said that she was a “BSN, NP.” In fact, while the profession is in the process of moving to a doctoral entry requirement for NPs, Nic would likely need at least a masters degree to practice as an NP at a major hospital. Of course, maybe we should appreciate the show’s suggestion that nurses have any college education at all, unlike the impression some other shows leave. Nic was at least nurse-identified; she corrected those who mistook her for a physician, as in episode 6. And the show’s focus on Nic’s technical skills did not prevent it from showing her in more familiar psychosocial roles, for example in bringing in puppies for pediatric patients.
In episode 3, Nic outwitted a “billing consultant,” in a plotline that was somewhat reminiscent of an episode of Nurse Jackie. Early on, much of the cast had to attend a meeting with this consultant about increasing reimbursement, including through “upcoding.” Later, the billing villain talked a physician into ordering an unnecessary but lucrative MRI scan of a pre-operative patient. When Nic learned what was going on, she stopped the scan, explaining that the MRI magnet posed a danger because the patient had a metal penile implant. Nic told the consultant that not every test was advisable, and this one could have actually cost the hospital a lot, including through possible legal action. And Nic vowed to file a report that would prevent the consultant from returning.
Episode 8 had a great example of the Conrad-Nic clinical partnership. In that one, they admitted a homeless “Jane Doe” who had been dumped by another hospital; Nic could tell which one by examining a remnant EKG lead. Working together, Nic and Conrad brainstormed about how to keep the patient there until they could figure out what was really wrong with her. When the patient coded, Nic got to say things like “activate massive transfusion protocol with the blood bank.” When they finally identified the patient as a painter who was the daughter of a wealthy Georgia family, Nic took the lead with the family members, who strongly believed their daughter had paranoid schizophrenia and wanted her back on medication. But Nic and Conrad eventually determined, through observations and tests, that she had the rare autoimmune disease Wegener’s, which can cause psychosis. There was gratitude all around. Nic was even promised a new painting!
More chemo more money
But Nic’s major care and advocacy project of the season involved the patient Lily and Hunter, the oncologist who was overtreating patients. In episode 4, having noted that Lily was struggling, Nic began a quest to get her records from Hunter’s clinic. Hunter agreed to that, but the chart mysteriously never arrived. Nic finally went to the clinic for the chart, but she got the runaround there too, even from an old nursing school classmate. In episode 5, Nic told Conrad of her suspicions, which she summed up as “more chemo more money.” But Conrad was slow to accept that it could be true of Hunter, a mentor of his. Later, Hunter told Nic that she objected to nurses snooping around her clinic and questioning her methods, so Nic would no longer care for any of her patients. Hunter threatened that if Nic did not watch out, she would no longer be anyone’s nurse. Nic responded by urging her physician pals Conrad and Devon to watch the patients for her. In episode 6, Nic told Devon that she had “pulled every ounce of research that I can possibly find on high-dose intensification programs, both here and abroad,” and Hunter’s chemo protocols were “significantly higher than even the most aggressive programs.” Nic convinced Devon, based on Lily’s aborted bone marrow transplant plan. But she needed more patient records.
In episode 7, working to persuade Conrad, Nic questioned the care of another Hunter patient, an older man with advanced lung cancer. He did not have long to live, yet Hunter planned a biopsy, chemo, and radiation. The patient himself told Conrad that the treatments would just “rob me of the few good months I have left.” Conrad agreed, but Hunter blew past his concerns and gave the patient a “fight the enemy” speech that resonated with the patient’s wife, who was having trouble letting go. The patient relented, but in surgery the surgeon perforated his lung, so he got a chest tube and drainage system. Hunter insisted on moving ahead with other treatments the patient did not want, but Nic and Conrad had other plans. Nic explained to the patient and his wife that he could simply leave without discharge, noting that his wife could manage a portable chest tube system at home until hospice got there. The couple hobbled off. And Conrad was convinced about Hunter.
In episode 9, Lily followed Nic’s advice to seek a second opinion, specifically an oncologist named Oster that Nic used to “work for.” When Oster asked Hunter for Lily’s records, Hunter asked who had referred Lily. Oster said the “terrific nurse” Nic. Later, Lily arrived in the ED, hypertensive, vomiting, with a severe reaction to the ongoing chemo. Lily told Hunter she didn’t want any more. Surprisingly, Hunter then asked Nic to again take over “supervising” Lily’s care. Hunter asked Nic to give Lily “a liter with 40 mil-equivalents of potassium.” Nic questioned whether Lily should get that much, but Hunter assured her it was better for Lily’s heart, if given slowly. Nic set that up, then left. We saw Hunter lurking nearby. Later, Lily crashed, with a heart problem. Conrad and a resuscitation team could not save her.
The fallout from Lily’s death drove the rest of the season. In episode 11, titled “And the Nurses Get Screwed,” Lily’s family sued the hospital and named Nic in the suit. A hospital risk management panel was investigating. Meeting with the panel, Nic described Lily’s poor condition after the last chemo dose, noting that Hunter’s protocols “take a toll on patients in every possible way.” But the head of the panel told Nic that the autopsy had found Lily died from a potassium overdose—the bag Nic had hung that night killed her. Nic said someone must have changed the flow rate. She also spoke about her care for Lily over the past two years.
Nic: I comforted her, talked to her about death, bathed her, fed her, I cared for her, not because I liked her, which I did, and not because she was one my favorite patients, which she was, I cared for Lily the same way I care for all my patients, because that is what nurses do. Now doctors order tests, they prescribe meds, then they go home, but nurses… You know, doctors think the patients are theirs, but they’re not. They’re ours. The nurses. Lily Kendall was my patient, and I did not harm her. But someone else did.
Later, Devon offered to help Nic by running bloodwork on some of Lane’s patients in the ER, but neither he nor Conrad could recall how to draw blood. Nic sighed, “doctors.” She tried to train Devon, but ended up drawing the blood herself.
Nursing supervisor Alexis, a member of the risk management panel, said nothing during the panel’s interviews. But she did privately alert Conrad that his interview had been canceled because Hunter had implicated Nic and had convinced the panel that Conrad could not be trusted because of his romance with Nic. Alexis thus showed loyalty to Nic and to good care, as well as some willingness to subvert the bureaucracy, which is a cardinal virtue in a show like this.
Nic was convinced that Hunter had intentionally overdosed Lily. But the hospital CEO fired Nic. That gave Nic time to continue investigating, which in episode 12 took the form of tracking down a former physician colleague of Hunter’s whose career she had ruined after he starting objecting to her overtreatment years earlier. He advised Nic to give up. Nic also visited the Georgia Medical Review Board, where her appointment was mysteriously canceled. Soon she noticed a suspicious car following her. Later a shady man delivered unordered “groceries” to her house. In episode 13, Nic called the police, to no avail. But Nic turned the tables by arranging for a relative of an old patient—a very intimidating man—to track down and deliver groceries to her grocery stalker. Nic again asked her friend from Hunter’s clinic for Lily’s records. This time, her friend asked Nic to meet her at the clinic at 4:00 a.m. But when Nic arrived at the empty clinic and entered, looking for her friend, the police arrived instead. She had been set up.
In episode 14, Conrad bailed Nic out of jail. Back at the hospital ED, the team learned that Hunter had diagnosed and started chemo on a hypochondriac frequent flyer whose blood work showed she was healthy as usual. Nic: “Lane’s giving chemo to patients who don’t even have cancer.” Nic, Conrad, and Devon called the FBI and presented their case to the hospital CEO. Conrad noted that Hunter’s treatment of healthy patients explained her miraculous cures. Nic said that Lily’s cancer could have been the result of aggressive chemo. The new CEO, a surgeon who had formed an alliance with Hunter, seemed reluctant. But ultimately he turned on Hunter and she was arrested. In the end, Nic was back at work, watching the CEO on television crediting her two physician allies “and a very determined nurse practitioner” for discovering the problem.
This massive plotline showed Nic’s clinical expertise, but even more, it presented her as an unusually tenacious and effective patient advocate, willing to risk her career and even her physical safety to protect patients. Parts of the plotline may have been implausible, but what will likely stay with viewers is the portrait of a nurse working basically as a peer with physician colleagues to defeat a major health threat. The season’s overall presentation of nursing left much to be desired, but the portrait of Nic was generally strong, and we thank those responsible.