The last season of NBC’s The Night Shift was a downshift for nursing
The fourth season of the hospital drama, which aired in summer 2017, still included the competent emergency nurse Kenny. But as always, every other major character was a physician. And even more than in the past, the show portrayed nurses as mere assistants to the physicians, with limited skills and no autonomy—especially in an egregious plotline in which a seemingly gifted nurse turned out to be a physician.
August 31, 2017 – The fourth and final season of NBC’s summer hospital drama The Night Shift saw a sad decline in the portrayal of nursing care. The San Antonio-based show had always been dominated by the heroism of the expert physician characters, several of whom were military and spent time in conflict zones. But the show also included major character Kenny and a few other emergency nurses. They were mainly assistive, but they also displayed some knowledge and at times played an important role, advocating for patients and giving psychosocial care. That remained true to some extent this season. For example, in one episode Kenny did help identify that a meningitis outbreak seemed to be underway at the hospital. And Kenny was an athletic ex-football player, showing the diversity of men in nursing. But the season also included a lot of messaging that harmed nursing. We saw old favorites like having someone insult a female physician by calling her a nurse, and even a few fleeting naughty nurse images, at a charity event. Probably the worst thing was the new character Cain Diaz, a nurse whose knowledge and authority set him apart. Other nurses gushed over how “special” Cain was. But Kenny’s hostile, jealous reaction to Cain marked Kenny as an insecure serf. A low point was Kenny arguing that Cain had to obey a junior physician simply because she was a physician. Finally it was revealed that Cain was actually a physician from Mexico who was unable to practice easily in the United States. So he just “got his nursing license”—as if nursing was merely a small subset of medicine, which it is not. After Cain’s true status became known, a senior physician fired him as a nurse but promptly re-hired him as a resident physician. So much for nursing managers. Meanwhile, the other nurse characters were even more assistive than in prior seasons, carrying out physician commands for tests and procedures, calling vitals, fetching things, displaying limited knowledge and no autonomy.
You work for me now
The first two episodes traced Cain’s transition from mysteriously skilled emergency department (ED) nurse to understandably skilled physician, and Kenny’s complementary shift from insecure competing nurse to somewhat resentful underling. Episode 1 found the resident physician Shannon Rivera orienting the traveling nurse Cain, who was from “down south.” One ED patient was combative and seemed like a probable drug overdose, so Shannon asked for valium. When Cain resisted, Kenny gave the drug, telling Cain: “Check it out Cain, you’re a temp nurse, she’s a doctor, do as you’re told – this isn’t debate club.” Later, the patient woke gagging, with only Cain there. Cain called for Shannon, but he did not wait long before removing the endotracheal tube himself. Discovering this, Shannon was upset, saying only physicians were permitted to do it and Cain could have gotten them both fired. Kenny privately complained to Cain: “What the hell you doin’ extubating a patient? We don’t do that procedure without an order from a doctor.” Cain calmly said he called for a physician, but there was no time to wait for one. Kenny: “You’re a nurse, and a temp one at that, do your job.” The patient professed to have no idea why he was in the ED. He said he was a cellist and did not do drugs. Cain believed him; Kenny was skeptical. The patient displayed musical knowledge and said he had to get to an audition the next morning. Cain noted the lack of evidence of drug use and gradually persuaded Shannon that something else was going on. When the patient’s labs did show the presence of K2 (synthetic marijuana), Kenny was not surprised, but Cain kept pushing for a closer took, suggesting that it may have been retribution by the police. Kenny: “Now you’re a doctor and a cop.” But it turned out that Cain was basically right. The patient’s neighbor had spiked his pizza. Kenny and Rivera apologized to the patient, who ended up doing his cello audition by video from the hospital. Cain’s insight was remarkable, and he appeared to be an exemplary (if boundary-pushing) nurse.
In Episode 2, the ED confronted patients from a mass casualty event at an amusement park. Shannon was impressed that Cain was “treating and streeting” and showing himself to be a “damn good nurse,” despite Kenny’s view that Cain acted like he owned the place. Another nurse helpfully added that Cain was “easy on the eyes.” The insecure Kenny saw a chance to dump a returning patient with crotch lice on Cain. Cain questioned that, in light of the mass casualties, but soon gave up, saying “you’re the boss, Kenny.” Later, Cain was managing a failing syncope patient whose family had a history of heart disease. After another cursory effort to find Shannon, Cain bagged the patient, gave epinephrine, and set up to handle the code with another nurse. Cain did the central line, although the other nurse was predictably terrified. When Shannon arrived, Cain reported that the patient had a third-degree heart block. Cain told Shannon that she would need to do a pacemaker. She said she’d never even seen one, but Cain said he would guide her through it. Now Shannon knew he was not an RN, because “a nurse can’t place central lines or float a pacemaker.” Cain admitted that he was an attending physician in Mexico, but he had gotten sick of cartel violence, “so I got my nursing license and a visa, I could work anywhere.” Cain said he had not practiced as a physician in the U.S. because of the language barrier and the fact that he would apparently have to start over as a resident. The chief ED physician Jordan fired Cain as a nurse, then hired him as a physician. The nurse who had been crushing on Cain earlier gushed: “I knew there was something special about you!” Kenny claimed there were no hard feelings, and Cain agreed, but he also told Kenny that “you work for me now,” and ordered Kenny to shave a homeless patient with a boil on his scrotum.
What was wrong with the Cain plotline?
First, it wrongly told viewers that physicians hire, fire, and manage nurses, as the interactions with Cain showed. Kenny did at first seem to have some informal right to direct Cain, presumably based on seniority, but there appeared to be no nurse managers, and Kenny repeatedly told Cain he had to do whatever the resident Shannon said. Cain’s final “you work for me now” was the exclamation point. The plotline also suggested that nurses are at a minimum too deferential to physicians (Kenny), if not pathetic physician fan girls (the other nurse). Cain’s explanation for not initially practicing medicine also embodied damaging misconceptions. It told viewers that a physician could easily get a nursing license, as if nursing was just a basic subset of medicine. Of course there is an overlap, but nurses know plenty that physicians do not, and Cain would need to study nursing. But here, if nurses had any unique scope of practice, it seemed to be dealing with scrotums; another stereotype, associating nursing mainly with unpleasant bodily functions. And Cain’s explanation included a reference to language skills, as if nurses do not need those. But as patient educators and advocates, nurses need language skills at least as much as physicians. In the end, the plotline strongly suggested that Cain was a superior clinician, as he displayed with his treatment of the cellist, because he was a physician. That’s what made him “special.” The effect of the Cain plotline was to enhance the image of physicians and greatly diminish that of nurses.
What she said
Apart from the Cain plotline, Kenny and the show’s other nurse characters were generally helpful team members, characters who did get names and a few lines. But they were also physician helpers with limited skills. They complied with physician commands for tests and medications, reported vital signs, called the blood bank, and provided the kind of physical support care referenced in the Cain plotlines (e.g., catching vomit, as in a scene in episode 3). Nurses did not usually play a big role in patient interactions. That was for the physicians.
At times Kenny did display knowledge, and even some authority, especially in psychosocial care. In episode 4, he seemed to have the ability to assign the sleep-deprived physician Drew a relatively easy ED case, revealing some knowledge of patient conditions in doing so. In that episode Kenny also alerted the ED physician Jordan that the senior surgeon Scott might be going overboard to save a patient, using all the available blood products and a lot of defibrillation. Kenny turned out to be wrong, but his concerns were well-founded and at least he was advocating. And in episode 9, Kenny actually detected symptoms (fever, headache, neck pain) in a patient from an immigration center that seemed to signal a meningitis outbreak.
But the season offered more portrayals that were damaging. There was a marked tendency for nurses to appear mainly to obey physician commands. In episode 8, a nurse named Jocelyn was assisting Shannon with a patient. Jordan asked what they were doing, and Shannon basically reported that they were applying hemoclips. Jocelyn: “What she said.” In other words, nurses are physician helpers who are only dimly aware of what they are doing in the clinical setting.
The show had its share of powerful women, but they were all physicians, in the standard Hollywood way. In episode 9, the immigration episode, an ICE agent insulted Shannon by calling her a “nurse.” She responded: “Doucheface.” Of course, she might have meant it’s wrong to make gender-based assumptions, but without any explanation, there was a clear sense that the comment was insulting because nurses are inferior to physicians. The season even had a fleeting naughty nurse image. In episode 5, the staff attended a cystic fibrosis fundraiser that pitted local hospitals against each other in a reality-show-style obstacle course. Unfortunately, the MC running the event seeming to be accompanied by a naughty nurse, who made several quick appearances on screen, although she never did anything else.
Sometimes the damage was more subtle. A plotline in episode 6 featured Kenny in a circumstance that is fairly common for Hollywood: focusing on a nurse character not for his nursing, which is seen as uninteresting, but as a patient or family member. In this case, Kenny was at a gym with the physician Drew and some of his buddies, training in mixed martial arts. One man went overboard applying a stranglehold to Kenny, and Kenny lost sensation in his legs. After Kenny arrived at the ED, the other nurses were skilled assistants, calling vitals and offering to page other physicians. There was even a perky “yes, doctor.” On the upside, Kenny at least advocated strongly for himself, specifying that he wanted no intubation so he could effectively manage his own care. So at least he was a strong, authoritative patient! In the end, the sensation in Kenny’s legs returned. But a sense of nursing autonomy and expertise remained elusive.
As the series ended, Kenny’s personal life developed in ways the show may have felt showed growth, but even these really did nursing no favors. In episode 9, Kenny asked for the physician Paul’s blessing to marry Paul’s sister Bella, a urologist Kenny had been dating. We suppose the fact that Kenny was worthy of marrying a physician counts for something; you would never see that on a show like Grey’s Anatomy. In episode 10, the finale, Kenny got a swanky engagement party and wedding, courtesy of Bella’s father, who was a corporate health mogul. And in a projection of where the characters ended up in the future, we saw Kenny walking down a hospital hallway wearing a business suit and bantering with this mogul. That seemed to reflect some corporate job for Kenny, but given the show’s lack of nurse managers, it also seemed unlikely that it involved nursing. More likely, Kenny had risen about his lowly nurse status.