The Soft Bigotry of Low Expectations

January 25, 2007 -- Tonight's episode of ABC's "Grey's Anatomy" includes a short scene in which attending physician Mark Sloane praises nurses as "helpful," "smart," and "already good at their jobs." We give the show credit for trying. But the scene presents Sloane as inflicting seemingly grotesque, trivial nursing tasks on interns Meredith Grey and Alex Karev as a punishment, with no hint that the tasks might be important to patient outcomes--a "Grey's" scenario that is sadly familiar (see examples 1, 2, 3, 4). So the scene suggests that physicians do nursing work, that nurses are helpful physician helpers, that nursing tasks are unpleasant and insignificant, and that nurses are all already good at their jobs because there isn't much to their jobs, in contrast to real professions like medicine, in which people must practice for years to achieve proficiency. The "smart" comment will have little effect given these problems, and given that "Grey's" has spent the last two years telling the world that nurses are disagreeable twits. Indeed, that comment may be the biggest insult of all, because it suggests the show thinks nurses can be mollified with such an unpersuasive pat on the head. The episode, Eric Buchman's "Great Expectations," was seen by 21.5 million viewers in its initial U.S. airing.

Please read below for more or go straight to our letter-writing campaign. Also see Mandy Mayling's alternative script idea for this episode.

In the episode, plastic surgeon Sloane (a.k.a. McSteamy) is annoyed with Meredith and Alex because they won't do his personal errands. At this point, Sloane is also about to leave Seattle Grace and return to New York, as his lover Addison Montgomery has dumped him. (See the clip in Quicktime--choose broadband or dialup speed.) We see Sloane introduce the "annoying interns" (as he calls them) to his patient "Jim." Sloane says Jim is "semi-comatose, and has stage 3 decubitus ulcers." Alex looks incredulous: "Bedsores?" Sloane smiles, and says that Jim will "need to be debrided, have his dressings changed, and be repositioned every two hours." Meredith notes that by the time they finish, they'll "just have to start again." Sloane assures her he's "crying on the inside." Alex wonders: "Can't the nurses help?" Sloane:

They could but...I like nurses...they're helpful, and smart, and already good at their jobs. So as a going-away gift to them, I'm gonna let you hang with Jim.

Later, we see intern Cristina Yang enter Jim's room where Meredith and Alex are working. She sees what they're doing and asks: "Who'd you piss off?" Meredith notes, in a resigned voice, that it was Sloane.

Some may view this as a laudable effort by "Grey's" to show nurses some respect. And the record will reflect that the episode presents the show's tens of millions of viewers worldwide with a respected attending telling two other physicians that he likes nurses because they're smart and good at their jobs. Sloane is making the nurse comments mainly to draw a contrast with his worthless interns, rather than because of a keen desire to credit nurses. But the show still probably means for us to take the comments more or less at face value. Some might also thank the show for the implication that the work nurses do is difficult. And maybe we should be grateful that the interns did not respond by saying, "Are you kidding? You're dumping this trivial nursing scut work on us?"--or, as Meredith herself once memorably said to Alex, "Did you just call me a nurse?"

Sadly, it's easy to see this isolated half-minute scene as a token effort to appease nurses after the show's many hours of damaging disinformation, especially since the scene is itself dominated by themes that cause the same kind of harm, messages that dwarf any benefit the Sloane character's compliments might have had. And the compliments themselves reflect not so much the "great expectations" of the episode's title as they do the soft bigotry of low expectations. Consider:

The scene indicates that physicians do nursing work. Sloane has directed the interns to do something they regard as outside the scope of their usual work, and the comments of both Sloane and Alex suggest that nurses would normally be at least involved, if not doing the work themselves. In fact, nurses do have the primary responsibility for diagnosing and treating bedsores, which makes sense since they have the expertise. In real life, surgical interns may be involved for half an hour if the wound requires surgical debridement, but the days and months of followup dressing changes and prevention by patient repositioning would be solely nursing, not physician work. And the idea that physicians would spend the amount of time in a patient's room that the episode suggests is absurd.
The scene clearly indicates that physicians direct nursing work. Sloane assigns these tasks to the interns as if he would be responsible for having this work done. He also presents his decision not to involve nurses as within his discretion; presumably, he directs both interns and nurses. However, if anyone was going to direct someone to do this work, it would be a nurse. Of course, the scene has no nurse at all, much less a nursing manager. The scene thus reinforces the widespread misconception that nurses are merely physician subordinates, rather than members of a skilled, autonomous profession.
The scene clearly indicates that nursing work is an unpleasant punishment, as the show has done more than once in the past (see examples 1, 2, 3, 4). All the physicians involved clearly regard these tasks as drudgery that Sloane has made the interns do because they are "annoying" and not "good at their jobs." As Cristina suggests, these are things you have to do when you "piss off" your boss.
The scene implies that nursing work is of no real significance. There is no suggestion that, although unpleasant, the bedsore tasks are important to the patient's health. In fact, patients die of bedsores, and avoiding them is a critical nursing function, one made more difficult by the short-staffing that is now common. The show's contempt for this care is evident in every line here, but nowhere more so than in Alex's incredulous "Bedsores?"--which basically means, "oh no you didn't just tell us that we, brilliant surgical interns, will be made to waste our precious time on something as trivial as bedsores."
Sloane's claim that the nurses are "already good at their jobs" sounds like a compliment, but it's not. In fact, nurses, just like physicians, are not all "already good at their jobs." Like any other professionals, nurses develop greatly with years of experience, as Patricia Benner has explained in her novice to expert theory of developing clinical nursing excellence. The suggestion that all nurses are fully formed when they leave nursing school implies that nurses are fungible clerks. Why would first year nurses be any better at their jobs than these interns are at theirs? The show might have saved this comment by having Sloane suggest that Jim's nurses were all skilled veterans, but it didn't. The unstated assumption is that nurses are already good at their jobs because it really doesn't take much to reach that point. Humans take two decades to reach adulthood. Dogs do it in a year or two.
Sloane's statement that the nurses are "helpful" is another apparent compliment that actually reinforces damaging assumptions. Of course "helpful" is a good thing in general, and in a sense nurses do "help" physicians. But this comment in context suggests that nurses are helpful in the physician mission of providing all meaningful health care, rather than in providing nursing care pursuant to an autonomous scope of practice. And in general, "helpful" is pretty faint praise for life-saving, critical-thinking professionals with advanced health skills. Would anyone suggest that physicians, as a class, are "helpful?"
Sloane's statement that the nurses are "smart" is, at best, of little help. Even if the comment is taken as an honest expression of Sloane's views, it's jarringly at odds with everything the show has ever said and shown about nursing, and with the underlying themes of this scene itself. It just makes no sense, and we imagine veteran "Grey's" viewers looking at each other and going, "huh?" In fact, it's arguably insulting that the show would glibly present something so clearly designed to score points with nurses. Does it really expect this short, tossed-off scene to mollify nurses for all the show has done to convince viewers that physicians provide all significant care, including a lot of things nurses really do, and that nurses are bitter or fawning losers whose jobs don't matter? You can't counter many hours of drama with one word, any more than a small Dora the Explorer band-aid is going to fix the damage from a massive shotgun wound.

Given all of that, we really can't give the show much credit for this episode. But we do, as always, urge it to consider how it might actually show nurses being "smart" and "good at their jobs," in compelling dramatic scenes that would mean something to viewers. Perhaps nurse characters could do some of the exciting, important nursing tasks we commonly see the physicians characters do, like the 24/7 monitoring, patient education, and psychosocial care. That would be a way to start alleviating the great harm the show has been causing to public understanding of nursing for nearly two years.

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New Script Idea

Please see below for a powerful alternative idea for the scene with Dr. Sloane written by Mandy Mayling, RN, HN-BC, Director & Program Developer for Holistic Services Assisted Home Hospice, Home Health, & Private Duty, Thousand Oaks, California. Ms. Mayling's script envisions what might have happened if Seattle Grace actually had nurse managers.

INT: Hospital, patient 'Jim's' room. A woman, obviously a professional, wearing a smart suit or dress, arrives and stands in the doorway, behind the interns, a look of confidence and intent listening evident on her face, as Sloane, and the interns, have their dialogue about 'Jim's decubitus' treatments. When they have finished, Sloane walks toward the woman standing in the doorway; a pleasant curiosity expresses itself on his face. He tries to engage her with his smile, and piercing McSteamy stare.

Woman: (smiles warmly) I'd appreciate it if you'd run this by the nurses in the future. All intern activities affecting nursing care need to be documented and coordinated with the nurse case managers, or the RN floor supervisors. Dr... ?

Sloane: Sloane... And you are?

Woman: Maggie Jones.

Jones points to her nametag.

Sloane: You're a nurse? (Incredulously) Well, "Nurse Maggie" (sarcastically), I don't 'coordinate' my activities with nurses.

Jones: If you're going to call me 'nurse' Maggie, I expect you to add PhD to that title.

Sloane: Oh, so you're 'Doctor-Nurse-Maggie'? (smirks)

Jones: Doctor Jones will do just find, Dr. Sloane. (Looks him directly in the eye, holding her hand out to shake his, her confident smile still evident.) I'm the new nurse manager, and I expect a professional level of cooperation with the physicians here, and your interns. If you're personally unable to coordinate this, then I'll need you to ensure someone else does.

Sloane: Well, we'll see about that (He purrs condescendingly.)

Jones: Yes we will. (She leans into him, talking in a quiet, but serious tone) Your reputation with our nurses precedes you. Newsflash. I don't report to you, neither do the nurses. We are not at the beck-and-call of the physicians here, or the interns. We work with physicians, not for them, under them, or because of them. Your disdain, and lack of respect for nursing roles, our skills, education, expertise, and professionalism are just a few of the things you're passing onto your interns. Now, if you're looking for someone you can pat on the head, and who will acquiesce to being a 'smart, good, helper' someone you can order around, then I suggest you go and buy a dog! (Talking louder now -- smiling again, as Sloane tries to recover). I look forward to continuing this discussion in our next meeting.

Sloane: What meeting?

Sloane calls out as Jones begins walking away.

Jones: (Talking as she's walking.) The first of many meetings to discuss coordination and teamwork between nurses and physicians. Oh, and the upcoming rotation your interns will be assigned under nursing supervision.

Sloane: You can't do that!

Jones: It's already done.

Jones turns a corner and is gone.

The interns in the patient room have been looking on, listening to the interaction. Sloane turns and sees their expressions, a mixture of surprise and admiration on their faces.