The beck and call girls
"Private Practice" ends as it began, with physicians in command and nurses standing by, awaiting orders
January 22, 2013 -- Several recent episodes of ABC's Private Practice, including tonight's series finale, had a few scenes with strong, smart, articulate labor and delivery nurse Stephanie Kemp. And actress Justina Machado, who seems to have made nurse TV characters a career specialty, brought her usual dignity and likability to the role. We appreciate this rare effort by show creator Shonda Rhimes and the other producers to suggest that nurses are not necessarily idiots and that they can be skilled members of the health care team. However, it could also be argued that the Stephanie character was a last-minute Band-Aid on the gaping wound caused by the show's overall portrayal of nursing during its six-year run. Stephanie's skills appeared to consist almost entirely of anticipating physician needs and acting as an assistant to physicians; she displayed little autonomy and rarely interacted with patients. In this sense, she was not unlike the show's now-deceased Dell Parker character, a nurse midwife who often functioned more as an office manager or receptionist than a health professional. At the same time, the other nurses in these recent episodes were even more extreme versions of the show's usual handmaidens, coming off as clueless and/or terrified mice, meekly obeying physician commands and performing the kind of "wallpaper nurse" tasks seen on Hollywood shows like Grey's Anatomy, House, and ER for decades. By contrast, Stephanie was even worthy of a relationship with hunky heart surgeon Sam Bennett. But that romance followed the same trajectory as nurse-physician relationships on show creator Shonda Rhimes's earlier show Grey's Anatomy. For example, in 2008, Grey's surgeon Derek Shepherd's relationship with nurse Rose ended when he returned to surgeon Meredith Grey, and in 2011, Grey's nurse Eli's relationship with surgeon Miranda Bailey ended with her returning to an ex-flame anesthesiologist (who has since become a surgeon; on Grey's, even non-surgeon physicians are unworthy!). Here, Sam ultimately left Stephanie to return to his ex-wife Naomi, a physician fertility specialist. It seems that a few unusually skilled and feisty nurses deserve some basic respect. But let's not get carried away. On Private Practice, it's a physician's world, and the nurses just live in it.
Paper flowers
The October 23, 2012 episode ("You Don't Know What You've Got Till It's Gone") was written by Fred Einesman, a physician who also spent years as a medical advisor for NBC's ER. In this episode, we see that Sam has been dating Stephanie, played by Justina Machado, who also played nurse characters on CBS's short-lived Three Rivers from 2009-10 and even on HBO's Six Feet Under from 2003-05. At one point, we see Sam and nurse Stephanie making out in some kind of hospital storage room. Sam asks if it's safe; in response, Stephanie jokes that a security guard comes around every five minutes and "de-licenses every doctor he catches having sex." She says her break is over in 15 minutes so he better get busy. He does.
Meanwhile, Charlotte King, the hospital CEO / chief of medicine (it's not totally clear) is pregnant and having a lot of nausea, but she is evidently determined to carry on with her work. She hires a new emergency physician named James. He arrives at the busy ER and instantly takes over, giving emergency department (ED) nurses lots of commands, which they silently obey, because they would never know what to do otherwise. Before long, James disagrees with hotshot neurosurgeon Amelia Shepherd about whether an emergent patient needs more tests or can just make an appointment with Amelia for later. A nurse at an ED station overhears their discussion. After Amelia departs, James asks the nurse to get a CT scan for the patient.
Nurse: "But she just said--"
James: "And I said get the CT."
The nurse complies with a small smile; the hardest part of the job is deciding which physician to obey! In the end, James is proved right; good thing that nurse chose wisely.
Later, the show's main character, the elite OB/GYN physician Addison Montgomery, approaches Stephanie and begins to recite what she (Addison) will need to treat a patient, in that usual commanding TV physician way. But Stephanie is actually on the same wavelength.
Stephanie: BOA kit, delivery tray, and an [inaudible] just in case.
Addison (shocked): You're just . . . terrific. You know, you're one of the best labor & delivery nurses I've ever worked with, and I do not say that lightly.
One of the best of a group of people who mostly just say "yes, doctor"? Fantastic! Meanwhile, Stephanie is displeased to learn from Addison that Addison and Sam have been good friends since medical school, that they dated recently, and that they are now next door neighbors--yet Sam has told Stephanie none of that.
Later, a young girl is apparently abducted from the ED. Charlotte, who has suddenly involved herself deeply in ED operations, confronts the ED nurse who gave James the small smile earlier.
Charlotte: You're sure you didn't see a little girl in a purple raincoat.
Nurse: We've registered 30 patients in the last 2 hours. I can't possibly remember
one little girl.Charlotte: I doubled the staff out there. How could you miss her?
Nurse: Same way you did I guess.
This last bit may sound like it redeems the scene somewhat, but the actress delivers the line with little force. So the overriding impression is that nurses are basically flunkies looking to cover themselves, while physicians are the ones who really care about patients and who would take an active role in searching for a missing minor patient and re-assuring the angry parents. Of course, nurses would likely take the lead in that kind of search and in dealing with the family. Charlotte's assertion that she doubled staffed is plausible in her apparent role as CEO, though most viewers of this show will likely have their pre-existing belief that physicians generally direct nurse staffing reinforced; of course, there have been no real nurse managers on the show. And this is too much of a throwaway to tell viewers anything about real life understaffing.
Later, we see Stephanie again, this time in the ED, where she has apparently followed Addison to care for a pregnant patient. Stephanie is able to read the pregnant woman's monitor, and when Addison concludes that the woman will need a C-section, Stephanie notes that she has already checked for ORs and none is available yet. Later, in surgery, Stephanie reports vital signs.
As the episode winds down, Sam tries to make amends with Stephanie, but she's not having it. She says she's not the jealous type, but she lists all the things he failed to tell her about Addison. He claims he thought it would not matter because it's been over for four months! She asks why it ended, and he admits it was because he proposed to Addison and she said no. Stephanie admits that although she has no respect for women who fall too hard for men and act foolishly, with Sam she did think that the man of her dreams may have finally shown up.
Stephanie: But you're on the rebound, and you have a lot of baggage, and you're just a mess . . . aren't you? And because you are a heart surgeon who looks like you, and because you are a truly kind man with a wonderful spirit, I bet every woman who meets you thinks they feel the butterflies and the candy hearts and the paper flowers . . . Damn.
He is sorry and really does like her. She says, ironically, "because I'm fantastic." He agrees that she is. She kisses him on the cheek and says goodbye.
In these personal interactions, Stephanie is certainly conscious that she has been dating a godly physician ("thank you Jesus!") but she also displays dignity, strength, and social awareness; she is not going to debase herself to be with Sam. At the same time, in the more important clinical interactions, she is smart and highly skilled, "one of the best" according to none other than Addison Montgomery, who clearly knows all about nursing. Such generalized TV physician testimonials are rarely meaningful, although this one does at least follow a specific illustration of Stephanie's health knowledge. Still, Stephanie is really just a skilled health assistant, and her highest aspiration seems to be to anticipate Addison's needs. Stephanie provides no evident autonomous care, and she doesn't seem to be responsible directly to patients, only to Addison.
See the film clips from the October 23, 2012 episode in Quicktime at broadband or dialup speed.
Hands on
The December 18, 2012 episode ("Georgia on My Mind" by Jennifer Cecil and Barbie Kligman) has the rest of the significant clinical interactions involving Stephanie, and they reveal a similar mix of qualified admiration for Stephanie in the midst of the show's unqualified contempt for other nurses. The main plotline here is head physician Charlotte's excruciating bed rest experience as she waits to deliver the second and third of her triplets; the first baby has already been born and is in the NICU. In early scenes, Stephanie makes a brief appearance, displaying her usual expertise, in this case in starting an IV. But the other nurses caring for Charlotte are both incompetent--unable to start an IV correctly or even get a pillow--and absolutely terrified of Charlotte, who is, admittedly, even more arrogant and abusive than she usually is. We realize that this nurses-are-mice portrayal underlines Stephanie's comparative toughness and skill, but it doesn't do much for nursing to suggest that all but a few nurses are useless idiots.
The NICU scenes about Charlotte's other baby feature some of those suggestions too, along with a lot of physician nursing. 
Although in real NICUs expert nurses provide most of the skilled care, here two surgeons and Charlotte's pediatrician husband Cooper Freedman seem to do that. Surgeon Sam extubates the baby seemingly with no nurse in sight, though at the edge of the screen there is a bit of a shadow that could be one. And Sam explains the benefits of skin-to-skin care, the nurse-driven care practice that has evidently penetrated the Shondaverse, since Grey's also featured a scene with a surgeon explaining it a few years ago! Naturally, here as there, no nurses are involved in the kangaroo care.
Later, when Stephanie returns, Charlotte asks her if she likes her job. Stephanie says she knows some see nurses as frustrated doctors, but she likes being more "hands on." Charlotte says great, Stephanie will be her private nurse, because no other nurse there has a clue. Stephanie protests that she is "the floor manager" and "can't cater to just one patient." Charlotte, the big boss, says that she can now! 
And so it goes, apparently for the remaining weeks Charlotte is on bed rest. There is no discussion of how the nursing staff will juggle things while the "floor manager" is occupied with one patient. At one point, declining to answer Charlotte's questions about her romance with Sam, Stephanie admits that she is Charlotte's "beck and call girl."
Later, Stephanie notices that Charlotte's IV bag is emptying too fast. She figures, correctly, that it's because Charlotte messed with the magnesium drip to stop her contractions. Later, Addison arrives--evidently Stephanie has told her--and Addison locks the pump! Of course, in real life, physicians don't know how to use these pumps well enough to adjust the rate, never mind to find the obscure pump-locking mechanism. Nurses, not physicians, administer medications. 
Charlotte is furious that Stephanie ratted her out and tries to fire her. Stephanie basically says that's fine, and good luck to Charlotte, because no one else there can stand to take care of her. We're left to conclude that Stephanie will remain and that she has stood up to Charlotte when that needed to be done. It also appears that Stephanie has acted in Charlotte's best interest--as a patient advocate--in ending her manipulation of the pump.
Meanwhile, a nurse character actually surfaces in the NICU, but not in a good way. Cooper seems to be doing a better job of monitoring his NICU baby than the there nurse is, and he identifies an apparent problem. The nurse reassures Cooper blandly and says she will make a note on the chart and let the attending know. But Cooper reminds her that he is a doctor and orders her to "get the damn tests, now." She slinks away. The tests show Cooper is correct that the baby has a problem--pneumonia. The baby goes back on the ventilator, and later, surgeons Addison and Sam, who seem to be in charge of monitoring the baby, operate. This NICU nurse is an unskilled lackey, unable to assess or discuss symptoms, able only to notify the attending to whom she presumably reports and to scurry away in fear when confronted with physician authority in the form of Cooper. Sadly, on those rare occasions when NICU nurses do play any significant role in NICU nursing on Hollywood dramas, they tend to be clueless idiots or obstructive battleaxes.
Meanwhile, Charlotte continues to freak out about her threatened babies, and at one point apparently suffers incontinence. Stephanie handles that with seemingly effortless professional compassion, calmly discussing other matters as she does so, and thus she preserves Charlotte's dignity. Later, a grateful Charlotte engineers a reconciliation between Stephanie and Sam, noting that Stephanie is "a woman worth fighting for." When Charlotte's water breaks and she on the way to deliver, Addison gives instructions to Stephanie about what set-up will be needed, including a NICU team, and Stephanie absorbs that information without significant comment.
Stephanie's limited scenes include quite a variety of messages about nursing. She is of course highly skilled and tough, more or less giving it back to Charlotte as much as can be expected. She is smart and savvy enough to have deduced what Charlotte was doing with the IV pump. And her managing of the incontinence is pretty impressive, a Nurse Jackie-like display of professionalism overriding personal loathing. Stephanie's statement that she prefers to be a nurse instead of a physician because it's more "hands on" is fair enough, at least implying that it's not because she lacks the required intellect. And her clear rejection of medicine is a step forward from that of nurse Dell Parker, whose early death was presented as being even more tragic because he had just been admitted to medical school, as if that was every nurse's aspiration.
However, the show's suggestions about nursing autonomy are, as usual, troubling. Stephanie tells Charlotte that she is the "floor manager," which implies some kind of nursing management structure. But without any explanation or actual nurse managers on the show, this is a throwaway that won't mean much to viewers. And Charlotte overrides all that because she is the chief of whatever. Thus, Stephanie becomes her "beck and call girl," a joke that captures the actual subservience of the show's nurse characters pretty well. Indeed, while the pump tampering incident is a fine showcase of Stephanie's knowledge, her tattling to Addison instead of managing the situation directly implies that nurses report to physicians and physicians do everything that matters. And right to the end, Stephanie still calls Charlotte "Dr. King."
See the film clips from the December 18, 2012 episode in Quicktime at broadband or dialup speed.
Goodbye
The January 22, 2013 series finale ("In Which We Say Goodbye" by Shonda Rhimes) wraps up the series and the Stephanie-and-Sam romance. The finale focuses on lead character Addison's marriage to her boyfriend Jake (guess what? a hotshot physician!). On the wedding day, Addison's old friend and former major character Naomi Bennett returns from New York (guess what? a hotshot physician!). Naomi is also Sam's ex-wife and they have a grown daughter. Stephanie attends the ceremony with Sam. Naomi tells Sam that Stephanie "seems really nice" and Sam agrees that she's "nice." But it's clear Sam and Naomi still have a thing for each other, and before long they are having sex in a handy nearby hotel room.
Some 13 weeks after the wedding, Naomi returns to LA, pregnant because of her liaison with Sam. Naomi denies that she still loves Sam. Addison is unconvinced and confronts Sam about whether he loves Stephanie. Sam waffles. Addison tells him that Naomi still loves him. Sam later tells Stephanie that she was right to break up with him before. Stephanie gets it quickly.
Stephanie: I'm going to go now because I do not want you to see me cry. . . . Sam, you're a good guy, but let me give you a little advice. The next time you try to get a second chance with a woman, you better mean it, because we're not as tough as we look, OK? . . . And I liked her. Your ex-wife, when I met her, I liked her. And now I'm crying. And now you're gonna come over here and comfort me, and . . . I hate you.
But still, her head is on his chest, because he's such a good guy! In New York, Sam barges into a big business meeting to tell Naomi he still loves her, in a Jerry Maguire moment. They re-marry.
In fairness, the show allows Stephanie some basic dignity, just as Grey's did for nurse Eli when surgeon Miranda Bailey was dumping him for a physician. Stephanie is savvy, articulate, and strong. But of course, she is ultimately unworthy. Nurses may be "really nice," but they really aren't marriage material for physicians. Don't get us wrong; having a nurse character actually marry one of these physicians would be no real mark of respect for nursing and could even reinforce the stereotype that nurses are desperately seeking those arrangements. It's just that the pattern we do see in these influential products shows disdain for nursing.
On the whole, the depiction of nursing on Private Practice remained deeply flawed till the end. With only occasional exceptions, the show's 111 episodes presented millions of viewers with a portrayal of health care in which physicians did everything that mattered, including key tasks that nurses do in real life, while the nurse characters who did occasionally appear tended to be meek handmaidens with no apparent expertise. Stephanie and Dell Parker were not idiots and they even displayed some health skills. But in the end they were pretty much physician helpers, and they presented no real challenge to the show's awful overall vision of nursing.
See the film clips from the January 22, 2013 episode in Quicktime at broadband or dialup speed.
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