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Nurse, fetch me the ball.

November 15, 2007 -- Today, nurses persuaded Seattle's Group Health to withdraw ads for its "Ask the Doc" service that included the tag line: "Nurse, hand me my laptop." The ads, posted on websites such as, promoted Group Health's program of having patients communicate with advanced practitioners by e-mail, instead of having to come in to the office for simple follow-ups or questions. We commend Group Health for using such a cost-effective care delivery system, and we get the "joke"--laptops are the new stethoscopes. But the ads' regressive text and imagery suggest that: (1) nurses are nameless handmaidens who fetch and carry items for physicians, rather than autonomous professionals who follow an independent practice model; (2) nurses' role in advanced care technology consists mainly of handing it to physicians, though in reality nurses are on the cutting edge of such technology; and (3) nurses lack substantive health information, and their role is to help patients reach the physicians who do have the expertise. In fact, nurses are the main patient educators, and nurses at Group Health itself regularly communicate with patients by email. We applaud Carolyn Elliott, Stephanie Hitzroth, Shari Hirshberg and their nursing colleagues for persuading Group Health to do the right thing.

The ads (below) showed a smiling male physician's head graphic over the main "Nurse, fetch me my laptop" text, with "Click here to Ask The Doc" in the corner below. This is a play on the media's traditional image of the nurse-physician interaction in which the nurse exists to hand tools to the physician, so the physician can save lives. Of course, tools can change--and the joke here focuses on that change in the digital era--but the ad clearly embraces longstanding assumptions about nurse-physician relations. According to these inaccurate assumptions, physicians are the smart, powerful providers of all important care, including vital health advice, whereas nurses are their servants, who are to be faithful and attentive to the physician's needs, but not to worry about the substance of care or technology, e.g., what might actually be on the laptop.

These are damaging distortions. In fact, nurses are the primary patient educators. Indeed, many nurses practicing at Group Health itself are in the consulting nurse service and they regularly communicate with patients via email (see below). The Group Health website even states that nurses communicate with patients via email. In addition, advanced practice nurses such as Nancy Knudsen, a Pediatric Nurse Practitioner, presumably communicate with patients through the "Ask The Doc" service just as their physician colleagues do--though the name "Ask The Doc" itself ignores APRN contributions, as do countless public communications by large health providers ("just dial 1-800-DOCTORS!").

The assumptions the Group Health ad makes with regard to nurse-physician roles are also pernicious. Despite the "joke," the physician in this ad is clearly giving an order, strongly reinforcing the traditional view that nurses report to physicians. This characterization of the relationship between physicians and nurses is inaccurate and harmful to patient care. Nurses do not report to physicians. Nurses have ethical duties to patients, not physicians. Physicians may write prescriptions (the term we prefer to "orders") for medications, tests or treatments, but these are requests--not commands. For instance, if physicians prescribe medications, nurses are duty bound to check if administering the medication as prescribed will be in the patient's best interest. If not, nurses consult with the prescribing colleague to suggest a better course of action, and, if necessary, take other steps to protect the patient. Unfortunately, many if not most media depictions of nurse-physician relations still reflect the tired notion that nurses exist to serve physicians, like loyal dogs. Even some nurses protest handmaiden depictions by claiming that nurses don't serve physicians now like they used to. Of course, nurses once had less social power relative to physicians than they do now, and a high level of deference was often required, but we do not believe excellent nursing care has ever involved blind obedience to physicians.

Group Health nurses, understanding these dynamics, asked their leaders to reconsider the ad. Carolyn Elliott, RN, MN, MSCIS, of Group Health's Consulting Nurse Service, wrote a message reading in part:

I am writing to express to you the absolute dismay I experienced when I saw a banner ad on for Group Health. ... One of the biggest blocks to the recruitment of nurses is the public's perception that nurses do not have a professional role in providing healthcare. (See the website for the Center for Nursing Advocacy.) This perception is fueled by Hollywood's portrayal of nurses as handmaidens. ... Regardless of the humor that is attempted and the message that GHC provides 21st century health care, there is also an accompanying message that nurses are no more than handmaidens to physicians. [This] can be truly damaging to the general public's perception of nurses, particularly when the portrayal is not by Hollywood, but by a respected health care provider.

I also would submit to you that in an age of a documented nursing shortage, there are nurses who will now not consider working for an organization that apparently regards nurses in such an unprofessional manner and devalues their knowledge and skills.

Ms. Elliott did not address whether her two master's degrees gave her the skills needed to hand physicians laptops.

One Group Health executive responded to the concerns of Elliott's colleague as follows:

I appreciate hearing feedback on the ads, and I do apologize that you and other nurses found this simple ad offensive. As I mentioned in my previous email, humor is subjective and we know that we can't please all people all the time. I am hopeful that you and others can let this go and we can all remember that we're all on the same team, trying our best on behalf of Group Health.

This is an excellent example of the kind of response nursing advocates tend to hear from corporate advertisers, especially from those in marketing positions. Note the failure to address the specific problems identified, the implication that those complaining are just hypersensitive, and the reliance on no-content defenses, like that "humor is subjective." However, the nurses were not complaining about the "humor," but about the messaging that was embedded in the ad aside from the humor. If a "joke" clearly used harmful stereotypes about a dispossessed group, it would be no defense to say that it was just a joke. Things can be jokes and reinforce damaging stereotypes. The executive also cannot seem to conceal her annoyance that the nurses have the gall to complain. Consider the reference to the ad as "simple"--as if the nurses were silly to complain about something so basic. Of course, most abusive epithets are simple too. And we also liked the executive's hope that the nurses "can let this go" and be team players and remember everyone is trying--as if good intentions would prevent the ad from causing harm.

Fortunately, Group Health CEO Scott Armstrong decided to pull the ad. While Armstrong declined to get into the specifics of the ad, he did note that he "respect[ed]" the reactions of the nurses and their sense of how the public would perceive the ad.

We thank Group Health for reconsidering its use of this ad, and we commend the nurses who advocated so effectively to make that happen.