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Dear Readers:

Below is our review of the first episode of Showtime's new television show Nurse Jackie. Please consider that what Nurse Jackie says about nursing is far different from what it is saying about its main character. We urge you to keep an open mind and watch the show in full. We know not all readers will agree with our review. Even so, we are hoping that nurses will use the show as a vehicle to teach friends, family and society what nursing is, what nursing is not and what nursing could and should be. A powerful, critically-acclaimed nurse-centered television show has been a long time coming. Let's use what we can from it to change how the world thinks about nursing. Thanks for tuning in.

Sandy Summers, Executive Director, The Truth About Nursing

 

The Henchman of God

 

Make me good, God. But not yet.

St. Augustine; Nurse Jackie

Nurse Jackie 
June 8, 2009 -- Tonight's series premiere of Showtime's "dark comedy" Nurse Jackie is a brutal subversion of the unskilled angel stereotype. The first significant nurse-focused show to emerge from Hollywood in more than 15 years, Nurse Jackie may be the strongest--though not most positive--fictional TV portrayal of a modern nurse that we have ever seen. Jackie Peyton is a New York City ED nurse. Like esteemed TV physicians Greg House (Fox's House) and John Carter (NBC's ER), Jackie is a high-functioning drug addict. But she is also a tough, life-saving nurse who works at the center of patient care, and the show is unusually alert to what nurses experience. Jackie displays formidable clinical expertise, advocates forcefully to save a patient from an arrogant young physician (though she does not save that patient), and provides adroit psychosocial care to patients and families, as well as tough love mentoring to an innocent nursing student--and the physician. Also, she is a major wit. Jackie is not a role model in some respects. To treat a bad back, she takes powerful painkillers that she gets illegally from her pharmacist boyfriend. She has sex with him in the hospital pharmacy. She forges an organ donor card after a young patient dies. She flushes a diplomat's severed ear down the toilet upon learning that he will not be prosecuted for a vicious assault on a prostitute. She steals a wad of the diplomat's money and gives it to the organ donor's impoverished, pregnant girlfriend. And viewers may not get that it was her job as a nurse (not just as Jackie) to protect her patient from the physician; they might wrongly assume that physicians are ultimately in charge of patient care, and Jackie is just unusually assertive. But nothing else here reinforces the stereotypes pull out quote Nurse Jackiethat have led the public to undervalue nursing. Jackie is deeply flawed, like real people, but she is not a brainless physician helper, a naughty nurse, or an angel, though the nursing student calls her a "saint." Since Jackie seems to leave few Commandments unbroken, "God's rogue henchman" might be closer to the mark. She is like a Jack Bauer (24) of the ED (Jackie Bauer!), an extraordinary operative doing things she has no real right to do so she can achieve her vision of social welfare. Still, there is more intelligent life in this pilot than in a whole season of some hospital shows, and Jackie may well end up as one of the most important fictional nurses in history. The episode was written by series creators Liz Brixius & Linda Wallem and Evan Dunsky.

Watch the first episode online (the password is "shift happens")

WARNING: SPOILERS AHEAD

The story so far -- plot summary

Jackie is an expert nurse at the center of patient care

Nurse Jackie breaks stereotypes

The episode's depiction of nursing has flaws, but they pale in significance to the good the episode does in countering misimpressions people actually have about nursing

Jackie is addicted to drugs

Jackie makes an impression on the physicians

Is Hollywood allowed to present a major gay male nurse character?

Jackie might be naughty, but she's not a naughty nurse

Is Jackie a battleaxe--or just caught in a battle?

Is there a saint at All Saints?  

Final thoughts

Please tell us--and the producers of the show--your thoughts on Nurse Jackie

 
The Story So Far -- plot summary

Because much has been made of some elements in the Nurse Jackie pilot, we'll start with a fairly detailed plot summary, to ensure that the context for these elements is clear. (Or skip straight to our analysis.)

The episode begins with a somewhat surreal scene featuring Jackie (Edie Falco), in a traditional white nursing uniform with cap, lying on the floor of a rest room with a pill bottle in her hand, as Dionne Warwick's "Theme from Valley of the Dolls" plays (featuring lines like "Need to get off of this ride"). However, Jackie's voiceover is not druggy, but razor sharp. She quotes T.S. Eliot:

Let us go then, you and I
When the evening is spread out against the sky
Like a patient etherized upon a table.

She salutes the 10th grade teacher who told her that those with the greatest capacity for good are also those with the greatest capacity for evil ("smart f---ing nun"), and jokes to herself, "What do you call a nurse with a bad back? Unemployed. Ba-dum-bum." (Actually that's not necessarily so, given the many nursing scholars, managers, and public health professionals; the misconception that nursing consists only of physical bedside care is a damaging one.) Then, we see the type of short drug interlude that will recur as a divider for some of the episode's longer scenes, as pills tumble onto a hard surface in extreme close-up, and Jackie, in modern solid scrubs, snorts them.

Jackie's first patient is a young bike messenger, Peter Donovan, who has been hit by a car. Enter Fitch Cooper ("Coop"), an arrogant young physician who approaches the patient while talking to a friend on a Bluetooth. Coop actually bumps Jackie aside to get to the patient, speaking in hackneyed man talk (e.g., calling the patient "chief"). Jackie states:   "Head struck, open tib fib, pulse is weak and thready." She tries to engage Donovan, asking him if he has pain. He denies it, but is not fully responsive; he can't show her two fingers when she asks. Actually, Donovan barely seems to register that Jackie (who is, after all, just a nurse) even exists, but he is able to suggest that Dr. Cooper should get an iPhone. Coop, somewhat distracted by his personal communication device issues, simply asks for orthopedics. Jackie assesses the patient's pupils, then speaks to Coop privately.

Jackie:   Blood in the ear. Let's check for glucose, rule out CSF, all right? This guy needs a scan.

Coop, laughing:   I know what I'm doing. Jesus, bossy. That leg's f---ed up.

Jackie:   Ortho, seriously? He's got a bleed, I'm telling you right now.

Coop:   He's totally lucid, 100%. (To the patient Donovan) Knock knock.

Donovan:   Who's there?

Coop concludes they just need film on the leg, tells Donovan they'll fix him up "real good," and takes off.

We cut to an image of Jackie standing next to Donovan, who is now dead. Jackie speaks in voiceover.

Jackie:   Acute subdural hematoma. The brain puffs up so fast it rips the blood vessels and you bleed to death inside your skull.

Jackie calls a transplant team, assuring them Donovan was a donor, pressing them to come immediately. Then she forges his signature on the donor card, assuring the patient that his death may have been a shame, but it will not be a waste. We see Jackie talking to the messenger's family. It consists of a mother who seems surprised her son was a donor, and the patient's brothers, a police officer and firefighter who bicker over where their dead brother's expensive bike is, and the irony of his death on the bike when they both worked 9/11 and came through unscathed. But they are clearly distraught, and Jackie practices what one nurse chaplain recently described as "deep listening."

Jackie confronts Coop, who displays no concern that his patient has died needlessly:

Jackie:   What you can do for me is this. You can stay the f--- out of my way, that's what you can do for me. What I need is for you to know that I know you. I have seen hundreds of you jerk-offs blow through these doors. You graduated, what, top 10, top 5% of your class? Test scores through the roof? But a total f---ing retard when it comes to actual patients? I know you. I just had to sit there and look that kid's mother in the eye and tell her that we did everything we could, you dumb sh--. That was my patient. I told you he was slipping, and he was. When I tell you to order a scan, you order a goddamn scan, because if you don't do it, I'll just go to the next doctor, and the next doctor after that. In the meantime, that kid died, and it is all on you.

Coop reaches out and grabs Jackie's breast, not hard. His hand stays there.

Jackie:   Is this happening, not happening? I can't even tell.

Coop seems to wake up, removes his hand, and is extremely apologetic, claiming he has a condition similar to Tourette Syndrome, but his involves inappropriate sexual touching when he gets nervous. Jackie does not look convinced, but she seems completely unfazed by Coop's action. It doesn't seem likely that he really wanted to do what he just did either, so the show leaves it there.

As Coop is helpfully assuring Jackie that he is not attracted to her, Eleanor O'Hara, a snarky British physician who is apparently Jackie's best friend, pops in. Eleanor tells Jackie that the "wicked witch" (evidently the nurse manager) is looking for Jackie. Jackie is obviously going to try to avoid that interaction. As she escapes down a hallway, she runs into another snarky close friend, Mohammed "Mo-Mo" de la Cruz, a veteran nurse. Mo-mo has with him Zoey Barkow, apparently a first year nursing student at a local community college, though it seems unlikely a first year student would have as extensive a clinical role as Zoey has here. Mo-mo holds Zoey up by the sleeves of her scrubs like she is a goofy piece of clothing he wants to show Jackie. Calling Zoey "fresh meat," he says it's Jackie's turn to handle Zoey since he took the last three.

The nurse manager, Gloria Akalitus, arrives.

Akalitus:   "These hours, Jackie. All Saints Hospital and its myriad subsidiaries do in no way endorse 80-hour weeks from its nursing staff. After 12.5 hours, nurses are 3 times more likely to make mistakes."

Jackie:   "Lies, Mrs. Akalitus, lies!"

In the next exchange, Akalitus asks Jackie to do a double shift on the following Monday.

Zoey quickly annoys Jackie with meaningless jabber. Jackie flatly tells her to shut up:   "I don't like chatty, I don't do chatty, I like quiet. Quiet and mean, those are my people."

Later, we see Jackie having sex in the pharmacy with Eddie Walzer, her pharmacist boyfriend. But they have to stop because of her bad back. After they get her to a cot where she can rest, she at first refuses the drugs he offers, then allows that "maybe a little Oxy" will help--a "no-thanks-well-maybe-a-little" reaction we will see from her again.

Next, Jackie--with only Zoey helping--receives a seriously injured patient from paramedics. The patient is a female prostitute with many stab wounds inflicted by a client. As they roll the gurney down the hall, the paramedic gives Jackie a severed ear, telling her the patient got the blade away from him and cut his whole ear off. Jackie: "Good girl." (This must be another example of her people.) Jackie gives the ear to Zoey and tells her to put the ear on ice. Zoey stops and seems uncertain. Without even looking back, Jackie calls down the hall: "Puke away from the ear, Zoey." Zoey follows this instruction.

Later, Eleanor takes Jackie to lunch at a posh hotel restaurant. Few settings would seem to fit the scrubs-clad Jackie less, but she is, again, unfazed. She tells Eleanor that Coop is dangerous: "He killed a bike messenger today." Eleanor tells Jackie, facetiously, that she is a tattle-tale.

Jackie:   What do you doctors have against healing people, for Christ's sake?

Eleanor:   Ah, yeah, you see that, that right there, healing, helping, fixing. Fantastic! That's why you're a nurse. (As she butters her bread.) When I was a little girl, I took a butter knife and opened up a dead bunny, to see how it worked. That's why I'm a doctor.

Jackie claims Eleanor cares as much as she does; Eleanor denies it, and says Jackie is the only sane one in the "f---ing asylum" (the hospital).

An older woman at a nearby table starts to choke. Eleanor and Jackie barely look, but they begin trying to get out of being the one to help, as if the choking woman were a baby that needed changing. Still, as Jackie notes casually, "Four minutes till brain damage." Finally, Eleanor starts to get up, but Jackie says she has it, since Eleanor is buying lunch. Jackie walks over to the woman, does the Heimlich maneuver with virtually no effort and dislodges the food, pats the woman on the back, then sits back down. Although Jackie just saved the lady's life, those at the lady's table barely seem to notice Jackie (recall that the doomed bike messenger reacted to her in a similar way).

Eleanor (turning to another table):   I think it's marvelous the hotel has a nurse on duty.

Later, paramedics hand off a new patient to Fitch Cooper.

Paramedic:   "16-year-old-male.   Shot a Roman Candle out of his ass.   Third degree burns of his scrotum and peri-rectal area."

Coop wants two things: an open GYN set-up and Jackie. In the room, the patient tells Jackie it's OK to laugh. She says, "No one's laughing, honey." Coop tells the patient his first goal is to get him out of pain. Jackie informs Coop (correctly) that the kid is totally loaded and not in any pain. Coop asks the kid what drugs he took, but the kid says he can't remember.

Jackie:   Hennessey and hypnotic? Smokin' a little kush?

Kid (laughing):   Yeah; how does she know?

Coop:   Because she's seen a hundred of you jerk-offs blow through these doors.

Jackie:   I have been exactly that drunk myself, because I used to drink a lot.

She also assures the kid she never drinks now:   "I like to have a clear head." Uh-huh.

Mo-mo shows up with Beth, the bike messenger Peter's very pregnant girlfriend. Beth is confused, saying that Peter never said he was an organ donor. Jackie does a good job of assuring her she is sorry, she understands the great loss, but that Peter will be a hero now, his body will save lives. Beth seems to accept that, but then says she wants his heart, or a kidney, to sell to rich people. Jackie says it doesn't work that way.

Beth (angry):   Doesn't he owe me that? For getting himself killed on that goddamn bike?

She is crying, and so broke she's not sure how she will get home. Jackie comforts her expertly, and Beth puts her arm around Jackie.

Later, Jackie sees that a patient has arrived without his ear; the police tell Jackie that he is the one who cut the prostitute, but he will not be prosecuted because he is a Libyan diplomat with immunity. Jackie provides care for the diplomat, who is impatient, wanting to know how long it will take. Jackie informs him, evenly, that the woman he cut took 287 stitches and 10 pints of blood. He claims that she likes to cut herself; American women are "very adventurous." Jackie plays along, suggests it must have been the woman's idea, she probably did it for attention! She picks up a wad of bills he has dropped with his pants and replaces them in his clothes. Then Jackie goes to another room, finds the diplomat's ear, takes it to a nearby bathroom, tells it "f--- you," and flushes it down the toilet.

Jackie and Mo-Mo converse in the hospital chapel about a painting there showing John the Baptist's severed head (get it? severed, severed). They muse on the benefits of dating a man without a torso. Mo-Mo segues this into a short rant about his unfaithful boyfriend.

Jackie tells Mo-Mo they could have saved the messenger kid. He is silent. She says, this is where you jump in and say I did everything I could, it's not my fault. Mo-Mo asks if she wants him to say that. Jackie asks if he believes it. Mo-mo asks if Jackie does. Silence. Out of his line of sight, she shakes head ever so slightly.

Later, Zoey asks Jackie another question.

Zoey:   Do you think there's a finite amount of pain in the world? Like if I take a thorn out of someone's hand, does that pain have to go somewhere else?

Jackie:   Yes, that's why there's drugs.

Zoey:   Like maybe God said, here, I want this much suffering to exist in the world. You people can sort it out any way you want, but I want exactly this much suffering.

Jackie: That's interesting. That would make Him kind of a prick, though, wouldn't it?

Before leaving, as Jackie adjusts a patient's IV, Zoey tells Jackie she thinks Jackie's a saint. Jackie stares at her. After Zoey leaves, Jackie suddenly notices that she has made an error with the patient's IV, and she frantically rips the tubes out of the IV machine. She is very upset, kissing the unconscious patient on the forehead and confessing: "I almost killed you."

Later, ending her long shift, Jackie finds poor, pregnant Beth, the messenger's girlfriend, sleeping in a waiting room. Jackie gets the wad of cash from the diplomat's clothes, along with what appear to be her own boots. She places the boots next to the sleeping Beth and tucks the cash into Beth's bag.

On the way out of the hospital, Jackie meets Eddie, the pharmacist. He gives her a Dr. Pepper (nice touch), a moon pie, and Vicodin, and she seems genuinely touched. She gently declines an offer to go over to his house. They tell each other they love each other.

As Jackie walks toward home, she waits for a light next to an unhelmeted bike messenger. She tells him to be careful. He says:   "F--- you." As he leans to the other side of his bike to adjust something, she punctures the tire of his bike, which he does not notice, and he rides off.

Jackie nears her modest rowhouse.

Jackie (VO): If I were a saint, which maybe I want to be, maybe I don't, I would be like Augustine. He knew there was good in him, and he knew there was some not-so-good. And he didn't want to give up his earthly pleasures before he was good and ready. Make me good, God. But not yet. Right?

Jackie enters her home, gives her two beautiful, happy daughters Eddie's moon pie to share. She walks toward the kitchen, putting a ring on her finger, and then greets her wonderful husband in the kitchen. He says:   "Hey babe, I made pancakes for dinner. How great is that?" She smiles.

Jackie (VO): It bears repeating. Make me good, God. But not yet.

  
Jackie is an expert nurse at the center of patient care

The pilot episode of Nurse Jackie powerfully and relentlessly counters the most damaging stereotypes about the nursing profession:   that nurses are mindless physician flunkies, that they are largely irrelevant to serious health care, that they are silly bimbos, and that they are unskilled angels who just do scut work. No one could ever imagine Jackie Peyton falling into any of these categories, and even after just one episode, she is among the most compelling TV nurse characters ever. Coincidentally, she has the same surname as one of the most clinically expert and formidable nurse characters on ER, the nurse manager Eve Peyton, who appeared in several 2005 episodes.

  
Nurse Jackie breaks stereotypes

The pilot does many things right that other Hollywood shows have rarely, if ever, done.

  • Jackie displays clinical expertise without a trace of pretense.
     
  • Jackie saves lives with so little effort it's almost offhanded, as at the hotel restaurant.
     
  • Jackie takes ownership of her patients.
     
  • Jackie knows or investigates what's wrong with patients, what their hidden injuries are likely to be, what drugs they probably took--even when physicians don't.
     
  • Jackie advocates strongly for patients.
     
  • Jackie is no handmaiden to physicians.
     
  • Jackie is unlikely to blurt, "Yes, doctor! Right away, doctor!"
     
  • Jackie talks to family members about serious things.
     
  • Jackie is the one who provides expert psychosocial care to patients and families, just like in real life.
     
  • Jackie talks to other nurses, constantly.
     
  • Jackie gets ambulance admits directly from paramedics.
     
  • Jackie teaches junior physicians and nurses--yes, some nurses are more skilled than others, just like real professionals in other fields.
     
  • When Jackie makes mistakes (as with the messenger or the IV near the end), patients can die. Just like with physician care.

The pilot is like 28 minutes of the best ER nursing scenes, with edgier and funnier writing. We could go on and on about how helpful it is to have a compelling, witty, tough, expert nurse character at the center of a high-octane premium cable show, a character who instantly invites comparison to the Jackie Peytonfew really strong major nurse characters in recent decades of Hollywood television, including Margaret Houlihan of CBS's M*A*S*H and Carol Hathaway and Sam Taggart of ER.

But we know that what many people really want to know is, what about all Jackie's negative qualities?!? Initially, we would note that what the show says about Jackie is not necessarily the same as what it says about nursing. If a nursing character's trait reflects a common stereotype, then it is fair to ask whether the show is simply reinforcing that stereotype without much thought. In general, Jackie's negative qualities are all her own (unlike, we might add, Houlihan, who had her battleaxe and naughty nurse elements). It seems to us that nursing will benefit far more from the positive things that the show has the potential to fix in the public's mind--that nurses are intelligent, expert, savvy life-savers who play a central role in patient care--than it will suffer from association with Jackie's flaws, none of which really reinforces stereotypes the public now has of the profession.

Before we get to all the issues some nurses have with the show, we'll discuss the issues we have.

 
The episode's depiction of nursing has flaws, but they pale in significance to the good the episode does in countering misimpressions people actually have about nursing

Perhaps the most troubling aspect of the episode's portrayal of nursing is whether viewers will understand how responsible Jackie is as a nurse for the messenger's death, and that it was her job as a nurse to save the patient from Coop's ignorance, because she is an autonomous professional who does not report to him and has independent legal and ethical responsibilities to the patient. Obviously Jackie is no shrinking violet, but several aspects of the episode send at best mixed messages about nursing autonomy and nursing duties. Jackie does tell Coop that the messenger was "my patient," and it's pretty clear, especially from her chapel discussion with Mo-Mo, that she knows she should and could have done more to save him. On the other hand, she tells both Coop and Eleanor that the death is all on Coop, that Coop killed him.

That is not so. Coop and Jackie share responsibility for the messenger's death, because both are legally and ethically bound to a certain standard of care. It is very possible, if not likely, that viewers will come away with the sense that Coop is ultimately in charge and ultimately responsible. Jackie does refer to the "next physician" she might have gone to--apparently the physician over Coop's head--but that is still consistent with physicians being in charge. Of course, nurses sometimes need physician or nurse practitioner prescriptions to get what their patients need, but this does not make them subordinate. We do meet the "wicked witch" nurse manager Mrs. Akalitus--who at least in this brief appearance veers toward caricature--but her job here seems to be making schedules and ironic remarks. It's hard to imagine a viewer seeing her as a clinical authority based on this episode.

And speaking of Akalitus, the pilot also lets us know that Jackie works dangerously long hours, with the winking encouragement of Akalitus, whose comment about research on nursing errors comes off as a minor joke. Jackie's response ("Lies!") is funny, but the reality is that research shows excessive hours can lead to deadly errors--like Jackie's own near miss with the patient IV at the end of her long shift. Is that near miss a subtle rebuttal of the earlier exchange between Jackie and Akalitus, neither of whom took the problem very seriously? If so, it's not clear how many viewers will put all that together.

The organ donation plotline is also somewhat troubling. Research has shown that serious misportrayals of organ donation on TV dramas (like ABC's Grey's Anatomy) actually have a negative effect on public views toward organ donation. When people think the relevant rules are not rigorously enforced--for instance, that health workers might take organs without patients' permission, or when they are not clearly brain dead--then people are less likely to consider becoming organ donors. Here, it does not appear that the bike messenger had expressed a view one way or the other about donation. Jackie makes the decision for him. The show presents this as saving many more lives, in a sense redeeming the messenger's death, but in this vaguely Christian scenario (in dying He restored our lives), Jackie is getting dangerously close to claiming a divine role. It may be that Jackie believes the messenger could not possibly care now that he is dead, but she is obviously discounting what his views on this may have been in life, which many people think does matter. Even leaving that aside, if viewers believe an ED nurse could simply make this happen at will, they may well distrust and avoid the whole process.

So nurses have reason to be uneasy about Jackie's flaunting of ethical rules with regard to the organ donation, as well as her discarding of the diplomat's ear and giving his money to the messenger's girlfriend. She does not have the right to make those decisions, and it is not impossible that some viewers may wonder if nurses should really enjoy the trust they do--something that is very important to real nurses. Will a nurse give me worse care if she thinks I'm a really bad person? Well, some nurses, being human, might do that. At least so far, we think the damage to nursing from Jackie's rule-breaking is likely to be minimal. None of these actions reflect nursing stereotypes, and the show presents them in a highly sympathetic way--many viewers are likely to agree with what Jackie did, even if they sense that it violates rules. Here again, the practical effect is likely to associate Jackie more with mavericks like Greg House and Jack Bauer. Of course there are reasons to question the actions of such characters, but given the prevailing views about nursing today, we doubt association with their traits will damage the profession much.

  
Jackie is addicted to drugs

Like the brilliant lead physician in House and the beloved John Carter of ER, Jackie is addicted to the drugs she takes to relieve physical pain. Many nurses have expressed concern about the show because of this, but for the most part we don't share that concern. First, drug addiction is simply not a nursing stereotype. On the contrary, in Hollywood as in real life, addiction can and does affect anyone, including the esteemed physician characters above (and Jack Bauer, incidentally). It's true that ER 's Abby Lockhart--both a nurse and a physician--was an alcoholic, but she certainly suffered greatly from her condition while practicing as a physician in the show's final years. And like Jackie, all these heroic physician characters were on drugs while at work. Did it endanger their patients? At times it probably did--as it would in real life. In the pilot, there is no indication that Jackie has made an error due to her drug use.

It's also the case that substance abuse is a major problem for real nurses. The show did not simply invent something with little factual basis, like the naughty nurse, or the idea that many nurses dream constantly of being physicians. In fact, Mary Ann B. Copp's extensive April 2009 report in RN magazine described substance abuse by nurses as a "quiet epidemic." Of course, as that report confirmed, nurses work in a profession that is extremely stressful both mentally and physically, and which in many cases permits easier access to drugs. Incidentally, substance abuse is not unknown in the entertainment industry either. The creators of Nurse Jackie did not just flippantly decide it would be cool to saddle Jackie with this interesting flaw because they think she's inferior. Both of the lead executive producers and Edie Falco herself are recovering alcoholics. They persuasively show Jackie's stresses and desires, her bargaining, and her self-delusion.

It seems to us that some of the negative reaction to Jackie's drug use may be rooted in the view that Hollywood is simply not allowed to present a nurse character with a flaw that some regard as a huge moral failing, rather than a disease, or at least a sad reaction to a hard life. Some think that nurses cannot be associated with such a huge flaw. But nurses are not angels, and it is not realistic to expect that a really compelling television character will have no significant flaws, whether she is a nurse or anyone else. Virtually all the major physician characters on recent Hollywood shows have had serious flaws. Like real life, good drama has a lot of gray areas, and sometimes the people with the greatest capacity for good are also those with a capacity to become addicted to drugs. We hope the show will make clear that drug abuse has consequences and maybe Jackie should get some help, but we're not sure you can expect the show to do that in one episode. It took House five years.

 
Jackie makes an impression on the physicians

Some have faulted Jackie for not advocating forcefully enough to save the bike messenger. Jackie herself would likely agree, based on her tortured reactions to his death. But we have to note, first, that her patient advocacy for the patient probably places her at least in the top 10, top 5% of her class of television nurses in that regard. And of course, Jackie's failure here is realistic. Sadly, we are not sure that most real nurses would have done any better, given the enduring power disparities between nurses and physicians.

And consider:   Was Jackie's advocacy really a failure? The strongest part of it came after the messenger died, and she did not save him. But what about her effect on Coop? It is clear that her brutal dissection of his care has shaken him. The next difficult case he gets, he wants Jackie. When Jackie once again displays her extraordinary grasp of patient conditions with the loaded 16-year-old, Coop pays a sly tribute by adopting her exact phrasing about the 100 jerk-offs she has seen come through the door. Of course, he misplays even that, as Jackie immediately makes clear that, far from judging the kid, she knows exactly what he feels like, and actually tries to offer him a positive counter-example of her own "clear head," however questionable that may be.

So although Jackie lost the bike messenger, she may yet save many others through the force of her personality and expertise on the young Coop, who may treat thousands of patients over the course of his career. And her training may actually be more effective because the patient died than if she had managed to save him by going around Coop and getting the test. That would never have made the impression that this death and Jackie's reaction to it did. Of course, that would not justify intentionally letting the messenger die--and the show is not suggesting Jackie did--but it could work out that way.

Lest we think that Jackie is anti-physician, her best friend is Eleanor, who, like Mo-Mo, matches Jackie's own edgy cynicism. This is actually no small thing in terms of letting the public know that nurses can be smart and interesting enough to befriend physicians, who continue to enjoy unmatched social status. Hollywood shows have rarely presented nurses and physicians as simply great friends. Of course it's pretty much unthinkable on shows like House and Grey's, and even ER did not really have much of it outside of the romantic context (e.g., Hathaway and Doug Ross, Taggart and Tony Gates). Only NBC's Scrubs clearly presented nurse Carla Espinosa and physician Elliot Reid as best friends.

  
Is Hollywood allowed to present a major gay male nurse character?

Many believe that men who become nurses must be gay. This inaccurate belief has kept many males, especially young ones, from considering the profession. We believe that gay and straight men alike are great additions to nursing, and we wish more men would become nurses. However, portrayals of nursing should not themselves reinforce stereotypes, by trying to hide the fact that there are gay men in nursing, or implying that it's OK to be a man in nursing as long as you're straight. (See our FAQ on men in nursing.)

The gay man in nursing is an example of a stereotype that Hollywood has actually gone to surprising lengths not to reinforce. Of significant recent primetime television shows, the only long-running nurse character we are aware of who was a gay man was ER 's Yoshi Tanaka (1997 - 2003), and he was not a major character. So Nurse Jackie's Mo-Mo may be the first one of the modern era. We find nothing stereotypical about him yet. Like Belize in Mike Nichols' 2003 film version of Tony Kushner's Angels in America, Mo-Mo seems to be smart, funny, wise, and strong; we haven't seen his direct care yet. The reality is that many men who practice as nurses in urban EDs are gay. As long as it does not reinforce damaging stereotypes about those men or other men in nursing, it seems to us that Hollywood should be allowed to have a character like Mo-Mo.

 
Jackie might be naughty, but she's not a naughty nurse

Of course, the pilot includes a scene in which Jackie has adulterous sex with Eddie in the pharmacy. Sex in the hospital--you know, just like virtually every one of the heroic physicians on Grey's. And adultery--just like the heroic Addison Montgomery, star of Grey's and the central character in the Grey's spinoff, ABC's Private Practice. No, sex in the hospital is not as common in real life as on TV--to say the least--but you can't really say that that alone makes Jackie naughty. She is not a half-dressed bimbo, but seems to be carrying on a long-term affair with Eddie. How much is it based on her desire for drugs? We don't know yet, but even if it was mostly that, it would still not really reinforce the naughty nurse stereotype. Naughty nurses are half-dressed sluts whose job is to have sex with patients and/or physicians. None of that description fits Jackie.

Some have also suggested that Coop's grab of Jackie's breast somehow reinforces a stereotype of the nurse as sex object, but that does not strike us as persuasive. That is not Jackie's doing. She does nothing to invite sexual attention from Coop. To the extent it's anything more than a throwaway attention-getting device--and it's not really one of the episode's better ideas, apart from Jackie's great "is this happening?" line--it reflects a reality of sexual assault that is all too common for real nurses. Nurses are not naughty because someone grabs them. The show might be a little too flippant about this, but we doubt it will have a major negative effect on nursing.

 
Is Jackie a battleaxe--or just caught in a battle?

Jackie can be pretty mean, not just to Coop but also to Zoey. She tells Zoey to "shut up," and explains that "quiet and mean" are her people. That does not prevent Zoey from calling her a saint. Showtime also promotes the show with an image of Jackie holding up a needle and syringe--in the same position in which Jackie's middle finger might otherwise be raised--and the tag line: "Life is full of little pricks." Jackie is obviously about tough love, but she never abuses people who are real and decent. She is a tough nurse confronting a tough setting, and she does not suffer fools, but she regularly displays intense empathy for those who are suffering and provides real support to those in need. She has nothing in common with Nurse Ratched of One Flew Over the Cuckoo's Nest. (Chapter 8 of Saving Lives delves more deeply into the battleaxe stereotype.)

 
Is there a saint at All Saints?

One claim we do not expect to hear is that Jackie, who on top of everything else is relentlessly profane, reinforces the angel stereotype. But Zoey does call her a "saint" and Jackie seems to consider the idea pretty seriously. The comment distracts her enough so that she nearly makes a fatal error with an IV on a patient. It also inspires her final ruminations about Augustine, which suggest both that she is conscious of trying to achieve what is right, and that she is aware of her own imperfections, whatever she may aspire to.

And what does she aspire to? Some clues lie in the equations of suffering that she and Zoey discuss, wondering whether suffering is basically like matter, something that can be neither created nor destroyed, but which God has decreed must remain constant in the world at the current seemingly high level. It's not clear if Jackie believes that, but it is clear that if she cannot decrease the suffering she finds in any direct way, she is not above redistributing it according to her rough notions of justice, as when she gave the diplomat's money to Beth (the bike messenger's pregnant girlfriend). She actually increased his suffering to try to match that of his victim by disposing of his ear. And when she punctured the other bike messenger's tire, well, maybe he got a little of the loaded 16-year-old's suffering. (Or worse. That messenger could fall and have an acute subdural hematoma--all because he was rude?)

You might also compare what Jackie is doing to a multiple organ donation, without consent:   She takes here, gives there, not necessarily between patients and family who have any direct relation (the money did not go to the prostitute, the messenger's organs did not go to Beth), but in order to achieve her broader vision of social welfare. She had no right to forge the messenger's donor card, but she hopes to save many more lives by doing so. And of course, she feels guilty for not saving him--maybe she is expiating that guilt, trying to make sure that his death at least was not a "waste."

Is she a saint? More like a divine henchman, a rogue who is not necessarily following her Master's guidelines exactly. That might make even more sense if you're not so sure about God's intentions to begin with. Of course, you could also look at Jackie's actions as a protest against God, an angry reaction to the suffering and injustice He allows, of which she has seen far more than her share. She cares very deeply about her patients and their families, but it's plain that her perceptions of moral worth affect the quality of her care. Of course, more broadly, Jackie's behind the scenes maneuvers are a theme that many real nurses will recognize. Nurses often believe patients are not getting the care they need but that the nurses lack the power to change that directly, and it is hardly unknown for such nurses to respond by working around the health care structure in ways that may not comply strictly with the rules. This is not surprising for a group that is generally underpowered and bumped aside, as Coop initially did with Jackie. Jackie pushes back harder than most nurses would in some respects, but to a large extent she is still working indirectly, secretly. She confronts Coop, but she does not give the messenger's family a chance to decide on the organ donation (and it's unlikely they would have done so). Nor is she starting a campaign to push the diplomat's embassy to allow his prosecution (and perhaps that is unlikely also).

But is any association of nurses with divine agency harmful because it may imply they are spiritual beings who don't need adequate respect or resources, as the common "angel" stereotype suggests? It seems unlikely that would be Jackie's view, regardless of whether she may aspire to be a saint. Her character has none of the qualities of the angel stereotype--or, for that matter, any other nursing stereotype.

 
Final thoughts

On the whole, Nurse Jackie has the potential to alter the public image of nursing more profoundly than any Hollywood show of recent decades. Even on ER, by far the best major show for nursing so far, the profession was never more than an occasional supplement to the real action, which was dominated by the heroic physician characters. But Nurse Jackie is an unusually compelling, witty character who works at center stage, dispensing expert physical and psychosocial care, saving and endangering lives, raising nurses' and physicians' level of play, deceiving herself and those who love her, making dubious moral choices--and presenting a radically different vision of what a nurse is.

 
Please tell us--and the producers of the show--your thoughts on Nurse Jackie!

The show's publicists and producers will be following comments on our discussion board, so please post your thoughts here. Thank you!

If you would like to send your comments to the show directly please send them to the show's publicist Faye Katz at  Faye Katz email address   and please send us a copy at letters@truthaboutnursing.org. Thank you!

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