All the work, none of the pay, zero glory
June 7, 2010 -- The second season of Showtime's Nurse Jackie continued to offer the most thoughtful and persuasive treatment of nursing issues on U.S. television. The season also featured more of emergency nurse Jackie Peyton's drug abuse, adultery, and webs of deceit. However, as always, Jackie's issues are not nursing stereotypes, but the troubles of one complex individual. As the season approached tonight's finale, Jackie and her protégé Zoey Barkow continued to display clinical prowess. Jackie skillfully worked the system to help a despairing lymphoma patient find some relief from his debilitating nausea and to provide some expert, if unpleasant, advice to an ex-football star with early onset dementia. Meanwhile, Zoey saved a boy's life by intubating and resuscitating him, and saved another patient by picking up on a blood clot that could easily have led to a pulmonary embolism, something the arrogant but marginal physician Fitch Cooper missed. The show's final episodes also included a somewhat ambiguous take on men in nursing. Nurse Sam is shown to be a fairly cool, perceptive individual with an attractive girlfriend, but she breaks up with Sam after sleeping with Cooper, saying she is doing so because Sam is a nurse. Sam proceeds to break Cooper's nose. This could be interpreted as a frank examination or even subversion of anti-male nurse bias, a reinforcement of that bias, or all of the above. More troubling were the show's confused messages about nursing authority. Several plotlines had Cooper wrongly asserting that he was in charge of and could even fire nurses, with no direct rebuttal. Cooper did more than once end up in nurse manager Gloria Akalitus's office seeking to have her discipline nurses, with little success, which at least suggested that he could not take a significant adverse employment action on his own. But why can't some character just state that although nurses do have less power, they do not report to physicians because they practice a distinct, autonomous profession? In any case, the show still provides U.S. television's most compelling account of the value of nursing, and it does not hurt that the show's dramatic quality remains higher than that of any other hospital show. We thank those responsible for the show.
Saving lives? All in a day's work
Even as Jackie's actions cause her personal life to crash down around her, she continues to show diverse clinical skills and patient advocacy that reflects a fierce commitment to her patients. One plotline in the April 12, 2010, episode, Christine Zander's "Apple Bong," finds Jackie and Cooper caring for a stage 3 lymphoma patient who has arrived at the ED in bad shape after his third round of chemo. Jackie actually enters an examination area to find Cooper holding a vomit receptacle for the patient, Martin. Cooper is thrilled to immediately give the receptacle to Jackie, and we get that he can't handle / thinks he's too good for this task. That does describe the general orientations of the two professions, though it may actually overstate the likelihood that a physician would be holding such a receptacle under any circumstances.
Jackie asks Martin a series of questions about his anti-nausea medication regimen, at times sympathetically suggesting the likely answers, always correctly. She clearly knows exactly what nasty side effects each drug causes, which is by itself a strong indication of nursing expertise. Cooper looks lost. Martin looks ill, exhausted, and depressed; he wonders if the treatment is worth it. He says he is cold, and Jackie gets him a blanket. Then she asks if he's tried pot for the nausea. Cooper is clearly shocked. Martin explains his nerdy lifestyle, and asks where he would get marijuana. The very uncomfortable Cooper breaks in and promises, unconvincingly, that he will find Martin some medication regimen that will work for him.
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Outside the exam area, Coop is furious. He tells Jackie "never" to suggest an illegal drug to combat symptoms when there are "perfectly viable legal medications." In responding, Jackie refers delicately to the fact that Coop recently paid a publicist to help get him listed in a magazine as one of the "top physicians" in New York.
Jackie: Oh, I see, is this part of the new image, the top 25 New York fuckin' douchebag doctors? Please, don't be such a boy scout, Coop. You know that if this guy lived in a different state, he'd be able to get a prescription for medical marijuana so he could at least try it.
Coop: He doesn't live in another state, he lives in New York.
Jackie: I don't give a shit if he lives on Mars. I'm gonna make a suggestion if I think it's gonna help a patient.
Coop: No, you're not. I make suggestions. You listen and agree. Seriously, Jackie, how high up do I have to go to lodge a complaint for you to understand that?
Jackie: Really, is there somebody higher up than you?
Jackie's responses are strong--she's not going to back down an inch--but nothing she says tells the audience that nurses generally do not simply "listen and agree." Maybe Jackie is some kind of rogue super-nurse--actually, she is--but the show suggests that nurses generally really do have to just shut up and do whatever physicians say, even if the physicians are as clueless and generally uncaring as Cooper. Cooper's general foolishness does not necessarily make his underlying point wrong, does not clearly show that physicians as a class do not own patients and have no business telling nurses what they can and cannot suggest.
Later, Jackie returns and sees Martin preparing to leave. Cooper has released him with a prescription for Emend and a referral to a biofeedback clinic, which Jackie plainly views as inadequate. She wheels Martin out in a wheelchair. As they pass Cooper, who is bragging to Zoey about his Twitter following, Jackie swipes a pen out of his shirt pocket. Jackie corrals the paramedic Lenny and says they're heading for his rig. She grabs an apple from a cart in the hall as she passes. On the rig, she uses Cooper's pen to fashion an apple bong as Lenny and Martin look on. Jackie has gotten the marijuana from Lenny, who hands her a lighter. She shows Martin how to smoke it; he coughs, not used to it, and she advises him to take a deep breath and hold it for minute. He does. Lenny wonders how Jackie knew he liked pot and would have some; she notes that he consumes Mountain Dew and Doritos. Martin soon reports that he feels better, even hungry. Jackie asks Lenny to give Martin a ride home in the ambulance. Martin thanks Jackie, and actually seems happy, asking Lenny to put on the siren and wanting to ride "shotgun."
Soon, we see Cooper telling Jackie that he'll be following up with the patient next week. Cooper says he knows he seemed like a "tight ass" earlier, but he says that Jackie has to understand that with his Twitter following and the top physician list, he has even more of an example to set. He says he really believes they have to use science and medicine to solve problems. Jackie, who is in conciliatory mode because she doesn't want to provoke further interest in Martin's case after what she's just done, says she understands Cooper's view, but sometimes prefers Mother Nature. Cooper, always insecure, assures her that he has tried pot. Jackie manages not to mock him.
Later, after work, we see Jackie arrive at Martin's apartment. She has actually baked him some marijuana cookies. He reports how much better he feels after the pot he smoked earlier, and he also compliments her on the taste of the cookies. They bond briefly over the Mets game he's watching on TV. Jackie has even included the cookie recipe on a card, along with the name of Lenny's dealer: "She's a nice lady, she's expecting your call."
The final scenes of this plotline form a masterly mini-portrait of Jackie. She uses her uncanny shrewdness, inventiveness, and boldness to help a desperate, probably terminal patient by any and all means at her disposal, giving a hidden kiss-off to Cooper (using his pen to make the bong), and, as she often does, working around the system, apparently violating the law by getting the drugs for Martin, an echo of her own use of drugs to relieve pain. Unfortunately, the plotline is undermined to some extent by Jackie's failure to adequately challenge Cooper's claim that only he, the physician, can "make suggestions" and that she must "listen and agree." Of course her actions show that she does not think any such rule applies to her, but the show's failure to tell viewers that this is not how the larger system works will likely reinforce the common view that physicians generally control nursing care, even if they may have to go to some administrator like Akalitus (right) to actually get a disciplinary action taken. But among nurses it's not only the rule-breaking Jackie who has the right and the expertise to discuss care options with patients.
In the May 24 episode, Liz Brixius's "Sleeping Dogs," we see Cooper approach Akalitus in a hallway and try to persuade her to continue an ad campaign for the hospital that uses Cooper's pretty face and the awesomely ridiculous tag line "If Looks Could Heal." Akalitus, trying to get rid of Cooper, asks him to answer his pager, noting that "someone may be dying."
Cooper: The nurses'll keep him alive till I get there, it's their job.
That's great--maybe. Keeping patients alive is part of nurses' job, but does the show mean for us to believe it, or just that Cooper is an irresponsible, self-absorbed slacker? And Cooper's narrow formulation reduces the nursing role to stabilizing patients so physicians can heal them. In fact, nurses' mission is not to serve physicians but to return patients to health, and we could just as easily define the physician role as a series of isolated technical interventions in support of the overarching nursing mission. Is the show so sophisticated that it is subtly questioning the deceptively inadequate way Cooper has paid tribute to nursing?
The patient Cooper eventually gets around to seeing is a 30-ish male with altered mental status. The paramedics report that he was found disoriented and naked, having started taking clothes off at a grocery store. The police were called, and he is cuffed. Cooper, always the sensitive one, notes right away that he's a "wack job." Jackie calls for a psych eval. Cooper loudly protests the cops "dumping their disorderlies at All Saints." Jackie comforts the confused and worried-looking patient. Cooper wants him sedated; Jackie notes that he's not agitated or resisting. The patient does not know his name. Jackie assures him that they will take good care of him. Zoey finds his wallet, which shows that his name is Marco. Jackie asks if he knows how he got there and what year it is, but he does not know. Jackie tells him the year and he thanks her. Cooper looks at the ID, which says Marco Prince. Cooper realizes that Marco is actually a famous football player and suddenly starts fawning. Cooper notes that Marco was a first round draft pick, which is rare for a linebacker. Now Cooper is very interested in the patient, asking for an MRI, full blood workup and spinal tap, in order to rule out infection, a brain tumor, and a bleed.
Cooper (to Jackie): Treat him like a king, huh?
Jackie: As opposed to a "wack job"?
Cooper wanders away tweeting, obviously thrilled at his good fortune at meeting Marco.
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Soon, Marco's wife arrives. Jackie offers him food, and he says that would be nice. Marco can see that Jackie is actually treating him with respect. Marco's wife tells him what happened with the disrobing in front of the grocery store patrons, and he's upset, but she says it's OK, since he's so good looking he probably "made their day." Akalitus approaches and does her own fawning over him, celebrating his blind-side sack of the Tennessee quarterback.
Later, Jackie meets Marco's wife in the hall, telling her that they're doing an MRI. His wife tells Jackie to cancel the MRI because their insurance won't pay and they can't afford it. She explains that Marco is not "sick sick," but he has early onset dementia. He's a linebacker, but not 6'5" or 300 pounds, "so he's fast and tough as shit." They don't need another MRI. Jackie says OK.
When Jackie stops by later, Marco says his condition is embarrassing: when you break your arm, you're still you; when you break your brain, you're not you anymore. He explains that they used to have a guy who lived with them and took care of him, but they went through all their money. He doesn't know why he wanders off, he doesn't want to. Marco says he has a beautiful life but it's slipping away, every day a little more. He and his wife look sad and scared. Jackie is silent.
Later, Marco's wife is with Jackie and Akalitus, in her office. Akalitus is apparently advising a divorce, because Marco's wife doesn't earn enough money to take care of him, but she makes too much to qualify for Medicaid. Akalitus says she doesn't make or even believe in the rules, but that's the way it is. Marco's wife is aghast at this suggestion, but Jackie says Akalitus has been "fucking the system for 30 years," and she agrees that they have to do something because Marco needs round the clock care. Akalitus tells her the costs are going to be catastrophic without Medicaid, that she'll lose her house, and they'll garnish her income. Akalitus says that today's visit alone, without the MRI, would be $11,000. Marco's wife can't believe it. Akalitus says All Saints will cover that bill. But the wife remains distraught about the divorce idea, and she leaves; it's not clear what she will do. Jackie is pretty impressed with what Akalitus did.
Although there's no happy ending for the patient, the show is again illustrating Jackie's strong patient advocacy and interpersonal skills, which it sets against Cooper's clueless insensitivity and self-absorption. Jackie takes Marco's wife to see the master bureaucrat Akalitus, who gives her what sounds like good advice, however awful it is that the United States' health financing system would require the couple to get divorced just so Marco can get the care he needs. And Jackie treats Marco with respect both before and after they learn that he is a famous person, giving him information, providing him with food, and protecting him from Cooper's needless sedation. But a lot of what we see is what Jackie does not do. She knows when to say nothing, and much of her psychosocial care takes that form, as she allows Marco to describe what he's feeling and to interact with his wife without interference. She has no easy answers and she offers none. She also does not push for aggressive diagnostic or other treatment that is not in the couple's best interest, something that could easily happen in real life, especially with a celebrity.
Of course, Akalitus is a nurse too, though the show rarely mentions it, and this plotline also illustrates how the show has pulled back from the battle-axe imagery that infected her character during the first season. She is still capable of ranting to some extent about misconduct around the hospital, but this season it seems less frequent, more justified, and to reflect some genuine concern for patients and staff. In other words, she is no longer mostly a cartoon figure, but a fairly decent, if gruff and sometimes nasty, human being. Whether Cooper is too cartoonish is another matter. Despite the presence of the skilled, wise, and witty senior physician Eleanor O'Hara, you could argue that Cooper gives too negative an account of junior male physicians. On the other hand, you could also argue that the show wrongly suggests that the attitudes he displays toward nurses and health care generally are limited to young male physicians.
Saving lives? All in a day's work
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Zoey, who sees Jackie as a mentor, has made great strides in clinical ability since the start of the show, when she was a bright but clueless neophyte. In the April 12 episode, Zoey meets a panicking mother in the ED waiting room. The mother's little boy is not breathing. Zoey carries him back quickly, asking for O'Hara and Jackie; she seems especially unhappy when nurse Thor tells her Jackie is not there. As Zoey and Thor enter a trauma bay with the boy, a nameless third nurse excludes his mother. (Even nurse shows like this one seem unaware of the trend toward allowing family presence during procedures, a trend that has been driven by nurses and chaplains. When the benefits of family presence finally are discussed in prime time, it may very well be presented as a physician innovation.)
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Zoey tells Thor that she needs epinephrine and solumedrol for the boy. She bags him as Thor gives the drugs. Zoey says that his breathing has stopped and they will need to intubate. Thor says O'Hara's on her way.
Zoey: He's turning blue. I can't wait.
Thor: Legally we can't do this.
Zoey says that they have to, and she asks for a pediatric crash cart, a 2 blade and 5.0 uncuffed tube. Thor helps Zoey put it together and she successfully does the intubation. Then they lose the boy's pulse. Zoey starts compressions. They get a heart rhythm and a pulse. Thor says, "Zoey, you did it." O'Hara arrives, and Zoey exits the room without a word.
Thor (to O'Hara): Zoey just saved his life, twice. Also she intubated. Don't be mad. No one can know, she could lose her license.
O'Hara: So, I suggest we stop talking about it.
Zoey speaks with the boy's mother outside.
Zoey: He's going to be OK. Dr. O'Hara's here now. She's an amazing doctor.
Jackie learns about this save later, in conversation with Thor, Zoey, and Lenny the paramedic. The men are impressed, but Jackie seems displeased. She tells Zoey privately how risky doing the intubation was. Zoey says she was just doing what Jackie would have done, and that she never thought Jackie would give her a hard time for getting the job done. Jackie seems stung.
Later, we see O'Hara leaving Zoey some flowers, saying softly, "They're for you. Good work." Zoey walks past Jackie, who follows her silently up to the pediatrics ward, where they look at patients through a window. Jackie asks if that's the kid from this morning. Zoey says yes, then confides that she thinks she herself may be pregnant (she later turns out not to be). Jackie touches Zoey lightly, comforting her.
Most of this plotline is great. It's a showcase for nursing skill and expertise, and Zoey does not even seem very concerned about her ability to do the intubation or the resuscitation--she doesn't act like it's a tremendous test of her technical skills. The reactions of O'Hara and the others are generally helpful, underlining that Zoey really did save the kid's life. Jackie's initial reaction seems to suggest that she has a hard time seeing her own kind of conduct from the outside, but she comes around and continues her tough love mentoring of Zoey, which is itself a helpful theme in the show; senior nurses do not necessarily undermine junior nurses. Perhaps the reactions of the others do suggest too much surprise that a nurse could do this, but it may just be that Zoey is relatively junior, so it really is a big deal for her. We hope viewers think that O'Hara's flowers are simply recognition from a colleague who has spare cash and some authority at the hospital, and not an indication that Zoey reports to her. The scene with Zoey and the boy's mom vividly illustrates how even nurses themselves can undermine nursing by reflexively crediting physicians for life-saving work that nurses really do. We might hope for less self-abnegation from a skilled nurse, but we would not necessarily get it. And as long as even health professionals hide the truth about nurses' expertise, nursing will have major problems.
Of course, it appears that at least part of Zoey's motivation was to hide from the mother Zoey's supposed misconduct in doing the intubation at all. And here is a problem. Viewers will clearly come away from this plotline thinking that nurses are never allowed to do intubations, and that is simply false. In general, any nurse with Advanced Cardiac Life Support certification can intubate, and nurses sometimes do. ED physicians would probably do it if present, as they have more experience, but at the same time, anesthesia professionals--including nurse anesthetists--have far more experience and expertise than ED physicians at the process. And paramedics intubate every day. It may not seem too harmful for the show to overstate the unjustified restrictions on nursing practice (there are plenty of those in real life) but this plotline could also be seen as suggesting that intubation is something nurses generally should not do. Maybe it's just that a really able nurse like Zoey might get away with it if no physician is present. The show could still have had a physician like Cooper or a patient objecting to Zoey doing this. But to have the nurses themselves and the well-regarded O'Hara appear to accept, if not endorse, a system in which nurses risk their licenses by doing what any properly trained nurse is permitted to do in real life is less than ideal. The plotline is a net gain for nursing, but not by as much as the creators probably think.
The May 31 episode, Rick Cleveland's "What the Day Brings," offered an example of Zoey's expertise without that kind of drawback. In this one, we see Zoey get a far less emergent patient and his apparent wife from the waiting room. Zoey mispronounces the man's name--Kieran O'Garrity--and he explains, "It's Irish." When Zoey says "Aye, so it is," Kieran's wife responds evenly, "We're Irish, not pirates." Taking this in stride, Zoey says, "Welcome to America," and takes them back. She examines the patient's leg, where it looks like he has a rash. Zoey asks the couple when they first noticed the apparent rash, and they seem to disagree about whether it was right off the plane (they have just arrived in the U.S.) or when they got to the hotel. Cooper comes in and soon decides, without careful examination, that it's just a rash. He asks for Cortisone cream, and says it's probably just an allergic reaction; he's preoccupied with his own allergy problems resulting from contact with a cat. Cooper leaves. Zoey takes off the patient's sock, which seems to hurt him. She asks if it does hurt (he says yes) and whether it itches (he says no). His wife points to the veins on his leg, saying they're worse than hers. Zoey examines them, looks thoughtful, and says mostly to herself, "looks like a rash, doesn't feel like a rash."
She goes to Cooper and tells him that the rash is tender, the patient has just made a Transatlantic flight, and he has bad varicose veins--which is not a bad portrayal of how many nurses feel they have to hint indirectly when they want physicians to notice something about a patient's condition, for fear of stepping on physicians' toes or bruising their egos. Cooper is too busy sneezing to listen. So Zoey goes to O'Hara, who comes to see the patient. Zoey is going to leave the exam area, but O'Hara asks her to stay because "it's your hunch we're following." O'Hara locates a barely perceptible blood clot, noting that the patient came close to having a pulmonary embolism, "which coulda killed ya. But luckily you have this young lady to thank for catching it. I'll leave you in charge, Zoey." O'Hara leaves and the couple thanks Zoey, who's very pleased but hiding it well; she notes that it's "all in a day's work" as she writes something on the chart.
Later, in an unrelated plotline taking place at the nurses' station, we see Cooper angrily order Thor to give an annoying addict who missed the hospital's daily clinic some methadone. Unfortunately, Thor complies with barely any resistance, though he clearly knows the patient well and is making the patient wait his turn with other ED patients in order not to reward the patient's behavior in missing the clinic. Based on Thor's reluctance, Cooper loudly claims that no one in health care cares anymore, but that he, Cooper, does. Zoey can't resist quietly noting, "But you missed a pulmonary embolism." Cooper says, "What?" Zoey responds, "Nothing."
This plotline once again shows viewers advanced nursing skill and some patient advocacy. Zoey focuses on the patient, asks the right questions, and considers the possible causes for what "looks like a rash" but may not be. She tries to get Cooper to pay attention, and when he will not, she doesn't just give up, but moves to another physician who will listen and help her. The show makes clear that Zoey may well have saved the patient's life. And in doing that, it again has O'Hara giving Zoey credit--providing a model for how physicians might act when a nurse displays good clinical skills. It's important for shows to demonstrate that there are physicians who actually respect nurses as colleagues, in order to build the public's awareness that the relationship can be that way, and perhaps to offer a model for such behavior should any impressionable physicians be watching. We can't say that Zoey is a great advocate for nursing yet, since she repeatedly slinks away when physicians arrive in a room, as if she has no right to be there. Nor is she a great patient advocate yet in the sense that she stands up to physicians the way Jackie does; Zoey is fortunate to have O'Hara around. Still, Zoey's semi-audible comment about what Cooper missed, and a few other comments in the final episodes of the season, suggest that she is developing the ability to tell physicians what they don't want to hear, but need to.
The last three episodes of the season included a plotline about nurse Sam, a second season addition to the show. Jackie has repeatedly tried to undermine Sam, ostensibly because he is a recovering addict, but really because he is a savvy person she fears will see through her own deceptions. In the May 24 episode, Cooper is looking for someone to have lunch with, but no one wants to. He ends up having lunch with nurse Sam in some hospital storage room.
Cooper: This is the way it used to be, hanging out in the back, talkin' shit about nurses…nice.
Sam: Go easy on the nurse smack.
Cooper: How come you're not a doctor, seriously?
Sam: I could ask you the same thing.
Cooper (seeming to wonder whether this is an insult): I am a doctor.
Sam: No, I mean how come you're not a nurse.
Cooper (laughing): All the work, none of the pay, zero glory…hmm? I'd die. I'd be dead.
Sam: It's not true. I have an awesome life.
Cooper: But would I think it was awesome?
Sam: I think you would. You should tag along with me and my buddies after work. Little Cooper Union; you can meet my lady. See my world.
Cooper agrees, wondering what he should wear.
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That night, we see Cooper hanging out with Sam and some friends in what looks like a park, presumably at or near Cooper Square. Sam and his friends are rapping and singing as they stand around a trash can fire. They're pretty good. Cooper talks to Sam's attractive girlfriend, and although he is not really at ease, he seems to make a connection with her. She says Sam used to get loaded, but now he does this instead. Cooper says it's "beyond cool," and tells her that cool guys never like him. He gives it a shot with a rap about his work, part of which rhymes "benign" with how he "hate[s] nurses who whine." Cooper knows it's pretty weak. But Sam's girlfriend seems to be into him. She says Sam will be out there all night, and Cooper walks her home.
The beginning of the next (May 31) episode finds Cooper waking up in bed, with the cat who will cause him to develop allergy symptoms. A cell phone rings; Cooper looks and sees that it's Sam calling. Sam's girlfriend enters, and we see that Cooper has slept with her. Cooper tells her that the situation is a little weird because he has to see Sam every day and "you're his girlfriend."
Girlfriend (moving to cuddle with Cooper): People need to expand their minds. And I need to break up with him.
Cooper: Why? He's a nice guy.
Girlfriend: He's a nurse.
Cooper smiles, but looks a little uncomfortable, and the scene cuts.
Later, Cooper confides to pharmacist Eddie, whom Cooper thinks is his friend, that he slept with "male nurse" Sam's girlfriend. Still later, Sam confides to Eddie that his girlfriend is blowing off his phone calls, and that the last time she did that it meant there was another guy. At that moment Cooper enters the pharmacy, and Eddie tortures him by discussing poor Sam's situation.
The situation comes to a head in the June 7 season finale, "Years of Service," by Liz Brixius and Linda Wallem. At one point in the episode, we see Sam sitting at a desk at the hospital, seeming depressed. Cooper approaches and asks if Sam's girlfriend broke up with him. Sam says yes.
Cooper: I'm sorry, man. Between us, you are dodging the world's biggest bullet. All that tie-dyed, hippy, everyone-is-equal shit. It's all for show. She wants to be a doctor's wife. Pretty much said it out loud. And that fucking cat, dude…
Sam (getting up): You slept with her.
Cooper (backing away): Yes, I did, my friend. That's why I'm telling you. Why would you want to be with someone who has a thing for doctors? You're a nurse--you deserve better.
Sam punches him, reinjuring an existing nose injury. Cooper swears and hunches over, but does not respond. Later, we see O'Hara patching up Cooper's nose, with Jackie standing nearby.
Cooper: I am so gonna fire that guy. So what if I slept with his girlfriend, people need to grow up.
O'Hara: Yeah, firing Sam would be very grown up on your part.
Later, we see Cooper and Sam in Akalitus's office.
Akalitus: The entire nation, Dr. Cooper, is experiencing a nursing shortage. I'm hesitant to let anyone go at this point.
Cooper: But he broke my nose.
Akalitus: It's my understanding that it was already broken.
Sam: He slept with my girlfriend.
Akalitus: Really, Dr. Cooper--you get to be a doctor, isn't that enough?
Sam: Am I fired?
Cooper: Yes! There is a chain of command here--
Akalitus (to Sam): I'm extending your probationary period. You can thank me by not assaulting any more of my staff.
Cooper is very frustrated. Later, still at the hospital, Jackie encounters a very drunk Sam; apparently he has drowned his sorrows in a lot of vodka. Perhaps surprisingly, Jackie helps him. She takes charge of covertly getting him to the basement with an IV. She and Thor keep him awake by dancing with noisemakers on their sneakers. It looks like Sam will be OK.
This plotline's portrayal of men in nursing is mixed. Sam appears to be a secure straight man in nursing, which is not something we see on television often. He calmly refutes Cooper's "male nurse" stereotypes, though his demonstration about why his life is "awesome" relates solely to non-work activities--isn't there anything "awesome" about nursing? Of course, at least as far as those extracurricular activities go, Cooper seems to regard Sam as "cool" in a way that Cooper is not. We never have gotten much sense of Sam's clinical skills, but he has always seemed calm, savvy, and strong. Though it was not right for him to break Cooper's nose, viewers will give him manliness points for doing so. It was Sam who quickly realized that Cooper had paid a publicist to get his name on the "top doctors" list. And it was Sam's ability to sense Jackie's own drug issues that made her wary of him for so long. Of course, Sam is an addict himself, and you might argue that having two nurses on the show with that problem overstates the incidence of drug problems in ED nursing. There's also the fact that, however secure and attractive Sam is, his girlfriend still sleeps with Cooper, then breaks up with Sam because "he's a nurse." We're sure some would have preferred that the show not portray something like that, since it is certainly not the case that men in nursing inevitably lose girlfriends because of "male nurse" stereotypes. Yet those stereotypes do exist, and it is not unrealistic that a woman might be uncertain about dating a male nurse. We do not fault the show for suggesting as much. And Cooper is not wrong in suggesting that Sam may be better off. Sam's girlfriend is physically attractive, but not really an attractive character. The show does not seem to respect her "expand their minds" comment, and she really does seem to sleep with Cooper mainly because he's a physician; he is the least positive character on the show. Likewise, while Sam's workplace drinking binge is not model behavior, it probably will not be seen as related to his status as a man in nursing.
The messages the plotline sends about nursing autonomy are confused and damaging. Cooper promises to "fire" Sam after the punch, and O'Hara seems to endorse his belief that he can do that, though she clearly does not think it's a good idea. Of course, this is not the first time Cooper has suggested that he is in charge of the nurses. Yet as we have seen, he can't seem to actually take any adverse workplace action against them without going to Akalitus (her reference here to "my staff" even suggests that Cooper himself reports to her). Akalitus makes clear that she is the one who decides whether a nurse is fired, or remains on probation, and she more or less rebuffs Cooper; her extension of Sam's probation is only fair, as he did strike a colleague. Indeed, Akalitus's support for her nurses this season in the face of Cooper's complaints would impress most real nurses. But in view of Akalitus's role, why would the show continue to have Cooper make statements about "firing" and the "chain of command"? The reality is that there is no clinical "chain of command" in which physicians supervise nurses, despite the power disparity--why can't anyone on Nurse Jackie just say that? Either that, or stop with the "firing" comments.
Of course, taking in the whole picture, the reason some parts of Nurse Jackie are such a complex mix of helpful and unhelpful elements is that the show makes such a serious effort to explore how nurses interact with colleagues and patients. We commend the show for that effort, and particularly for its strong portrayal of nursing skill, the challenges nurses face, and the central role that nurses play in hospital care.
Please tell us--and the producers of the show--your thoughts on Nurse Jackie!
If you would like to send your comments to the show directly please send them to the show's publicist Faye Katz at 
and please send us a copy at letters@truthaboutnursing.org. Thank you!
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