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OCD and Spidey sense
March 29, 2010 -- Tonight's episode of Showtime's Nurse Jackie included a cautionary tale about how easily a clinician as aggressively gifted as Jackie can slip into arrogance and corner-cutting. No one will likely suffer physical damage as a result of Jackie's error here (unwittingly giving a distressed family a few hours of false re-assurance about whether their child has cystic fibrosis) and the episode also includes examples of the veteran nurse's physiological and psychosocial skills. Jackie takes responsibility for the error, and it actually makes the overall portrayal of her expertise more balanced and realistic; it's not just brilliant physicians who can fall into the ego trap. Unfortunately, the episode also includes a brief reinforcement of the previous episode's suggestion that hospital physicians have some kind of direct authority over nurses. This week, nurse manager Gloria Akalitus tells Jackie that physician Cooper has lodged a "formal complaint" against her for "insubordination and general bitchiness." Jackie dismisses the complaint with a string of expletives, and Akalitus doesn't seem to care about it. But the episode does not clearly refute the idea that a physician might legitimately complain about a nurse's insubordination. Nor does it refute the implication that nurses really do, in some sense, report to physicians. They don't, and suggestions that they do feed the handmaiden stereotype that has plagued nursing for decades. However, the episode still shows viewers that nurses are skilled clinicians with some autonomy who play a leading role in patient care. The episode, "Twitter," was written by Mark Hudis.
Early in the episode, Jackie approaches and greets two very concerned parents with a child who is about five years old back in one of the ED rooms. The boy is sitting up, but he is receiving oxygen through tubing in his nose.
Dad: It's our son Harry, he has a history of breathing problems. Our pediatrician said it could be cystic fibrosis? We scheduled the sweat test to be sure, but it isn't for another month.
Mom: He woke up choking. Could you help him?
Jackie: Sure. Harry? My name is Jackie. Can I listen to your chest? [She examines him.] Well, it's restricted, but he's definitely getting some air. Harry, do you like coloring books? OK, why don't I get you some coloring books and I'll have a doctor come and take a look, OK?
Harry: I don't like doctors.
Jackie: Yeah, me neither. (To the parents.) Lennox Hill has newer equipment, but we can certainly bundle him up and give him the sweat test here, if you'd like.
Dad: That would be great.
Jackie: OK, why don't you sit tight, I'll take care of that. And Dr. Cooper will be right in.
Soon, we see Cooper with the family, trying to bond with Harry, who is now bundled up for the sweat test. Coop asks how he's feeling. Harry says "hot," and Coop allows that was a silly question. Coop addresses the parents.
Coop: Anyway, it seems strange I know, but it is the standard test to confirm or eliminate the diagnosis for cystic fibrosis. Force Harry to sweat, and then we measure the amount of chloride in his perspiration.
Mom (gently): We know, Jackie explained everything to us. ... How much longer does he have to wear all this?
Coop: Not much longer. Then I'll do everything I can to get you the test results quickly.
Jackie: And I'll do everything I can to make sure he does.
Coop (trying to maintain good humor about this): But I'm on it.
Jackie (doing likewise, but not giving it up either): And I am on him, so...
Coop: I got it.
Jackie: I'll just check. And double-check.
Coop: Little bit of OCD, but...not a bad thing if you're a nurse.
Jackie: Your son's in good hands.
The family is a little weirded out by this evident conflict. Coop wanders away, tweeting. Jackie guesses correctly that he's writing about the kid, and she tells Coop he can't do that because of confidentiality. Coop assures her that everyone but him remains anonymous. She's not placated.
Coop (mostly to himself): If I said "cys fib" would you know that's cystic fibrosis?
Jackie: If I said F.U., would you know that's "eat sh--"?
She walks away.
Coop (speaking what he's typing): Bee-yotch.
Later, with another patient, Jackie asks Coop to stop "Twittering" and focus.
Coop (speaking what he types): Bitchy nurse, being bitchy again.
Later, Jackie stops by to see Akalitus in her office.
Jackie: Hi, a few things. First of all, Coop will not stop Twittering. It is interfering with work and it's pissing me off.
Akalitus: That's interesting. Dr. Cooper lodged a formal complaint against you.
Jackie: Against me, really? For what?
Akalitus: Insubordination and general bitchiness.
Jackie: Insubordin-- (She laughs bitterly.) Twitter-tweetering f---ing d---head.
Without addressing the Cooper issue any further, Jackie goes on to complain to Akalitus about new nurse Sam, a recovering addict who now sees drug abuse all around him (in Jackie's case he is correct), and to ask Akalitus for a pediatric psych referral for "one of my nurses." We know this is actually for Jackie's own daughter Grace. Akalitus clearly suspects this is for Jackie, but she gives her a referral for "the best child psychiatrist" she knows, noting that she was "tremendously helpful with my boy," in what seems to be for her a rare moment of kindness.
Next we see Jackie approach a lab technician and ask if she can get the results of the CF sweat test for Harry's family, as she would really like to be able to send the family home. The technician says she can only give the results to the "doctor who ordered the test." Jackie says, falsely, that "Dr. Cooper really wants the results but he's in with a trauma right now." The tech resists, and politely notes that it's "really preliminary" at that point anyway, so better not to say. Jackie moves as if to leave, but does not. She spots a photo of the tech's own baby and asks about him. After a moment, Jackie observes, "It's really awful when they get sick." The tech relents and tells Jackie that "the whole run's not complete, but the prelims look good." Jackie thanks her.
Jackie goes to the family.
Jackie: OK, I went to the lab, and talked to the tech. You have to keep in mind that the doctor has not seen the results yet. But so far they are looking very good.
The family has not focused on Jackie's hedges, and they clearly take this as a virtual all clear signal--a reaction not discouraged by Jackie's big smile. Jackie tells them they can go home and get some rest. They are tearfully grateful.
Later, Jackie discovers nurse Thor sneaking donuts in the hospital chapel. She gently rebukes him, noting that he's already lost one eye to his diabetes. He's amazed she knows that and asks how--she notes that, during an earlier trauma, Thor could not see her peripherally for quite a while, and also, she used her "Spidey sense." He thanks her for covering for him in the trauma, and notes that no one else knows about the eye, not even his new boyfriend. She looks at Thor's eye with such open interest that he takes it out and shows it to her; she looks at it and him with approving wonder, and not a trace of the squeamishness some might display.
Later, Coop asks Jackie where the "sweat test kid" is.
Jackie: I sent him home. Why don't you run to Akalitus and lodge a formal complaint?
Coop: What do you mean you sent him home?
Jackie: What don't you understand? They were sittin' here for over six hours while you were d---in' around somewheres, so I went to the lab, I got the results, which were negative in case you're interested, and I sent them home.
Coop: Negative. What the f--- is wrong with you? Those test results were preliminary. I was waiting for the final results, which by the way were positive. The kid's got cystic fibrosis.
Jackie: Oh, f---in' God, no.
Coop: Harry and his parents are home celebrating, and now it's my job to pick up the phone and tell 'em that their kid's not going to live to see 30. ... What's the matter, no snappy comeback?
Jackie (crushed): Let me call them?
Coop (slamming the file down in front of her): Have a nice goddamn night.
So that Spidey sense isn't quite infallible. The cystic fibrosis plotline presents Jackie as someone who regards Cooper as annoying and largely irrelevant to Harry's care. And it really doesn't seem like she needs him--she has already explained the details of the sweat test to the family, she appears to set it up without any obvious involvement from him, and she seems to chafe under the structure that requires her to involve him at all. Jackie clearly does not trust Coop to follow up on the results, and she doesn't mind letting Harry and his family know that, which doesn't seem especially helpful. How much of this is because Coop can be pretty clueless about both the technical and interpersonal aspects of care? He is often lost in some kind of personal technology, like the handheld device, or in some isolated physical aspect of care, unconcerned with the patient as a whole. And how much of it is, as Jackie admits to the family, that she too doesn't "like doctors"? Of course, Jackie's best friend Eleanor O'Hara is a physician. Perhaps some of Jackie's corner-cutting is due to her views of Coop, but it seems to be at least as much due to her firm belief in her own advanced skills and health care sense. Maybe she simply decided the kid did not have cystic fibrosis, partly relying on that Spidey sense, and regarded the sweat test as a bit of a formality. It is also possible to read the plotline as a simple case of nurses not being up to the responsibility of managing patient care; only physicians can be trusted with that, and so there's a reason why Jackie needs Coop to sign off on such things.
But in the overall context of the episode, it's probably less that Jackie can't handle the responsibility than it is that she's human, and has allowed her views of her own skills and Coop's to momentarily overwhelm good practice. It is important to keep the error in perspective. There will be an emotional cost to the family for the premature good news, but it's unlikely to cause any physical damage, and to Jackie's credit, she immediately takes responsibility for calling the family to break the news. She has courage and a sense of integrity, and she would never hide behind a physician for an error that was hers, which is not exactly unknown in real nursing practice. An apology to Coop might also have been in order, but that's not exactly her style. Even with her error, Jackie has saved the family from another month of not knowing, by initiating the sweat test. Other elements of the episode underline that she is an expert health professional. Jackie's other interactions with Harry and his family display her usual note-perfect handling of patients. Jackie also spots that Thor has lost his eye to diabetes when no one else knows, and she helps him to feel better about his condition. And though Jackie's use of the information she extracts from the tech is misguided, her scene with the tech illustrates again Jackie's extraordinary ability to get what she needs out of people in order to help her patients.
But the scene with Akalitus continues the show's ambiguous depiction of nursing autonomy. Yes, Akalitus is clearly Jackie's boss, and Jackie herself seems to wield some authority, presumably as a charge nurse, reporting to Akalitus about various personnel issues. But "insubordination"? Neither Akalitus's nor Jackie's reactions to this make clear enough to viewers that there is no basis for such a complaint about a nurse by a physician. Making fun of Coop as a Twittering fool and disregarding his complaint is not enough, because he may just be a fool for making the complaint about Jackie, as opposed to making it about any nurse.
In any case, on balance, Jackie's flaws and over-reaching can actually make for a more persuasive portrayal of her as a formidable health expert, just as such character traits often do with physician leads on other shows (like House). When Jackie makes a mistake, it matters.
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