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Always remember to help ladies on with their coats!

June 29, 2009 -- Tonight's episode of Showtime's Nurse Jackie highlights the expert psychosocial care Jackie Peyton and her nurse colleague Mohammed (Mo-Mo) de la Cruz give to ED patients and families. No one could mistake these nurses' thoughtful, sensitive care for unskilled hand-holding. The episode also suggests that physicians are often less adept at these tasks, even though they may receive all the credit from those the nurses have helped. Once again, the show's nurses play a central role in patient care, and Jackie ably trains more junior health team members. At the same time, the episode features a remarkable scene in which a school nurse goes head to head with Jackie about whether Jackie's daughter has a potentially serious anxiety disorder that may require medication; both of them seem to have valid points. One less impressive aspect of the episode involves Jackie ordering the removal of a patient's non-disruptive mother and twin brother from a trauma room without asking if they want to stay, just like the physician characters in other hospital shows do, with no hint of the potential benefits of family presence. This fourth episode, "School Nurse," was written by Christine Zander.

Psycho-social care

The school nurse

Family presence

Psycho-social care

The main patient in the episode is Julian Armando, a boy who has fallen from some playground equipment. Paramedics roll Julian to the ED with a collapsed lung. Jackie spots him as "a kid" from her first glimpse of his sneakers down the hall, and you can hear the sadness in her voiceover. Jackie, Mo-Mo, and senior physician Eleanor O'Hara gather in a trauma room and provide skilled physical care to the boy. Mo-Mo seems to identify strongly with Julian, noting that basic city playgrounds like that from which the boy fell are not very safe:  

Central Park gets those rubbery ground covers. Alphabets get monkey bars and concrete.

Jackie asks nursing student Zoey to remove the boy's mother and twin brother from the room while they treat Julian. As Eleanor skillfully inserts the chest tube Jackie has chosen, Mo-Mo holds the boy's hand: "Hang in there, little man."

Just outside the trauma room, the mother and her uninjured son Justin observe junior physician Fitch Cooper doing a silly celebratory dance because he will soon get to treat a gunshot victim. Zoey struggles to explain to Julian's family why Cooper would act that way. Later, Eleanor and Jackie update the mother. Eleanor tells the mother that her son is stable, but the physician scares the mother by describing some of the terrible things a CAT scan might reveal is wrong with her son, with no indication as to how likely those outcomes are, and no evident recognition in her voice of how awful they would be. At the same time, Jackie is mouthing the words "it's not that bad" to the mother. Aloud, Jackie notes that the boy is sedated and that they got the fluid out of his lungs. Jackie also engages the uninjured twin Justin by surmising that he is slightly older than his brother. After Eleanor and Jackie walk away, Jackie turns and signals Zoey to give the mother and brother a hug. Zoey does this awkwardly, but the family accepts and seems to appreciate it.

Later, Eleanor returns with CAT scan results showing that Jackie is correct about the injured Julian's status. The mother tearfully thanks Eleanor, who says the mother can go see her son. The uninjured twin Justin simply hugs Eleanor and will not let go, even as the physician tries to walk away. Eleanor--who dresses expensively, is a bit of an elitist, and regards children as aliens--is at a complete loss. She does not think to return the hug, but instead calls in vain for Jackie (her best friend) to come and help her handle the boy. Later, Eleanor tells Jackie that she wishes the nurse had been there to deflect the boy's "hero worship" with her "nursey" qualities.

Still later, we see Justin return to the nurses station to give Eleanor alone a picture he has drawn to thank her for what she did for his brother--though Jackie is also standing right there. Once again, Eleanor has no idea how to handle this. She thanks the boy, tapes the picture to the nurses station, and, searching blindly for some parting words of wisdom for a child, advises Justin to "always remember to help ladies on with their coats."

In a later scene, Julian lies in his hospital bed, still sedated. Alone at the boy's side, Mo-Mo softly sings him a beautiful song in Arabic.

In another plotline, Jackie, Mo-Mo, and Zoey receive an elderly patient named Lucille, who apparently comes into the ED from her skilled nursing facility on a regular basis for help with her end-stage chronic obstructive pulmonary disease (COPD). Jackie assigns this patient to Zoey, after Zoey lets Jackie know she has been shut out of all the interesting cases that day. Zoey tries to get Lucille to keep her oxygen mask on. When Cooper arrives to examine Lucille, she flirts openly with the attractive young physician. And she is mock-distressed when Cooper discovers she wears a wig. Coop--under Jackie's watchful eye--handles this with surprising sensitivity, and at the same time actually encourages Lucille to keep the mask on. He leaves.

Unfortunately, Lucille soon dies. Zoey is very affected by this. Jackie helps her through it, noting that "everybody has a first; it's never easy." Zoey wants to "do" Lucille's eyebrows so she will look better, and Jackie assents. Meanwhile, outside, Coop is celebrating like an idiot after helping to save the gunshot victim ("Coop, one; death, zero!"). Zoey asks Jackie if they should tell Coop about Lucille. Jackie tells her to let him enjoy his success with the other patient.

Many of these scenes have comic elements, but one cumulative message is overwhelming:   Jackie and Mo-Mo are the psychosocial care experts. Other aspects of this episode do show that Jackie is not perfect at handling her own family's issues, in particular her daughter's apparent anxiety problem, but at work she is both a virtuoso and a gifted conductor of interpersonal relations. She makes just the right moves with Justin's family, while skillfully managing the professional development of Zoey, and even of Coop--a role in which, incidentally, she clearly surpasses the young physician's nominal superior Eleanor. As for Zoey and Coop, they have a lot to learn about sensitive care, though each shows some potential. Eleanor is hopeless. Yet it is she, as a senior physician, who receives all the tearful thanks from the mother and brother of Julian, the boy injured on the playground. Similarly, although Coop handles the COPD patient Lucille well, her intense concern about how he sees her is not just because he is an attractive young man; it is also because he is..." Dr. Cooper !" Jackie and Mo-Mo are operating with great skill, and getting great results--but little credit.

The school nurse

An important plotline involves Jackie's elementary age daughter Grace, who has grown increasingly focused on large scale disasters and seems very depressed. In this episode, Jackie and her husband are called to the school for a meeting with Grace's teacher, the school nurse, and a school psychologist.

The teacher introduces them by saying: "I've asked Connie, our school nurse, and District psychologist Skip Nannerine to weigh in." The nurse gets only a first name, as if she's a pet, whereas the psychologist gets a first and a last name. Ideally nurse characters would get full names as other professionals do, though of course we can't claim the scene is entirely unrealistic, since a nurse like Connie might well have been introduced this way.

The school staff express concern about Grace, explaining that she circles her desk three times "so the planes don't fall out of the sky." They note that the pictures that Grace draws have no color and no sun, which is a red flag for children, who tend to draw optimistically. Jackie's husband asks how they should proceed.

Skip:  I'll be happy to furnish you with a list of psychiatrists. Sliding scale for income/insurance. They'll be able to diagnose Grace.

Connie:  And put her on what I think is necessary, an age-appropriate low-dose anti-anxiety medicine.

Jackie snaps:  OK, that's enough out of you.

Jackie is very defensive about whether her daughter has a problem, especially the suggestion that she may need medication. It's true that the psychologist is presented as a pretty odd man. But after the meeting, Jackie follows the nurse down the hall and seems to try to make peace, noting that they are both nurses, and almost pleading for some recognition that perhaps they are exaggerating her daughter's problem. But Connie gives her nothing, noting stonily that it's "a big deal. ... Your daughter has serious issues." A student stops with a note for nurse Connie. She reads it, feels his chin and notes that he feels warm. Jackie snaps: "Yeah, you better get him started on Prozac."

These interactions don't show either nurse as a wonderful person, but they do present them as tough professionals who at least think they are advocating for Grace's interests. And both may have valid points, at least to some extent. The school nurse could have been more sensitive, and it goes without saying that Jackie could have. But the show is plainly suggesting that Grace does have a problem, and would Jackie have listened to any other approach from the school staff? As for Jackie, some health professionals do believe that others are too quick to put children on potentially harmful anti-depressants, when in many cases the children's issues may be addressed through social or dietary changes, such as ensuring the children are receiving sufficient amounts of DHA. Of course, we are doubtless meant to understand that Jackie is reacting with hostility to some extent because of her own drug problem. But that is hardly unrealistic, and it's nothing we have not seen from physician characters on other hospital shows, who often have difficulty managing family members' health issues.

Family presence

One issue we saw in the episode was that, after Julian arrived in the trauma room and the team gathered to treat him, Jackie told Zoey to remove the boy's mother and brother. Of course, this is essentially what happens on the standard physician-centric hospital drama:   A physician commands a nurse to get family members out, presumably because they will disrupt things or cannot handle seeing the procedures. But we hope for more from Nurse Jackie. In fact, in recent decades nurses and chaplains have led the movement toward increased family presence during emergency procedures, a practice that nurses have shown can benefit both patients and families [see links one, two, three]. It's true that in this case, Julian's mother was fairly upset, and the chest tube procedure might have been a challenge for her, but Jackie should have at least offered her the option to stay. And Jackie, Mo-Mo, or Zoey might have offered the mother and brother a little guidance to help her understand and come to terms with what was going on. This might have been especially helpful since the episode makes a point of emphasizing how close twins are, having Mo-Mo describe to Zoey the bond he feels with his twin brother, even though the brother died at age one.

On the whole, though, the episode offers viewers yet another powerful look at the central role expert nurses play in emergency care.

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