March 22, 2010 -- Tonight Showtime aired the second season premiere of Nurse Jackie, the "dark comedy" about an expert New York City emergency department nurse who's not afraid to bust a few heads, and pop a few pills, to get the job done. The episode includes more examples of Jackie's clinical virtuosity. She advocates strongly to get a plastic surgery consult for a deaf woman who has had several fingers shot off, despite resistance from junior physician Cooper, who does not seem to get how important fingers are to a person who uses sign language. Then Jackie uses her incredible range of interpersonal skills to get the woman's insurance company to cover the expensive surgery, against all odds. The episode's portrayal of nursing autonomy is mixed. It shows the nasty nurse manager Gloria Akalitus exercising authority over the nursing staff. And Jackie, apparently acting as charge nurse, protects diabetic nurse Thor from Cooper's abuse, then privately counsels Thor to manage his symptoms better. Another scene has Cooper lodging a complaint against Jackie with Akalitus, arguing that he is "at the top of the food chain" and Jackie is "at the bottom." Cooper (who has a thing for Jackie) actually cries in the meeting, and Akalitus does not take the complaint seriously. But viewers may still assume that nurses generally must do what physicians say, it's just that Cooper is unusually callow, while Akalitus and Jackie are unusually feisty. Jackie still handles some things badly, and her seemingly pathological risk-taking continues. Now that the married nurse's former boyfriend and drug supplier, pharmacist Eddie, has been replaced by an automatic pill dispenser, she steals drugs from the machine (Eddie ODs in an effort to get Jackie to return his calls). The show seems more interested in addictive behavior than in nursing. But it still seems set for another compelling season of portraying nurses as skilled professionals who play the central role in patient care. This episode, "Comfort Food," was written by series creators Liz Brixius and Linda Wallem.
One plotline involves the treatment of the gunshot victim by Jackie, Thor, Zoey (who is apparently still a nursing student) and the junior physician Cooper. A paramedic handing the patient off reports that she is the daughter of a cop who reached into a car's glove compartment and got shot with a .357 Magnum. The blast blew off several fingers, which the paramedics have wrapped. The ED team transfers the patient, Lucia Merz, to a bed on Jackie's count. Lucia is clearly in great pain. Coop rudely pushes Thor aside to examine the patient, but doesn't speak to her. Jackie does. She is clearly the leader.
Jackie: Hi honey, my name is Jackie. You're OK. Do you know where you are? [No response.] We're going to give you something for the pain, are you allergic to any medicines? [The patient shakes her head, and seems about to cry. Jackie comforts her, touching her face.] You're OK, you're OK.
Cooper (to the nurses): Call Ortho, have 'em prep the OR.
The camera shows us that the patient is making complex gestures with her hand. Jackie, who misses nothing, sees this. Coop does not.
Jackie (softly, to Coop): What about Plastics?
Coop (louder, as he examines the patient's mangled hand): Be lucky if we can stabilize any of the bones.
Jackie: Well, I think Plastics should weigh in. And look at her when you're talking.
Jackie: Because she's deaf. If they could stabilize the bone, maybe do a vein graft--
Coop: That's a big maybe.
Jackie: Well, we're talking about the hands of a deaf woman.
Coop: Fine, call Plastics.
Jackie: OK, I will.
Coop: Yeah, and they'll tell you the same thing. Twenty hours of surgery for a non-life-threatening injury? Fat f---ing chance. It's pudding, Jackie.
At this point Thor, who has been standing away from the bed at the side of the frame, begins to rattle some equipment. Coop irritably asks what he's doing, calling him "officially useless." Jackie quietly ejects Thor from the room.
Outside the room a moment later, Jackie tells Cooper that she knows he's mad at her (not just because her superior skills embarrass him, but also because she has been spurning his advances, after encouraging them once last season). But, Jackie says, he should not take it out on Thor. She tells Coop that Thor is diabetic, so he had a reaction, but Coop went after him "like a bully on the playground."
Coop: How am I supposed to know?
Jackie: He wears a big f---ing bracelet that says, "I am diabetic."
Thor, standing nearby at the nurses station, holds it up. Now everyone is watching. Coop actually goes over and apologizes, even hugging Thor. After the physically attractive physician leaves, Thor (who is gay) says "totally worth it." But Jackie asks Thor to come with her. They sit in the chapel where Jackie used to hang out with her friend nurse Mo-Mo (a character who is no longer on the show, a major loss in part because he too projected real clinical expertise; it's not clear who will fill that gap this season).
Thor: I'm so sorry, I didn't time my insulin right.
Jackie: You can't do that, Thor. Nurses passing out on patients? Mmm, not good. It's a good thing it was Coop. The other doctors don't scare so easy.
Thor: He can't tell Akalitus that my blood sugar dropped in trauma. She'll move me to...the chemo ward, or...maternity. Ugh. I love trauma.
Jackie: You just gotta remember to eat. You gotta lay off the fried sh--. And the cake. Jesus, Thor, what is it with you and cake?
Thor: I don't drink, I don't smoke, I eat cake.
Jackie: Cake is good.
Thor: It's comfort food. Why do the things that are so bad for you make you feel the best?
Jackie: I hear ya.
Later we see Zoey tell Jackie that Mr. Merz, the deaf patient's husband, is having trouble with their health insurance company. Jackie introduces herself to Merz, who is on the phone with the insurer. He tells Jackie that the company says they are not covered for the procedure to fix his wife's hand. Jackie asks if they have "catastrophic coverage." Merz doesn't know, saying he's been on hold for 20 minutes.
Jackie takes over, urging the husband to go be with his wife. Jackie proceeds to work her way through the insurance company, and we see her speaking in different locations around the hospital with different insurance company people apparently scattered around the nation. She uses tactics that range from sympathizing about how people don't read their policies carefully enough, to pointing out what the woman's policy does cover, to noting that as a deaf person the woman really does need her hand, to going over people's heads, to bonding about how awful it must be to work for a company that sells people "something they can't use." Finally, Jackie bonds with a Chicago supervisor about Irish bars on the South Side of that city, which she actually knows nothing about, but has simply Googled as she is talking. She zeroes in on this manager, telling him that he doesn't need to consult anyone else, this is his "moment" to "step up and do the right thing." Later, as Jackie leaves at the end of her shift, we see an insurance approval from this manager come in on a fax machine addressed to "Jackie / Nurses' Station."
A fantasy? If so, of all the fantasies that populate the universe of serial U.S. television, surely this is one of the most compelling--that a talented and committed professional can find some way to provide for critical health care needs that would otherwise be unmet in one of the wealthiest nations on the planet. Of course, it is also a blunt criticism of the existing private health insurance system, which many believe offers inadequate coverage to those fortunate enough to be insured at all. And the plotline shows Jackie to be an extraordinary patient advocate, fighting to get Lucia Merz the plastic surgery she needs to resume her life, both in persuading Coop and in single-handedly getting the insurance company to pay for the procedure that Coop said would never happen, with an impressive mix of logic, toughness, deception, charm, and moral suasion. Somehow the show brings this off, and it's partly because Jackie is so flawed that her extraordinary gifts make sense--like other talented people, she's very far from perfect, and we can also see how some of the same traits that feed Jackie's addictive conduct, particularly her ability to manipulate and deceive, also make her an effective nurse. Of course, nurses should not have to act that way to protect patients. But in this world, sometimes they do.
Jackie's efforts on Thor's behalf are also impressive. She protects him from Cooper, even extracting an apology in front of much of the ED staff. But she also counsels Thor to do better, or else he will place patients at risk. She does so without preaching, and expresses understanding of his situation. Whether it will be effective is unclear. But in terms of nursing autonomy, the point is that she projects authority effectively both in protecting her nurse colleagues and guiding them, promoting their practice and protecting patients.
Still, are Jackie or her boss Akalitus bullies, or to use the nurse-specific term, battleaxes?
When Jackie arrives to start her shift, she is almost shot by an unidentified gunman, who is then subdued down the hall. Akalitus, meeting with Zoey in her office, hears the shot but shrugs it off, simply asking someone on the phone whether anyone has been hit and if security has been deployed. Jackie pops in and reports that she was not hit, but a statue of the Virgin Mary was. Of course it's funny that these two veterans are unfazed, though some real nurses might find that the scene trivializes the very real problem of violence against nurses, which is often not adequately addressed.
Akalitus is meeting with Zoey because the manager is concerned about the nursing student's possible involvement in several recent ED problems (all of which we know have far more to do with Jackie). The main issue seems to be that the "shrinkage" rate of the Pill-O-Matix drug dispenser at the pharmacy has "caught the attention of the state." Jackie, who herself is responsible for some if not all of the missing drugs, tells Akalitus that it's just "a robot."
Next we see Akalitus forcing Jackie, of all people, to lead a meeting of all the nurses in which she is supposed to come down on them for the missing drugs. Jackie is not warming to the task, and Akalitus can't resist breaking in and stressing how unacceptable the situation is ("This is not a candy machine, people!"). Jackie turns even this event into a drug-acquisition opportunity, using a demonstration of how to handle the machine to swipe some Ativan right under the noses of Akalitus and everyone else.
Later, Akalitus introduces new nurse Sam to Jackie and Jackie's best friend, physician Eleanor O'Hara. Sam is an addict, as Jackie reminds Akalitus privately, referring to a time (last season) when he worked in the ED as a temp ("You know I dismissed him because he was wacked out on Benzos, right? You do read my staffing reports?"). But Akalitus says Sam is recovering and has great recommendations. Sam is quiet but seems perceptive; he quickly tagged Jackie as a fellow drug abuser last season, and although he's far more sensitive now, it's clear he has not changed his mind. Of course, seeing Jackie trash another nurse as an "addict" is amusing.
Later, we see Akalitus on the phone in her office, telling some All Saints Hospital administrator that she will "come down there and kick [his] ass" if she is not promptly reimbursed for a "refurbished med-fusion syringe pump" she recently bought for the ED, with his approval. Akalitus smiles and closes the conversation: "Thank you, Monsignor." Coop arrives and says he needs to "lodge a formal complaint against a nurse." Akalitus says, "Super."
Coop: It's Nurse Jackie. She constantly challenges my decisions, is bossy, and rude, and...unpleasant. Bully...that's the word, she's a bully. There's a chain of command here that she refuses to acknowledge. I am at the top of that chain of command, OK, and she is at the bottom. And I am at the top! If this were a food pyramid, I would be the steak.
Akalitus (taking notes): Well, technically, I think the fats and oils are at the top of the food pyramid.
Coop (starting to lose it): I am a good f---ing doctor, and for a nurse, a nurse, to be messing with my head by constantly undermining me...Am I going too fast? Because I can slow down if you need me to. What happens when a patient gets wheeled in here some day, and that poor guy sees Jackie yelling at me like I'm the world's biggest a------e? How do you think it makes the patient feel?
And he actually starts crying. Akalitus stares at him, then thanks him and says she'll "get into this." He says he feels better, and leaves. We see the complete text that Akalitus has written on her pad, repeated four times: "World's Biggest A------e."
All of these plot strands show Akalitus acting as a nurse manager with genuine authority over her staff, though of course Jackie does not take her especially seriously. Jackie is presented as having some authority over the staff nurses as well, apparently as a charge nurse. At least on a day-to-day basis, it is clear that the nurses on the show report to other nurses, not physicians, and neither Akalitus nor Jackie really abuses her authority here. This may not seem like a big deal, but Hollywood shows continue to struggle with whether nurses report to physicians. They clearly do on House and Grey's Anatomy. And the battleaxe stereotype, in which nurses who do have authority are bitter crones obsessed with enforcing trivial rules, remains a factor in Hollywood shows.
The scene with Coop sends a more ambiguous message. Akalitus is not taking him too seriously, and there is no indication that she plans to come down very hard on Jackie for his complaint. But Akalitus doesn't respond directly to his remarks about the chain of command either. Mocking Coop about whether he's steak or fat doesn't tell viewers that, though physicians do have more power than nurses, they cannot actually give them "commands." Viewers may conclude that Coop and Jackie are outliers, and in general, nurses do have to obey physicians. In fact, other nursing figures on the show--Thor and Zoey spring to mind--are too deferential to the physicians, as if physicians are basically in charge. The episode doesn't tell viewers what is true: that nursing is an underpowered but still autonomous profession, and there is no one "chain of command." There are two separate chains of command--one for each profession. Is it OK for nurses to challenge Coop's decisions as part of their vital patient advocacy role, or is that out of line, but just something Jackie gets away with because she's Jackie? Of course, one underlying message seems to be that nurses like Jackie should have more power than they do (and perhaps that physicians like Coop should have less).
Are Jackie and Akalitus bullies? Last season, Akalitus was often presented as a type of bureaucratic battleaxe, despite showing a softer side (rarely). In this episode, she's hardly softer (consider her handling of the Monsignor), but at least she is acting to protect legitimate interests. She should be reimbursed for her equipment purchase, and she has a right to expect that nurses not steal narcotics, to say the least. Here Akalitus is not enforcing trivial rules for no good reason. It's true that she doesn't defend Jackie to Coop. On the contrary, she gives Coop the impression that she welcomes his complaint and will take it seriously. So although nothing much seems likely to happen, Coop has learned nothing. Still, on balance, in this episode Akalitus is probably more of a savvy, hard-nosed manager than a battleaxe. As for Jackie, her less-than-respectful treatment of Coop is well-deserved, it's in the service of important goals, and it's largely reactive--she does give Coop a chance to do the right thing, and it's only when he fails so miserably that she responds with force. His dismissive, disrespectful treatment of the deaf patient is especially egregious. So it's hard to consider Jackie's treatment of him to be bullying. And her interactions with the insurance company are really different forms of persuasion.
Jackie still has a serious drug problem. Some nurses cringe at this part of the depiction, and now there is another nurse character with a drug problem, the new nurse Sam. But as we noted last season, such conduct really is not a stereotype that nurses have traditionally faced, and there is plenty of precedent for drug abuse as a problem of gifted TV physicians, from House to ER's John Carter to M*A*S*H's Hawkeye Pierce. So while Jackie is no role model in this respect, the character is tremendously helpful in showing the show's viewers again and again that nurses can be tough, expert clinical leaders who save lives. Of course, it would be helpful if another nurse character also displayed the kind of expertise that Mo-Mo did on occasion last season, so it is clear to viewers that Jackie is not the only nurse with advanced clinical skills. In this episode, none of the other nursing characters really fill that role.
Nurse Jackie isn't exactly comfort food, and there's not much fat. But the show remains, along with NBC's Mercy, at the top of the pyramid of Hollywood shows with nurse characters.
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