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Cunning, baffling, powerful

Nurse Jackie returns

Nurse Jackie and Mike Cruz 
April 14, 2013 -- With the fifth season of Showtime's Nurse Jackie set to begin tonight, it's time to review the last season, which aired in spring 2012 and once again highlighted the central role nurses play in patient care. Most of the season focused on Jackie's recovery from her drug addiction and other personal issues. But when there were clinical scenes, the show continued to present Jackie, at least, as essentially a peer of the physicians. She was a clinical leader providing creative technical and psychosocial care. And in the last two episodes of the season, she actually took over the emergency department in the midst of a staffing crisis, running it expertly until the malevolent hospital CEO Mike Cruz fired her. The show also featured more credible, compelling interactions among nurses, and between nurses and physicians, showing that nurses are sentient three-dimensional beings. All of that is rare in Hollywood. Jackie's quirky mentee Zoey Barkow continued to show potential as a future version of Jackie--at several points Zoey showed the kind of clinical courage and initiative that Jackie does. There is still no really strong male nurse character, though nurses Thor and Sam do seem to have settled into their roles as competent, funny Jackie acolytes. On the downside, the show continued to struggle to portray nursing autonomy. There were several more suggestions that physicians control nurse staffing, and, after Cruz demoted nurse-manager Gloria Akalitus to staff nurse, the show proceeded without any apparent nurse managers at all. Still, on the whole, Nurse Jackie remains probably the best show for nursing in U.S. primetime television history. The executive producers of the show are Linda Wallem, Liz Brixius, Richie Jackson, and Caryn Mandabach.

I also work for you

I'm a nurse

The new All Saints duds

I'm in charge

Might be a genius


I also work for you

dumping bag out for counselorEarly in the fourth season, Jackie has split from her husband Kevin after he confessed to an affair. Meanwhile, Jackie's drug use has begun to catch up with her. In the April 8 episode ("Kettle Kettle Black Black" by Liz Brixius), we see Jackie arrive at a drug rehabilitation facility, where the tough, savvy counselor Laura tells her she is now accountable and makes her empty out her bag, looking for drugs. The counselor notes that it looks like "detox is gonna be a bitch."

The show flashes back to 24 hours earlier. Jackie's colleagues, at the nurses' station, have just learned that their hospital, All Saints, has been bought by a large, highly diversified company called Quantum Bay. Gloria Akalitus, a nurse who dresses in suits and has some unspecified management position, tells Jackie that she has to work a little while longer that day.

Jackie arrives at a patient's bedside and checks his IV, addressing a nearby woman wearing patterned scrubs: "Oxy sat? Any word from the ICU?" The woman says she doesn't know. Jackie: "Oxygen levels, what are they? By the way, crying on the floor? Not cool." The woman says she's not a nurse but the patient's girlfriend; she's a dog groomer who came from work. Jackie changes her tone immediately and says she is "so sorry, I thought you were a temp nurse." The girlfriend, whose name turns out to be Cory, is distraught, saying that "that English lady [physician Eleanor O'Hara] said his organs might shut down." Jackie assures Cory that they will get plenty of warning signs of that, so she should not worry. Zoey loving dog groomer's patterned scrubsZoey, who is normally attired in pink bunny scrubs, steps in beside the dog groomer: "Not great timing, fully aware, but I love your scrubs." Jackie returns later with some supplies and tries to calm Cory. She advises eating some of the vending machine snack food she has brought, noting that Cory will not want to eat in the ICU. After Jackie leaves, Zoey pops in for one more patterned scrubs affirmation; Cory smiles at her indulgently. These scenes, beyond showing Jackie's casual skill, renew the show's gentle criticism of patterned scrubs, which are now worn by many people with little or no health care training and which many feel undermine nurses' efforts to be perceived as serious professionals.

Meanwhile, Jackie has her first encounter with the new hospital CEO Mike Cruz. The white-coat-wearing physician executive is text walking when he bumps into Jackie, who is balancing a number of items for the unconscious patient, including blankets. The distracted Cruz says, mildly, "Watch yourself." Jackie: "Watch your own fuckin' self." Cruz: "Is that really necessary?" Jackie: "To get your doctor head out of your doctor ass? Yeah, I guess it is. My hands are full. Yours aren't." (OK, maybe even a tough nurse like Jackie would not be likely to use that language right off the bat here, but this is premium cable, where the idea seems to be that viewers need regular jolts of profanity or they aren't getting their money's worth.)

Jackie, O'Hara and dead guy in Jackie's apt.Jackie stops at a church on her way home, picks up a stranger, who is also a fellow addict, takes him home and gets high with him. Then he dies in her living room. Jackie and her physician friend O'Hara manage to cover it up, but after three seasons of addiction, Jackie is ready for rehab. The well-connected O'Hara gets Jackie into a 28-day facility specializing in pills, starting after work the next day.

We see Jackie, back in the emergency department, caring for the patient with the dog-groomer girlfriend Cory. His name turns out to be Dustin and he is now conscious. Jackie notes that his white blood cells are going up and wonders if they are packing for the ICU. Cory says Dustin wants to go home, and that he wants to "dine 'n' dash"--go home because he cannot afford the hospital stay. Jackie says no, though if she could "sneak you out the back door with a couple of pills, believe me, I would do it." He says he is starting to feel better. Jackie: "Because you spent the night on supplemental oxygen and IV fluids. You're gonna need 72 hours of bed rest and intravenous antibiotics. This is not something you can do on your couch." He agrees. But Cory quietly confides to Jackie that he will still leave. Jackie tells her to just keep him there till she returns: "Sit on him, he's too weak to push you off."  

Cruz holds an informal meeting in the emergency department to introduce himself to staff, noting that he is a physician who works for Quantum Bay, "but I also work for you." He promises to take All Saints, for which he seems to have some contempt, into the future. As he speaks, Jackie enters a room to the side, apparently to get medications. Akalitus chastises Jackie for ignoring Cruz, but Jackie correctly notes that he told them to keep working. Corey sitting on DustinJackie takes Zoey back to Dustin and Cory, who actually is sitting on Dustin. Jackie asks Zoey to show Cory how to start an IV line and administer meds, because she is sending them home with 72 hours of antibiotics. Jackie asks Zoey to get them cab fare, and tells Cory to give Zoey her number so she can check in: "Zoey Barkow, most reliable nurse I know, rely on her." Of course, Jackie knows that she herself will be in rehab and not available, because this is the sort of thing she normally would have taken responsibility for. Soon, Jackie tells Akalitus that she has to leave early and cash in 28 days of vacation. Akalitus gets it. These scenes are good portrayals of nursing skill and authority; presumably physicians are involved, but Jackie is calling the shots, and trying to give this apparently terminal patient and his distraught girlfriend a measure of peace and control.

Akalitis refusing to shake Cruz's handThe episode includes several final interactions with Cruz. At one point he sees Jackie, and wants to know if she's going to pay for "those meds you stole during my intro." Jackie: "Dock my pay." She just walks away with O'Hara, toward the car waiting to take her to rehab. Later, Cruz meets with Akalitus. After a few compliments about her intellect and job performance, Cruz basically demotes her back to staff nurse because "the mortal enemy of efficiency is redundancy" and he's doing her job now. Cruz tells Akalitus she can go back on the floor for two years and collect her pension. She asks Cruz if she is still "their boss," meaning the other nurses, and he seems to says yes. But Akalitus won't shake his hand, noting that "it's cold season, Dr. Cruz." 

Akalitus has always seemed to manage the nurses and have some administrative authority over the whole emergency department, the pharmacy, and in some respects even the physicians. But the Cruz development appears to leave the show without nurse managers. And as it plays out in further scenes throughout the season, this new order will reinforce the sense most viewers already have that nurses generally report to physicians rather than other nurses--a damaging inaccuracy.

I'm a nurse

CharlieThe rehab counselor Laura was right:  detox is hard for Jackie, and in the April 15 episode ("Disneyland Sucks" by Liz Brixius), we see Jackie suffering in bed for days on end. When she is out of bed, she is surrounded by annoying fellow patients, including her kleptomaniac roommate Doris. Invited to tell about herself in group therapy, all Jackie can come up with is, "I'm a nurse." Jackie and a green-haired 17-year-old named Charlie bond. Jackie tells the group that she only used narcotics when not doing so would affect her ability to do her job. Laura wonders if the drugs make her a better nurse. Jackie says she can work longer hours, and "not lose my shit with the patients." But another patient notes that "narcotics impair your judgment." Jackie claims that she first took Vicodin for actual back pain, having slipped on a pool of urine.

Later, Jackie again has occasion to remind Laura that she is a nurse.

Laura:  I need you to stop identifying as a nurse.

Jackie:  I can see how the glamour might intimidate people.

Laura:  You're good at your job. You suck at life. You're not a nurse, you're a patient.

Jackie, Grace, O'HaraJackie bonds more with Charlie, who is on his fourth rehab; he's ready to die, and he sees through Jackie's lies, telling her he knows she was into pills before her work injury. Jackie admits she started using to handle her first baby Grace's crying for 2 years; she stole some Percocet and never looked back. Jackie telephones O'Hara, which is actually not allowed, and asks her to bring Grace to see Jackie, which is also not allowed. When O'Hara does bring Grace, Jackie creates a diversion by telling the woman at the nurse's station that Charlie is hiding a phone in the janitor's closet and then manipulating the woman into getting it, claiming it's a secret that threatens Jackie's sobriety. When the woman leaves to investigate, Jackie takes over her station so she can pretend to Grace that she is actually practicing nursing there at the rehab center. Grace wants Jackie to come back home--because she needs her mother's help in switching from Catholic school to public school. The rehab staffer returns and kindly plays along with Jackie's illusion for a few moments until Grace and O'Hara depart, but later, the counselor Laura is less cooperative. Laura asks Jackie to pack her things. Jackie tries to explain that Grace is not an easy kid, and confesses that her drug use is about Grace, not her back pain. Now it is Jackie's turn to want to leave, but she pleads with the counselor to let Charlie stay, because outside, Jackie says, he'll be dead in a week.

Counselor:  What really concerns me is that you think you are less sick than he is. … Cunning, baffling, powerful. You don't even see it. … You are a drug addict.

Jackie (barely keeping it together): There is sweat pooling in my bra. I can't keep any of my food down. So whatever point you're trying to make, it's made. It's already made!

Now it is Laura's turn to restrain Jackie from leaving.

Counselor:  Cut the shit. Respect the rules. You're not a nurse. You don't work here. The only life you get to save is yours. Put your shit away.

But the show can't resist tweaking that message. Later, Jackie hears her roommate Doris having trouble breathing. Jackie brings her water. But Doris doesn't move. Jackie's tone changes immediately and she starts speaking gently and calling Doris "honey." Doris having a strokeJackie goes to the door.

Jackie:  Can I get a hand? She's having a stroke. (Hearing a voice ask that an ambulance be called, and returning to the bed.) OK, honey, can you lift your arm for me? How about a smile? Can you smile for me? I know you hate me, doesn't have to be a happy smile. There you go, that's great, you see how great you're doing? You're OK, you're OK. Everything is all right.

While saying all this she is stroking Doris's hair and arm. Doris looks stunned, though it's not clear how much is the stroke and how much is Jackie's behavior. As paramedics wheel Doris out, Jackie and Laura watch.

Laura:  Fine, you saved a life. Happy? Go to bed.

Jackie concedes that she is happy. And catching the stroke early so that medications and interventions can limit the potential damage is a life-saving nursing assessment that is immensely valuable.The scene reminds viewers that Jackie is indeed a gifted life-saving professional. Beyond that, the rehab scenes underline how central nursing is to Jackie's being. She does seem to identify more as a nurse than anything else, and it gives her purpose and strength, although it's also clear she has used nursing as an excuse, claiming to need the drugs to cope with her job. The show throws in the idea that narcotics can impair her judgment, although that is something that it has never made as much of as it probably should have. Jackie's been doing tons of drugs for three seasons, but we have virtually never seen it undermine the quality of her care.  

Team stopping for CruzThe episode also includes some scenes back at All Saints, and these are a mixed bag. Both nurses and physicians clearly miss Jackie's clinical presence, with O'Hara asking at one point what Jackie would have done, and Coop saying that Jackie would have loved something he did to tweak a friend of a patient who was annoying the patient. But there is also an unhelpful scene with CEO Cruz and the other physicians that falls into the conventional "physicians manage nurses" narrative. In that one, Cruz is pitching big ideas for All Saints to become a level one trauma center to O'Hara and Cooper; of course, no nurse is involved, since nurses would presumably have no role in that conversation. (!) O'Hara is concerned that Cruz will "get our nurses' hopes up, then cut and run when your profits don't materialize." Cruz claims Quantum Bay is committed, "so you tell your nurses that Mike Cruz just hired a crew to expand the elevator shaft for a helipad." The foolish Cooper is very impressed. The problem here is the suggestion that the nurses somehow belong to O'Hara, and that it's her role to try to sell them on Cruz's new ideas.

The new All Saints duds

Kevin, Eddie fightingJackie leaves rehab only half way through, but she manages to stay sober, in part by getting rid of Kelly Slater, a fellow drug user who looked like a good nurse last season, but who tries to tempt Jackie with drugs upon her return to the emergency department. Kelly disappears after Jackie confidentially tells him that hospital management is on to his past drug thefts. Unfortunately, pharmacist Eddie has told Jackie's husband Kevin about his long affair with Jackie, and then Kevin assaults Eddie. In the May 6 episode ("One-Armed Jacks" by Rajiv Joseph), Kevin serves Jackie with divorce papers.

The episode has another bad plotline for nursing autonomy. The hospital CEO Cruz prepares to set a new uniform policy, telling physician Cooper that Cruz will be "dropping a morale bomb on the troops today . . . uniform scrubs on the nurses." Coop says that's "not gonna fly."

Cruz:  It's not a question of personal taste. Patients need to know who does what the minute they walk in here. Trust me. I don't relish the role of the villain.

Cooper volunteers to break it to the nurses and Cruz says he would appreciate that. But when Cooper convenes a meeting of nurses at the hospital chapel to introduce "the new All Saints duds," things don't go as he had hoped. The scrubs are dark blue and could be worse, but the nurses are not having it; one says he assumes it's optional. Coop says no. Nurse Sam wants to know why Coop is "such a dick." Many of the nurses present agree he is one. Zoey asks why Cruz is making Cooper do his dirty work. Thor: "Tell Cruz we said no." They all leave. Later, Coop hands Cruz one of the boxes of scrubs and saying, "Those people are animals."

Coop displaying new scrubsActually, a hospital CEO might reasonably impose this policy, given the recent proliferation of unlicensed caregivers who look like nurses but don't actually have the skills to do nursing. So the Cruz character might be given credit for pushing this; some CEOs seem happy to have patients think they are surrounded by nurses when in fact they are not. But the big problem is the nurse-free conception and rollout. Having Cruz push this policy through Cooper, with no nursing involvement, will clearly suggest to most viewers that nurse managers don't really exist, and that whatever weird job Akalitus once had, the general rule is that physicians manage nurses, even down to their uniforms. Of course, the nurses hardly respect Cooper, so at least they are not timid mice. But having the nurses abuse Cooper, however much fun that might be, is no substitute for telling the truth:  nurses are managed by other nurses. The show has again fallen into the convenient, but very damaging, Hollywood stereotype that nurses lack autonomy.

I'm in charge

Jackie, Cruz and CharlieAs the end of the season approaches, Jackie stays sober. But her work life falls apart anyway, largely due to the vindictiveness of the CEO Cruz--who turns out, in just a bit of a coincidence, to be her young addict friend Charlie's father. One plotline features Jackie and Cruz together getting Charlie through a drug-related episode. Of course, Cruz learns that Jackie was in rehab with his son. Charlie asks his father to promise not to fire Jackie. Cruz does promise that, but he would clearly like to fire her; his experiences and bad relationship with Charlie don't seem to have inclined him toward giving addicts fair treatment. And since Cruz can't fire Jackie, he fires Eddie and Akalitus for enabling her drug use over the years.

Collection jar for Akalitus and EddieAt the start of the June 10 episode ("Are Those Feathers?" by Liz Brixius and Liz Flahive), Cruz is annoyed that the nurses have set up a fundraising jar for Eddie and Akalitus. And he is especially on edge because Quantum Bay board members are in town and he is trying to get free to go meet with them. Jackie, back at work, manages to tolerate Cruz up to a point, apparently feeling that she can't allow herself to get fired when her two friends have gone down for her.

An intoxicated and unconscious male patient arrives in the emergency department. Jackie and Cruz take the case. Jackie starts ripping off the patient's clothes to get a condom catheter on him before he urinates all over. But Cruz wants his blood pressure and heart rate first. Jackie says there is only a tiny window and she doesn't want to clean up pee. Cruz: "I asked nicely, do it now." Jackie hesitates, then says fine and starts ripping the patient's jacket so he can get on the monitor. Feathers flyingBut this sends the feathers inside the jacket everywhere. Jackie says she did what Cruz wanted and invites him to fire her. He says he promised Charlie not to do that, plus he doesn't have to fire her because she's a drug addict and will screw up at some point. He tells Jackie to do the vitals, set up a catheter and a banana bag, and put the patient in the hall, then he leaves. This scene shows how nurses can suffer when physicians are abusive. But the scene also suggests that Jackie reports to Cruz, or at least that he is in charge of how nurses prioritize their care. Her revenge is funny, but as with the abuse Cooper took about the uniforms, that's not enough.

Another clinical case in the episode better illustrates Jackie's skills, particularly as a mentor to Zoey. In this plotline, Jackie and O'Hara treat Tasha, a patient who seems to be having her first migraine. Jackie asks if she is a smoker. Tasha says yes, off and on, more since her mother became ill and recently died. O'Hara notes that stress can trigger migraines. Jackie reports that her BP is high. O'Hara asks for a CT scan. Later, O'Hara reports that Tasha has a sub-arachnoid hemorrhage and needs surgery quickly. Jackie's comments may have been hinting at a diagnosis like this, but it was probably too subtle for most viewers. Jackie tries to comfort Tasha, but she is concerned about her father, who is about to be released from Bellevue hospital, having recently fallen. Tasha wants to leave so she can pick him up. Jackie asks Cruz if they can have someone pick up Tasha's father. He says no, if she wants her job. Zoey doesn't like that and in general can't understand why Jackie isn't pushing back against Cruz more. Jackie: "You want things to be different, you handle it, like you're me." And so Zoey does, going to get the patient's father herself. But the father refuses to take a cab back to All Saints, so she rolls him on a gurney (!).

Zoey pushing gurneyMeanwhile, Jackie pushes Cruz to approve six temporary nurses because the emergency department is facing a crush of patients (the show does not take note of how Zoey's absence would affect this situation). Cruz refuses to increase staffing, presumably to control costs, perhaps in part because he's so focused on heading out the door to the Quantum Bay board meeting. But on his way to the meeting in a cab, he sees Zoey and Tasha's father on the street. Cruz actually gets out of the cab and helps Zoey push the gurney the rest of the way. Still, Cruz seems mad on arrival at the emergency department.

Jackie: What's Zoey supposed to do? Leave the guy on the curb? He just lost his wife, his daughter's going up for brain surgery. Please, please let her do her job.

Cruz (seeming unwell):  If the last 24 hours have demonstrated anything, it would be that I'm not afraid to cut you loose. And that goes for all of you. Mutiny at your own risk.

Zoey notes that Cruz is wheezing. Jackie says it's a panic attack; she has actually seen him have one in a prior episode. Cruz claims it's asthma, and demands a chair, a nebulizer, and albuterol. Thor says he will get it. Cruz on nebulizerJackie stands near Cruz, but he says he doesn't want her help. Jackie walks to the packed emergency waiting room.

Jackie:  OK, I know you've been waiting a long time, everybody. I'm sorry, we will get to everybody.

Patient 1:  You know what? I don't wanna talk to you. I wanna talk to your boss.

Jackie:  Actually you can. He's sitting right back here, Bay No. 5, his name is Mike.

Patient 2:  What the fuck? Why did she get to go inside?

Jackie:  She wanted to talk to my boss.

Patient 2:  I've been here for six hours. I'll fuckin' talk to your boss.

Jackie:  OK, be my guest sir, his name is Mike Cruz, he's the guy trying to catch his breath, down here, Bay No. 5, make a left. Anybody else?

Cruz on nebulizerWe see Cruz trying to calm Patient 1 while breathing through a nebulizer mask. The patient sees this as Cruz as getting "some relief" for his illness while she is not. Cruz asks Jackie for help, but she says "you don't need my help." Patient 2: "We'll wait right here. Keep breathing, asshole." Coop asks Jackie if she wants Cruz there; she says she wants him gone. Coop tells Cruz tells he has to go to pulmonary. Cruz doesn't want to be wheeled out of the emergency department, presumably to preserve a sense of power. Coop asks Thor to "escort Dr. Cruz up to pulmonary, and if he faints, will you please carry him." Cruz, angry, tries to make it on his own. Of course, this is brilliant:  in one stroke, Jackie calms the waiting room down somewhat, giving the most vocal complainers a way to vent; possibly motivates Cruz to increase staffing; and in any case gets a measure of revenge on Cruz, aggravating his condition and further incapacitating him--maybe on purpose.

As soon as Cruz is gone, Jackie starts moving to manage the emergency department, which doesn't seem to have any leader now. She tells Zoey the bays are full and they should start doubling up gurneys from the hallway. Zoey reports that she has been trying to get more supplies from housekeeping. Jackie sees Sam trying to "confirm coverage" of nurses for the next shift, but tells him instead to go around and assess needs. Jackie asks Thor to handle some vomit, and tells Akalitus, who is passing by, that she could help, since Cruz is not there. Patients continue to complain about waiting for hours. Zoey says they're working as fast as they can. Jackie in chargeBut Jackie says they are not, and she's going to show them how they used to do it, telling Zoey to call "the agency" for "six nurses, one in admitting (presumably this means "triage"), five on the floor." Zoey notes that Cruz won't authorize that, but Jackie says "just do it, I will take the hit." She tells Zoey to make it seven nurses. A patient in a gown approaches and asks, rudely, who is in charge.

Jackie:  "I am. I'm in charge."

This plotline showcases Jackie's clinical leadership and expertise. Even the physicians seem to regard her taking control as a natural development; note Cooper's question, even before Jackie moved to take charge, about where she wanted Cruz. And the short-staffing element is good as far as it goes. Nurse Jackie has rarely shown understaffing, or its effects on patients. This plotline features a problem that could happen at any emergency department but that has become chronic in many care settings, due to misguided cost-cutting. But the plotline actually understates the problem. Understaffing does not just annoy patients, but also leads to worse outcomes, even death, as overwhelmed nurses are unable to provide the level of skilled monitoring and care patients need. And understaffing harms nurses, contributing to burnout and turnover. Here, no patient seems to come to serious harm, and the nurses do not seem all that stressed out. So in that respect, the plotline is a missed opportunity.

Might be a genius

In the June 17 season finale ("Handle Your Scandal" by Liz Brixius), Jackie seems to be running the emergency department, masterfully directing the staff, asking Zoey to go meet the temp nurses, and checking on the other nurses' patients. Sam says that they've cut gurney backup in half, the rest have meal trays, and that Jackie "might be a genius." Thor is amazed that someone (presumably a patient or family member) actually thanked him. Of course, the happy new situation of having an emergency department nurse manager could make a viewer wonder what was going on for the show's first three seasons when Akalitus was nurse manager, but then again, not all nurse managers are equally effective.

Cruz leaves hospital bedCruz wakes up in a hospital bed, disconnects himself and leaves the room, brushing past a nurse who tries to persuade him he had a cardiac episode, and returns to the emergency department. He sees a temp nurse and asks Sam who authorized her. Sam says he couldn't tell him. Cooper tries to distract Cruz, but Cruz asks if Coop authorized the nurses. Coop says he did not, but he points out how great things are with enough nurses. Cruz calls out, loudly: "Hey, Peyton." Jackie hears this, but rather than appearing, speaks to her patient.

Jackie:  Hey, listen closely, OK? Burns are the worst. They're going to change your dressing every six hours or so. Make sure to ask for IV pain medication, sometimes they forget. Hang in there, sweetie, OK?

This last bit of patient education and psychosocial care out of the way, Jackie leaves to confront Cruz in the open area of the emergency department. He tells her to go to his office.

Jackie:  I don't know, isn't there something about going to a second location with a gunman, or--

Cruz:  You wanna do this here?

Jackie:  Sure. (Shushing the apprehensive O'Hara.) It's alright.

Cruz:  Hot shot's got it. She's fine, aren't you?

Jackie:  I don't know, you tell me, look around--shit's under control.

Cruz argument with JackieCruz:  Whose control?

Jackie:  You know, does it really fuckin' matter?

Cruz:  Yeah, it really fuckin' does.

Jackie:  Fine. My control. It's under my control.

Cruz: (approaching and swiping her ID badge off of her uniform)  Jackie Peyton, RN. That's it, that's the scope of your powers.

Jackie (trying to get it back):  Can I have my badge, please?

Cruz (evading her):  You're a nurse. A totally replaceable, too-high-on-the-pay-scale nurse. You think I give a shit you got a union right now? Because I don't.

O'Hara:  Don't say another word, either of you. He can't fire you, Jackie, doctors can't fire nurses.

Jackie and O'HaraCruz:  As head of All Saints, I can fire whoever the hell I want.

Jackie:  Give me my badge back. (He won't; she turns to go.) Oh, you know what, for the love of God, go fuck yourself.

Cruz:  There you go, that's what I was looking for. (Finally tossing the badge back.) Hey, put it in your scrapbook. You're fired.

Jackie: Ladies and gentleman, Mike Cruz!

Zoey stands up and starts clapping, a protest. Everyone, even the physicians, joins her.

Cruz:  Shut it down.

They don't.

Jackie (turning around as she goes):  Take a look around, Mike. I'm still in charge!

Taking Grace out of schoolAt her office, O'Hara tries to calm Jackie and advises her to call her union rep and her lawyer. The pregnant O'Hara is having a contraction. Jackie says that's normal for the eighth month, so she should just stay off her feet. Cruz returns with a security guy to escort Jackie out. On the way, Cruz says he doesn't want Jackie "riling shit up at the nurses station" so he won't have her come back for her exit interview for a week. Jackie notes that firing her is "nice way to keep your promise to your kid," but Cruz says it has nothing to do with Charlie, and "frankly, I don't give a shit what my kid wants." Jackie says that's the difference between her and Cruz. Jackie gets her daughter Grace out of the Catholic school--in the middle of class--and takes her right to the public school she wants to attend. Jackie meets Akalitus and Eddie at a bar, and they hear from Zoey; the emergency department staff is holding a candlelight vigil for Jackie.

Zoey, Cruz and the bookLater, Zoey stops by Cruz's office. He urges her to think before she speaks. She gives him a little red book. He says it looks like a passport.

Zoey:  Kind of it is. It's a map to the people who work for you, it has their birthdays, anniversaries, things that make them happy, things that make them sad, who cries when a patient dies, who makes a joke and then cries in private. Things you should know. … You expect us to be good at our job. We expect the same of you.

Cruz (paging through):  Drawings [are] mixed in here.

Zoey:  Dazzle camouflage. Can't just hand you the keys to the kingdom. That would make me a traitor. You want it, you gotta work for it.

Jackie, Akalitus, Eddie at the barThe show doesn't really pursue this, but aside from suggesting that you can't be a good manager if you show no regard for the humans you manage, it shows further growth in Zoey as offbeat Jackie protégé, a nurse increasingly unafraid to advocate for patients and colleagues.

O'Hara goes into labor and calls Jackie, still at the bar with the others. Akalitus orders O'Hara to go up to a birthing suite. Jackie tells her to get Coop to help her upstairs. Coop meets Jackie on arrival at the hospital, but Cruz discovers her. He flips out. Jackie advises Cruz to calm down before he "keels over again" and says she is just going to maternity. Coop notes that O'Hara's in labor, but Cruz doesn't care. Sam, down the hall, says that an ambulance is arriving with an overdose patient who was resuscitated in the field but now has no pulse. Cruz says he'll handle that, and he relents about Jackie visiting O'Hara, but wants her gone the minute the baby is born. Jackie, looking down the hall, sees that the OD is Cruz's son Charlie. Jackie orders Coop to go to trauma (presumably thinking this is not a job for the patient's father) but she does not say why.

Cruz (outraged):  Do you ever fuckin' listen? Are you kidding me? Who do you think you are? You don't even work here, and yet you're callin' all the shots? (Coop moves to go anyway.) Stay right there. Doesn't anybody listen to--

Cruz does CPR on CharlieAnd then Cruz sees Charlie. Cruz takes Jackie's arm, starts down the hall, and tells her she's doing it with him. He examines Charlie, as Jackie stands nearby. Cruz, without much rancor, gets rid of the other nurses and the paramedics. Jackie tells Cruz he did everything he could. He says, "You got a lot of nerve." Jackie says she's sorry, but Cruz is talking to his son. He starts compressions. Jackie starts to say, "Charlie--" Cruz says not to say his name, "it's not yours to say." He continues to try but can't get Charlie back. Jackie puts her hand on Cruz's shoulder. He says, "leave us alone." Just as Jackie exits the room, Cruz begins to have what seems to be another cardiac event. Jackie, not seeing that, runs upstairs to O'Hara, who has just given birth. Both are ecstatic.

O'Hara and adorable babyIn this plotline, Jackie shows that she is not only capable of managing patients one-on-one--a clinical virtuoso--but also able to manage larger health systems--a conductor. She is an effective leader partly because of her technical expertise and decisiveness but also because she can inspire dedication and good spirits in the staff, as shown by their improved morale and strong support for her, even in the face of opposition from the hospital CEO. Jackie generally does pretty well in standing up to Cruz. He does seem to get the better of her in the ID exchange, goading her into the profane insult that will make firing her easier. Indeed, however clueless Cruz seems about how to manage the emergency department generally, he probably finds just the right way to push Jackie in focusing on her status as nurse, which is, as we know, critical to her identity. As for what Cruz actually says about nursing--that Jackie is just a nurse, overpaid, replaceable--that is what many physicians and too many other people do seem to think. Of course, the episode and the show as a whole run counter to this view of nursing. It must also be said that Jackie does a good job of identifying and exploiting Cruz's vulnerabilities as well, especially his need for control and his problems with his son. And given Cruz's seemingly tenuous health situation at the end--a situation that Jackie has, perhaps intentionally, made worse--it's not clear yet who will have the last laugh at All Saints.

One odd thing is that during the Jackie-Cruz showdown, O'Hara chimes in that physicians can't fire nurses, and Cruz responds that he can fire anyone, regardless of any union agreement. First, it seems pretty clear that a CEO could fire anyone, consistent with the law--which would include a binding union agreement. O'Hara is correct that hospital nurses do not report to physicians as a group, but everyone reports to the CEO, who may be a physician, nurse, or someone else. O'Hara's line sounds a little like something that was just dropped into the script to make a general point in passing, without sufficient explanation. Similarly, Jackie was able to step into the emergency department management vacuum because the show has never, apart from Akalitus, included any nurse managers or made clear that nurses manage nurses, physicians manage physicians, and so on.

In any case, despite the show's continuing confusion about nursing autonomy, it ended the fourth season with compelling illustrations of nursing expertise and advocacy. We thank those responsible.



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