The 1991 film What about Bob? depicts a psychiatrist who is treating Bob, a recluse with an incredible number of insecurities and phobias. Bob becomes so attached to the psychiatrist, Dr. Leo Marvin, that when Leo goes on vacation, Bob conquers his phobia of traveling alone and arrives at the lake in New Hampshire where Leo is vacationing with his family. Surprisingly, Leo’s family, who seems to be bored with Leo, finds Bob’s wit and fun personality a welcome diversion. Leo, however, becomes so annoyed with Bob’s intrusion on his personal time that he finds himself plotting unethical approaches to try to lure Bob back to New York. The film was quite successful with audiences, even though some noted it was a dark comedy that challenged credibility; one review of the film noted that the “quirky family comedy…encourages viewers to stop being so straight-laced and start having fun” (What about Bob, 2009).
Perhaps this is one perspective for us to consider in relation to a new “black comedy,” the Showtime series Nurse Jackie, which has emerged recently as a controversial representation of the daily work of a nurse. So, what about Nurse Jackie? Nurses, nursing organizations, and the general public have weighed in on the merits (or lack of them) of the show. The American Nurses Association (ANA) has issued a statement of disappointment at how the show portrays nurses and nursing in negative images that could erode the trust of patients and even discourage young people from considering a career in nursing (ANA, 2009b). And yet, only 53% of respondents answered "yes," to the poll on the ANA (ANA, 2009a) Web site asking for opinions on whether negative images of nursing, as portrayed in TV shows like Nurse Jackie, significantly hurt the profession.Forty-seven percent of the 1026 votes submitted online responded that the shows were not damaging.
The character of Nurse Jackie is a skilled emergency room nurse, who is dedicated to her patients, and who in the pilot episode fearlessly takes to task a doctor whom she sees as responsible for the death of a patient, yet blames herself for not persisting with her intuition that the patient had a cerebral hemorrhage. Unglamorous and outspoken, with little makeup, a short, unstylish haircut, food spilled on her scrubs, and a quick rebuke for those who do not meet her expectations, Jackie is definitely not the “naughty nurse” or the doctor’s handmaiden that we often accuse the media of portraying. Jackie is smart, caring, respected by her peers, and a vigilant advocate for her patients. She also, however, takes drugs from the hospital pharmacy for her back pain, has a sexual encounter with the pharmacist on her lunch hour, forges an organ donation form, and purposely flushes the ear of a rapist down the toilet because she can see that the legal system will not punish him – all this before she goes home to assume her wife/mother role with her loving husband and two adorable daughters.
The language and actions of Jackie are shocking. And yet, after only one episode was aired, the show was so popular that it was picked up by Showtime for a second season. In fact, it was the highest-rated season premiere in Showtime history (Bauder, 2009). People are watching.
And perhaps, when they watch, they will gain a new sense of the ethical issues with which “real” nurses grapple daily. Nurses’ comments on blogs have noted that Jackie speaks out candidly about injustices in a way that they wish they could. Many nurses can relate to the irony of the hospital administrator warning Jackie about the hazardous effects on patients of working double shifts, and then her being asked to stay for a second shift. She does stay and almost makes a serious medication error with her patient. Jackie’s ignoring of traditional ethical principles in nursing practice is shocking. But her caring and sense of advocacy for her patients come through strongly. Zoey, the first-year nursing student assigned to her, looks up at Jackie with admiration, and says to her, “You’re a saint.”
Perhaps controversial shows, such as Nurse Jackie, provide an opportunity for the nursing profession to communicate in new ways. They offer a fresh approach for looking at ethical issues in nursing practice from the perspective of the media and the public’s response to fictional nurse characters. I can envision students having passionate ethical discussions focused on issues raised in these programs!
Rising healthcare costs with limited healthcare resources have created a call for data that document the value of nursing. These data are critical to assure that the future healthcare system does not under-invest in nursing service (Rutherford, 2008). Recognizing this need, the ANA has implemented talking points to communicate the value of nursing (Shulman, 2009). These include:
- The public trusts nurses.
- Nurses are there for patients.
- Nurses recognize that patients are more than a set of symptoms that need to be treated.
- Nurses help patients navigate the system and understand health needs.
- No one spends more time at the patient’s bedside than a nurse.
- Nurses are the puzzle solvers and guardians.
- Nurses are cost effective in tough economic times.
- Nurses are leaders.
- Nurses are role models.
- Nurses have many faces.
All of these talking points suggest the inherent value of ethics in the nursing profession. It has been stated that nursing is “the most ethical profession” (Bauder, 2009). Yet, what evidence do we have for this statement? The daily press, as well as nursing literature, contains frequent articles about unethical behavior by individual nurses and by healthcare organizations. To ignore these problems in an effort to portray nurses always in a positive light is dangerous. TV viewers are not likely to assume that nurse characters who make unethical decisions are characteristic of all nurses, just as they are not likely to see the psychiatrist’s behavior in What about Bob? as characteristic of most psychiatrists’ behavior. But they are likely to think about shocking breeches of ethical behavior and wonder why these behaviors occur. Perhaps shows, such as Nurse Jackie, constitute a mechanism for nurses to dialogue with the public and each other about the real pressures that nurses face.
There is a growing body of literature focused on quantifying the economic value of services provided by nurses (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dell, Chen, Seifert, Maddox, & Hogan, 2009; Horton, Tschudin, & Forget, 2007; Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006). The American Nurses Association, on behalf of the larger nursing community, announced in 2008 the release of a first of its kind study on the economic value of nursing. Improved understanding of the economic value of nursing services can help inform staffing decisions and healthcare policies. The study by Dell, Chen, Seifert, Maddox, and Hogan synthesized findings from the literature on the relationship between registered nurse staffing levels and nursing-sensitive patient outcomes in acute care hospitals to estimate the economic implications of changes in registered nurse staffing levels. The researchers found that as nurse staffing levels increased, patient risk of nosocomial complications and hospital length of stay decreased, resulting in medical cost savings. The researchers noted, however, that only a portion of the services that professional nurses provide can be quantified.
Ethical approaches to nursing care are one aspect of nursing practice that is difficult to document in terms of economic value. The ethics of care are a primary focus for many nurses, as caring is an integral part of nursing practice. Yet, how do we measure the value of caring? Malloch and Porter-O'Grady (1999) noted that although the task of ascribing economic value to human caring is incredibly difficult, we can create new economic rules that recognize caring as foundational to nursing practice. They describe a model of “partnership economics” that incorporates not only capitalism, but also social responsibility and support for caring and ethical human relations. This model can provide a mechanism for documenting the positive relationship between relational caring behaviors and the cost of healthcare services. We are challenged to partner with other healthcare professionals, policy analysts, economists, and ethicists to build a more equitable and humane economic system that gives real value to the work of caring.
As noted in the ANA talking points, nurses have many faces. Nurse Jackie is one of these faces, and she is not one we are used to seeing in the media. Although we may find some of Jackie’s behaviors appalling, they do provide an opportunity to create a rich dialogue about the value of nursing ethics and why, in the current healthcare system, Jackie may make the decisions she does. The public trusts and likes nurses like Jackie who are so obviously there for patients, recognizing that patients are more than a set of symptoms in need of treatment. Nurses like Jackie help patients navigate the system and understand health needs as they spend time at the bedside and serve as puzzle solvers and guardians. Nurses like Jackie are cost effective in tough economic times. They can be role models and leaders.
Malloch and Porter-O'Grady (1999) suggested that the nursing profession must move beyond feelings of loss and resistance to change to “actively write and produce a new script for health in America” (p. 307). This new script will demand new ways to communicate the value of nursing. With a new administration in the White House, one that has placed healthcare reform at the top of its agenda, nurses have an incredible opportunity to help shape a healthcare system that is based on ethical, as well as economic, values. Creating new faces like Nurse Jackie in the media may provide a new script for discussion of the value of nursing ethics.
Read Letters to the Editor on this Column:
- Letter to the Editor by Wilson
- Letter to the Editor by Moore
- Letter to the Editor by Macke
Jeanne Merkle Sorrell, PhD, RN, FAAN
© 2009 OJIN: The Online Journal of Issues in Nursing
Article published July 22, 2009