The image of nursing: The handmaiden
In the fourth of our series of blogs on the image of nursing, Sandy and Harry Summers wonder if to the public nursing is mostly about saying “yes, doctor!” and “no, doctor!”?
About the author
This article was written by Sandy and Harry Summers authors of Saving Lives: Why the Media’s Portrayal of Nurses Puts Us All At Risk
People might think so based on the popular media, which still tends to present nurses as the lowly assistants of physicians who direct all important health care. On major Hollywood television shows like House and Grey’s Anatomy, the paradigmatic interaction between the two professions is a bold physician “order” followed by a meek nurse’s “yes, doctor!”.
The “handmaiden” stereotype infects the real health care workplace. Physicians enjoy greater social and economic power, and many of them still see nurses as subordinate. So if physicians engage in or request care that is unsafe, it may be difficult for nurses to resist, even when they must do so to protect patients.
In December 2007, the Associated Press reported that operating room nurses at one U.S. hospital had failed to stop life-threatening surgical errors because they lacked the practical power to do so. And in December 2004 the Times of India reported that, after a local nurse dared to point out to a physician that he had failed to place a used syringe in the proper receptacle, offended physicians chose to “start a fight” with the nurses. Police were called in to restore order.
The handmaiden stereotype also encourages the belief that nurses can be abused with impunity, which is a factor in nursing burnout and the global nursing shortage. In November 2005, South Africa’s Cape Argus reported that research in South Africa, the U.K., and the U.S. suggested that nurses experience disproportionately high levels of violence and psychological abuse by patients and colleagues, especially physicians.
In fact, nursing is an autonomous profession and a distinct scientific discipline. Of course nursing overlaps with medicine, and one element of nursing is carrying out care plans crafted by physicians. But nurses train, manage, and regulate themselves. They have independent legal and ethical duties to patients, with a unique focus and scope of practice, including special expertise.
Occasionally the media has given a sense of nursing autonomy, for instance, describing nursing research or clinical leadership. A January 2010 BBC News report about Scottish medics on their way to war-torn Afghanistan featured authoritative commentary by a nurse who was to be the commanding officer of the field hospital the medics would soon take over. Ian McEwan’s 2003 novel Atonement and Joe Wright’s 2007 film adaptation also include strong accounts of British wartime nursing, showing the formidable authority of senior nurses in World War II.
But in the most globally influential entertainment media today, nurses are peripheral physician subordinates. Nurse characters on House probably speak and do even less than nurses on the other major Hollywood hospital shows, and as a result, the show’s handmaiden portrayal may be the most absolute. The vast majority of nurse appearances involve a character popping up out of nowhere to absorb a physician command, usually in silence; compliance is assumed.
In an April 2008 episode that included a nurses’ strike plotline, House glibly said that he did not “use nurses.” Leaving aside how dead House’s patients would be without nurses, House could have simply said that he wouldn’t let nurses get near his patients. But “use” suggests that nurses are just physician tools. The show confirmed this attitude in an exchange between House and “dean of medicine” Lisa Cuddy indicating that Cuddy was in charge of the striking nurses.
No one could possibly think, from watching Grey’s Anatomy, that nurses were anything but physician subordinates. The vast majority of nurses who appear are mute servants. Nurses on Grey’s can display resentment and petty vindictiveness when they are abused by their physician masters. And nurse Tyler, a bitter lackey, appears once in a while to tell the physician heroes about the unpleasant tasks awaiting them, but he plainly has nothing to offer patients himself.
In an October 2009 episode, the main Grey’s hospital merged with another hospital, and chief of surgery Richard Webber—who also seemed to function as the hospital’s chief of medicine and CEO—made staff cuts. With no suggestion that nurse managers exist, Webber let many nurses go, including the pathetic nurse Olivia. Surgeon Derek “McDreamy” Shepherd offered to give Olivia a reference, since he doubtless knew her nursing skills well after years of supervising her.
ER certainly offered better nursing portrayals, occasionally even showing nurses providing important care on their own, but the long-running show also repeatedly indicated that nurses report to physicians.
In one December 2008 ER episode, after nurse Sam Taggart had taken time off to care for her injured son, chief of ED medicine Cate Banfield offered to give Taggart more time—clearly indicating that the chief ED physician was Taggart’s boss. And in a November 2007 episode, then-chief of ED medicine Kevin Moretti implemented new triage policies and at one point told Taggart that she was supposed to be covering triage. Taggart complied.
Even Nurse Jackie has suggested that nurses serve physicians. Early 2010 episodes at times indicated that physician Fitch Cooper directed patient care and even had some ability to have nurses fired, despite the presence of the strong nurse manager Gloria Akalitus and the fact that Jackie and her colleagues often provide life-saving nursing care with little or no physician involvement.
The entertainment media is the leading source of handmaiden imagery, but it can be found in the news as well. In September 2006, ABC News (U.S.) ran a report about long A&E waits, after an Illinois woman was found dead of a heart attack in a waiting room after a nurse told her to wait. The piece relied solely on comments from physicians. One advised patients who were dissatisfied with the triage nurse’s actions to “speak to the emergency physician,” as if that physician (instead of the nursing manager) directed triage and the triage nurse.
In fact, the handmaiden may appear anywhere. In February 2007, a New York Times Crossword Puzzle sought the answer “RNS” with the clue “I.C.U. helpers,” again suggesting that nurses are merely physician assistants, rather than central players in intensive care.
And yes, we tried the answer “DRS” first. No luck!
We use the term “physician” because using the more common “doctor” to refer only to those who practice medicine wrongly implies that they deserve more respect than others.
Nurses and others earn doctoral degrees and make contributions to health and society that are just as valuable as contributions made by physicians. So the honorific should be available to everyone with that degree or to no one.
We also note that “physician” has been used in this way in texts ranging from Shakespeare to recent issues of the British Medical Journal.