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OPINION

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!

Read more

The image of nursing

*Authors’ note

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.

Readers' comments (39)

  • I totally agree with the essence of this subject, but I'm not sure I feel this 4th part of the debate is well argued. I'm left wondering whether the writers are American, given their nearly total referral to US drama? I do wonder whether in the US, as in some other countries whether the medic/nurse relationship is different? I confess to not watching Casualty or Holby City, but in the past there was a strong nurse presence in Casualty and I believe a Nurse Consultant in Holby? I stand to be corrected but perhaps the UK media does portray them differently, I believe they have nurse advisors? I caught the end of one show - not even sure what channel - called Super Nurses, and although I only saw the last 10 minutes that programme was showing the work of Oncology Nurses.

    Nurses should NOT be relying on US dramas to spread the word about their level of profession, capability, education or autonomous standing, that is the responsibility of the profession and body's such as the NMC, RCN and Unison - who I feel deserve more criticism than ER or House for not telling it how it is. House doesn't even represent medicine in a good light!

    We have to be stronger and better than to expect others, who are not even in this country to promote us properly, it isn't their responsibility it is ours and part of the problem is we haven't taken that responsibility.


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  • Yes Doctor, no Doctor? Of course the public are geared for that! That is mostly because the general public think that Doctors are the only ones who study and practice Medicine, so therefore they are the only ones who's opinions matter. Oh of course Nurses might know a few things but they are untrained aren't they? Best to check that opinion with the Doctor.

    I'm sorry if that sounds a bit cynical but that is the way it is for the vast majority of people.

    It is about time society came to realise that Physicians are not the only ones who have medical training or knowledge. Nurses also have that, albeit based around a different caring paradigm, but that does not make it any less valid. We are as well placed, if not more so, than many physicians, to offer medical assistance and advice. What is so hard to realise that we are both (Physicians and Nurses) autonomous medical specialists in our own professional right?

    Anonymous | 7-Oct-2010 9:36 am, I get what your saying, but (and I have to admit not watching any of these programmes either), even when Nurses in these programmes (American or British) have a high rank (such as Nurse Practitioner), aren't they almost always STILL seen as inferior handmaidens to the glorious Doctors when they sweep in and save the day, and then embark on an affair with the aforementioned practitioner of course?!

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  • Well, I am working in the US at present and here when a physician writes an 'order' it is exactly that. Even if not discovered until late in the evening ( the physicians don't usually speak to you directly!") you still have to wake the patient to give them the pill or do whatever, right away. It can't wait until the morning however simple it may be. To delay giving something (unless it is actually unavailable or needing to be ordered ) is considered a drug error warranting an incident report!

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  • Philip Darbyshire

    See the latest AMA response to the IOM report on Nursing in the US. http://bit.ly/aqm6vN to see that the old rules still seem to apply. For so many doctors, teamwork means: 'lots of people doing what I say'. What a waste of collaborative and interprofessional potential. In the UK, facing billions of pounds worth of spending cuts, and in almost every other country where health funding will never be 'enough', the idea that we can just keep working away the way we have done for the last 20 or 50 years is just crazy.

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  • I agree Mike, but it is not the responsibility of any programme maker, particularly ones from another country to be responsible for promoting the role of British nurses, particularly when we do such a rubbish job at it ourselves. They are responsible for making entertainment and given the popularity of those programmes they are getting it right and we are not.

    I re-assert my point that our professional and representative bodies are the ones letting us down - not House or ER.

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  • Society is not just going to 'realise' the role of the nurse - we have to educate them to it supported by unions and NMC.

    I don't in honesty 'realise' the true role of other professions or jobs.

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  • These shows are for entertainment purposes only...and its not as if they show medics in a particlularly good light either! They seem to spend most of their time sleeping with each other, getting wasted or arguing amongst themselves. Do you also think that The Bill or Waterloo Road are accurate descriptions for these public servants? Of course not. Those who are sad enough to believe what they see in TV drama/soaps are not going to want to know the reality of life in the NHS (or the police or teaching professions for that matter). If we want to change the image of nursing- and lets face it, only a very small percentage of the public will come into contact with us-we need to be pushing the NMC and unions to present a more positive image of nurses. TV soapland is not the place to expect the truth...

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  • Susan it is very very different here, a Doctor diagnoses a problem and suggests a course of action/treatment, (after all that is their specialty); but then a Staff Nurse would have no hesitation disagreeing with that if necessary and suggesting a different treatment, or if the course of action is sound, will at least use their own clinical judgement (based on best practice) as to how the treatment should be carried out. I would in no way wake a patient up at 3am just to give say pain relief for example (when they are obviously not in pain), (and yes I know thats a blatantly obvious example but I'm tired!lol!) Perhaps things really are that different in the US?

    Anonymous | 8-Oct-2010 2:00 pm, It's not that I disagree with you, you are absolutely right that Nurses are crap at asserting themselves and our so called unions SHOULD be fighting our corner so to speak. It IS their responsibility to be asserting our true role and they (and we as a profession) are failing miserably). But I still argue that the vast majority of the public out there are akin to sheep like zombies when it comes to forming opinions, and television DOES control what a lot of people think (unfortunately). I used an example in one of the previous articles in this series on how that pathetic reality TV can effect public thinking. In that way, if all people ever see on TV is Nurses as inferior and obedient handmaidens, then no amount of 'education' on our part will change their perception of that.

    Finally, Anonymous | 8-Oct-2010 2:03 pm. You may not fully know the ins and outs of every job out there, fair enough, but I don't think there are as many roles (lets just take the major public services for example) that are as misunderstood as Nurses.

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  • Hi,
    Thanks for your response Mike. It is very different here in the US but I suppose they don't know any different! I am very homesick for the UK especially the NHS which is so much better whatever anyone says. Working as a nurse is also better for the reasons you stated. There is a strange paradoxical situation here where they both expect nurses to work independently in the absence of doctors ( reporting changes in condition by telephone ) yet still have this 'orders' system which must be obeyed.

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  • No problem Susan, I was surprised to hear that is the situation in the US, I know that isn't the case in Oz, and I'm pretty sure it isn't the case in Canada either?

    To be fair though, I think even the Doctors over here in the UK do have the same superior ego and the expectation that everyone will follow orders (I think that stems from the past when they did use to be the sole authority on medical matters), but are sorely surprised when they find that Nurses here won't stand for that.

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  • I'm not trying to defend medics at all, I have met some right arrogant individuals, however, probably the majority of doctors I have met have been open to discussion, explanation, and willing to listen.

    I had heard from friends in the US that it was based on the 'orders' system and strange for an NHS nurse, I understood that that had come from fear of litigation, and also that in any case of patient complaint the finger got pointed firmly at the nurse - I would like to hear Susan's perception of that.

    Given that - perhaps the US programmes are a dramatic portrayal of the US situation - we can't expect them to represent NHS nurses - no matter what the people who watch may think?

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  • .Anonymous | 9-Oct-2010 2:23 pm you are right I'm sorry, I was tarring all Doctors with the actions of a minority here.

    As for the case of blame and litigation though, that is certainly true here, the buck does stop with us, not the physicians!

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  • why are nurses so concerned by the virtual reality of tv programmes - it is only entertainment media but which sadly seems to impregnate our culture. does it really matter if a few members of the public are dumb enough to believe what they see on tv is the absolute truth. if nurses are worth their salt, which some are, they are self confident in the work they are doing and their attitudes towards their patients and shouldn't be obsessing about their image.

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  • its all about teamwork around the patient who is central and not about who is more important than who else - those who value their patients and getting on with doing the best job possible don't concern themselves with such trivia.

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  • Anonymous | 10-Oct-2010 11:59 am and .Anonymous | 10-Oct-2010 12:30 pm
    I suggest you go back and read every one of this series of articles and all the comments because I think you've just missed the entire point.

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  • I am not really aware that there is a point!

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  • cinema is cinema and nursing is nursing. don't mix the two and there is no need to watch the entertainment. in fact some of these tv programmes are well researched with the script writers following nurses around in hospital for a period of time so there must be some element of truth and reality in some of them.
    but again those serious about their job have no need to take virtual reality into account it is confidence in what they do that is important.

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  • if you behave in a submissive manner to doctors, patients, managers, colleagues, visitors or anyone else it is human nature that they will take advantage of the situation and treat you accordingly. Grow up!

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  • The problem is that Jo Public DOES believe what they see on Tv and films. Their perceptions of nurses only alters when they are in direct contact with us as professionals.
    There are a group of doctors who look down on nurses as 'failed' doctors and not professional or, god forbid, interllectual equals. God forbid if you question their actions or treatments. I have spent half my professional life arguing with these bastards.
    AND If someone asks me again if I give out bedpans and why I have not married a doctor I shall kill.

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  • if one thinks of or refers to our medical counterparts in such derrogatory terms it is no wonder there is such a divide between the two professions. Such an attitude does nothing to improve interprofessional relationships. Many younger doctors also feel threatened by nurses and fear they may know more than they do or show them up. When on our ward it is up to us to set a good working atmosphere and working relationship and put them at ease. We need good public relations and diplomatic skills as well as all our other positive attributes.
    How can nurses be considered intellectual equals to doctors if one can't even spell the word correctly!
    Besides doctors have a doctorate, which most nurses do not have, to prove their intellectual superiority.

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