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OPINION

The image of nursing: The handmaiden

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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.

  • 39 Comments

Readers' comments (39)

  • doctors are human beings too and if nurses wish to be treated with respect they need to learn to treat others with respect as well!

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  • Dear oh me. Here is me with all my qualification including two degrees being criticised for bad spelling.
    One has to ask if anonymous, and I hate conversing with someone who will not give their name, has had any experience in the hard world of hospital life argueing with difficult doctors whilst trying to be the patient's advocate. Or even being a patient themselves - as I have - and being at the butt end of arrogant medical staff. I have never called a Medic a bastard to his face you foolish person I am and always have been professional and polite unlike some of the medics I have had to deal with. My personal experience was compounded recently when I was admitted to hospital with severe abdominal pains (gall bladder probs) and was told by the doctor that there was no point in admitting me as the only analgesic he would prescibe was paracetamol. Fortunately the nurses were kinder.Hurrah for us as advocates and why do I attract these dreadful medics? I was plagued by them as a child in hospital aswell before you ask!

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  • there is little point in arguing with someone so bolshy and insulting but there must be good reasons for such a sad attitude.

    I have never called a Medic a bastard to his face you foolish person

    I am certainly not foolish and using these derrogatory terms is cowardly and hypocritical. and yes I also have a higher degree which i don't need to brag about and 20 years of working on acute medical wards in a uni hospital plus further and diverse experience in other areas but I have never seen the necessity to fall into dispute with anyone let alone the doctors with whom I have always worked in partnership and in a climate of mutual respect

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  • from Anonymous | 11-Oct-2010 1:53 pm

    It is so sad that such hostile remarks and attitudes as those above pervade and destroy working relationships on wards and throughout the organisation. This has damaging effects on the reputation of the ward and the team as well as on recruitment and retention of ward staff, also with the results that doctors would prefer not to have to work there.

    those nurses who always pass their own judgements on others are often those who show no tolerance of others, with the exception perhaps of some of their patients, and provide no peer support which is essential for the well-being of all connected with the ward in some way and the inter-disciplinary team.

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  • The arguments above detract from what, until then had been a reasonable debate. And the person who said most doctors have doctorates - no they don't, although certainly some may do so.

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  • What is nursing? I ask this in all seriousness. It is not practicing medicine...or at least it didn't used to be.

    I'm not saying that it's wrong...it just blurs the boundaries a bit.

    Within nursing there are those that want to nurse and those that want to be called nurse but really aren't....and again that's no criticism...it's just the way of the world.

    Nursing is in the state it is in because the leadership over the past 20 years has been non existent.. The diversity of nursing hasn't been recognised, appreciated, rewarded or utilised properly.....and that is why we are still seen as Dr's lackies.

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  • Anonymous | 11-Oct-2010 10:18 am, first of all, Doctors do not actually have a Doctorate, that is a fallacy. The have a Medical DEGREE, which because of the length of time it takes (longer than a traditional degree but not as long as a Doctorate), and because historically they were the sole proprieters of medical knowledge, the title 'Doctor' is an honorific bestowed on them by the academic community. A more correct and traditional term would simply be 'physician'. Anyone who DOES study for a true Doctorate in any academic discipline is - academically speaking - superior to a Physician, and that includes Nurses with a Doctorate in Nursing. So bear this in mind when talking about intellectual equals.

    I respect Doctors and the role they play, it is a very different - if often intertwining - role than Nurses. But I will not accept the attitude, often from Doctors themselves, that they outrank Nurses and are superior to us. They are not, in both respects. To be fair, this attitude is getting less prevalent and is ususally worse in the older Doctors (just as the subservient attitude is still prevalent in many older Nurses). We are EQUALS, performing seperate yet similar roles in the care for our patients. Yes they get things wrong and are corrected by Nurses, just as Nurses get things wrong and are corrected by Doctors. It is a partnership, our two professions support each other and work well together to encompass a full circle of care for our patients.

    Yet despite this being the reality, the image is STILL (amongst some Doctors, some Nurses, and the public especially) that OUR medical opinion and body of knowledge is not to be respected, it is inferior to that of the Doctor and it is them to who they should turn. This has a knock on effect to many aspects of our profession, from lack of respect from the government and the public, low pay and a continued belief that we can be the easy targets for cuts and low pay (please read my post on the 'open letter to the NHS' thread, I asked why the government would not go after a GPs bloated salary for example and continue to cut our already woeful salary instead). ETC ETC ETC.



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  • P Damien, as I said in my last post, Nursing to me is a seperate role from that which a Doctor performs, but it is still closely intertwined. We are not practicing medicine from a physicians perspective, we give medical care from a Nursing perspective.

    And no, Nursing is nothing like it used to be. It is about time that is recognised.

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  • We have a TV in our waiting room that is tuned to BBC 1, which means that patients on a Saturday and a Tuesday sit and watch Casualty and Holby City; and people definitely expect real life to reflect what they see on the TV.

    The attitude of some of our senior medics towards nursing staff tends towards 'I am a doctor and I am superior to you', although a consultant being called 'nurse' by a member of the public because you happen to be female wouldn't help.

    It is not only medics that demonstrate this attitude, I have seen it in nurse practitioners who seem to have lost the word nurse that is present in their title.


    Sometimes I feel dismayed that here we have two sides of the same coin trying to score points off each other, neglecting to see that we are both trying to achieve a positive outcome for OUR patients.

    I will admit that if had a PhD, then I would insist that my ID badge included the title Dr. on it, although my role would still show Nurse. As it is, could I insist on my current title Mr. be included, or could I be mistaken for a surgeon?

    That is another example of the medical professions historical snobbery, calling someone who practises surgery Mr., because they were considered inferior by physicians as surgery was traditionally performed by barbers without training. Now on transition from physician to surgeon adapting the title Mr. is seen as a step up, bizarre.

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  • i have worked with doctors from all around the globe for 40 years and been raised and lived in a doctor's household for 50 years and in a medical social environment but never have i been made to feel inferior as a nurse or female nor had my professional opinion not listened to or accepted by any of them. the only times I have met disrespect is from senior nurses and some peers who also give the same treatment to their juniors, medical colleagues and worse still their patients. it seems to be a question of attitude and if you treat others with respect this will be reciprocated.

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