Nurse Ratched’s Backstory

This week the assignment I gave students in my narrative medicine course was to apply the close reading drill they’re learning to a ‘read’ of a feature length movie. I gave students a choice of six movies around the theme of caregiving: The Diving Bell and the Butterfly, The Doctor, The English Patient, Midnight Cowboy, Rain Man, and One Flew Over the Cuckoo’s Nest. Besides doing a ‘close read’ of the movie of their choice, I asked them to reflect on the following questions: 1) What is the nature of caregiving as portrayed in the movie? 2) In the film, who is being cared for and who is doing the caring? (I should note that this narrative medicine course is a hybrid, with a mixture of in-class and online/distance learning. Last week and this week were both distance learning.) Not surprisingly, many students chose to watch and write about One Flew Over the Cuckoo’s Nest (1975) with the unforgettably villainous Nurse Ratched (Mildred) played to perfection by Louise Fletcher.

As I recently re-watched this movie, it struck me how good a nurse Mildred could have been. She is smart, sensitive, and perceptive, and could have used these attributes to be a strong therapeutic psychiatric nurse; instead, she used them to be a manipulative, destructive nurse. I kept asking myself: what went wrong with Nurse Ratched?

With all due respect to Ken Kesey who wrote the novel that the movie is based on, I offer my version of Nurse Ratched’s backstory. Perhaps it can be instructional on ways not to be a good nurse—or on good reasons for someone not to be allowed become (or continue to be) a nurse.

Backstory: Mildred Ratched grew up in rural Oregon, the first of seven children in a devout Catholic family. Her mother was a stay-at-home mom and her father was a logger. They all lived in a doublewide trailer. Her father was a heavy drinker and he regularly beat his wife. Mildred’s self-appointed (or assigned) role in the family quickly was established as caretaker and protector of her younger siblings. Her mother was timid, withdrawn, and depressed, to the point that she spent days and weeks in bed. Mildred’s father loved to shout out at the dinner table that women were only good for baby-making and housekeeping and were stupid. Mildred was a smart, precocious young girl who learned to read at age four, and then went on to excel in school. Her mother encouraged Mildred to get out of Oregon—to become either a stewardess or a nurse so she wouldn’t get stuck in a loveless marriage as she had. Her mother most strongly encouraged Mildred to become a nurse because that’s what she’d wanted to be, and nursing had the whole saintly, angelic, Catholic connotations. But Mildred dreamt of being the first in her family to finish college. What she really wanted was to become a lawyer (wouldn’t she have been an excellent lawyer with that poker face, intelligence, and ruthlessness? Perhaps she wouldn’t have been strangled by McMurphy—Jack Nicholson—and lost her voice if she’d become a lawyer).

Mildred was a freshman in high school when her father fell out of a tree at work and was paralyzed. He wasn’t eligible for L& I or other disability benefits because the hospital ED physicians established that he was legally intoxicated at the time of his fall. Mildred was forced to drop out of school to care for her father as well as all her siblings. She also started waitressing at a nearby diner. Her father died a year after his accident and then Mildred went to a nursing diploma program through the local Catholic hospital. In her last year of the nursing program she met her first boyfriend, a trucker, who found nurses sexy. Mildred got pregnant right away and immediately married. Her new husband openly cheated on her from the very beginning of their marriage. He also physically abused her. Her son was stillborn and her husband left her the following week.

Meanwhile her mother was showing signs of dementia, so Mildred moved back home to care for her mother and her siblings who were still at home. She had been working as a labor and delivery nurse, but after her own baby died she couldn’t face working in that setting, so she took a graveyard shift at the nearby state psychiatric hospital. Flash-forward twenty years and Mildred has worked her way up the ranks at the psych hospital and is now head nurse (“Big Nurse”). She still lives with her ailing mother, cares for her at night, and works days at the psych hospital. She never dated again after her husband left her. She goes to church by herself, has no hobbies, and has only a few female church friends (stuttering patient Billy Bibbit’s mother). Her only source of enjoyment in life comes from the thrill of being in charge, in power at the psych hospital.

Nurse Ratched would have rocked as a good nurse. My only hope is that the sweet young junior nurse shown shadowing Nurse Ratched in the movie (the one who goes into hysterics when she discovers Billy’s bloody body in the psychiatrist’s office) doesn’t become another Nurse Ratched.

On a related note, here are my all-time favorite movies with memorable nurses as major characters: 1) Magnolia (1999) with an amazingly good male hospice nurse, Phil Parma, played by Philip Seymour Hoffman; 2) One Flew Over the Cuckoo’s Nest (enough said about it above)…. and 3)????? I guess that’s it for movies with memorable nurses, at least for me. I do like the character of Abby in many of the ER TV series—as well as the Mississippi nurse practitioner in the “Middle of Nowhere” episode in season five (although it over emphasizes all the negative stereotypes of Southerners). Nurse Jackie is just too soap-operaish and silly for my taste. Come on Hollywood! Give us some more good and realistically portrayed nurses in movies! Maybe I need to start writing screenplays, but I envision myself as Barton Fink with writer’s block, stuck in a flaming hot hotel room somewhere…. Being stuck in the godforsaken Reno airport with a delayed flight home is nightmare enough (where this post was written). Especially since I got stopped by security and interrogated as to whether I’m any relation to naughty former Nevada Senator Ensign (the answer, thankfully, is no). Sometimes life is stranger than fiction—or movies.

Follow the Money

All nurses should be required to take college-level micro/macro economics. Trying to teach nursing students the basics of health policy is almost impossible if they are not comfortable with economic terms and concepts.

I was reminded of this recently, when in a fit of fall office cleaning, I finally gave away my copy of Samuelson’s economics textbook. It was stuffed full of class notes, health economic diagrams and highlighted paragraphs. Two quarters of economics were required for my public health degree, and both were taught by a passionate German economist who waved dollar bills around his head for effect. I begrudgingly signed up for his course, found it—and him—fascinating, and it has been the single most useful class I’ve ever taken in any of my health care programs. That and a water and sanitation class: the basics of health care.

Economics of health care finds its way into my mailbox. My home mail these days mainly consists of utility bills and glossy medical newsletters by local hospitals. The cover of the latest one (photographed here) is oh so Seattle, showing two smiling but scary looking roller derby women. I’ve met one of the women (off rink thankfully) and she is quite nice in person. Inside the hospital newsletter/magazine is a two page article about the women’s roller derby team, the various sports injuries team members have endured, their team orthopedist and the orthopedic surgical ‘cures’ performed at the hospital. I get similar hospital newsletters from two other local hospitals I’ve been a patient at. All three highlight the hospital cash cows of cardiac surgery, cancer care, and orthopedic surgery (none of which I’ve been there for).  I’ve been successful getting off the mailing lists of most all major catalog/merchandise companies, but have not been able to stop getting these hospital newsletter/magazines. It is oh so NOT Seattle, being decidedly un-green and tree/salmon-killing.

I know that I am bombarded with these hospital newsletters because: 1) I have decent health insurance, 2) I’m getting towards the age when cardiac/cancer/ortho surgeries may be needed, 3) I might be crazy enough and able to afford to make a monetary donation to a certain hospital unit/program, and 4) perhaps because I am a health care provider and can recommend certain hospitals to my friends and relatives.

Most experts on hospital advertising agree that the main purpose of such advertising is brand recognition—and that hospital advertising increases (as do the costs obviously) as competition increases for insured/affluent/paying customer-patients. If you ask hospital PR people (I have), they will say their newsletters are an important patient education/health literacy effort—a public service of sorts. But when you analyze the content of articles and print ads, this claim doesn’t hold up. Most are not written or reviewed by clinically-knowledgeable people, they play up emotional content (her heart was fixed and she can now play with puppies and kittens and grandchildren!), and they exaggerate benefits/leave out adverse effects of surgeries and other treatments. Hardly real health education. Most industrialized countries ban or severely restrict health care advertising.

A fascinating underlying reason for hospital/physician advertising (as I learned from Paul Levy’s blog post on this topic), is that it strokes the egos of physicians and senior executives of hospitals. The doctor egos need stroking because they make money for the hospitals and doctors are free agents and can move to a different/higher paying hospital. Funny how there aren’t too many hospital ads or newsletter articles highlighting nurses.

The final reason that health care economics is on my mind is the excellent article in today’s Seattle Times by health reporter Carol Ostrom: ER Building Boom is Wrong Prescription, Experts Say.” In this article she discusses the economic and regulatory issues behind our Seattle-area resort-spa-emergency department craziness—a problem not unique to our region. If you want to understand health care, take or review Economics 101.

Violence at Work

ER (TV series)
Image via Wikipedia

This past week our local public radio station, KUOW, ran a series on workplace safety in Washington state. For those of you not familiar with Pacific NW-specific high-risk jobs, these include loggers and commercial fishermen, including scuba-diver harvesters of geoducks (world’s largest clams/highly priced aphrodisiac in China and Japan—when you see a photograph of one you’ll understand why). Then there are the non region-specific high-risk jobs of police officers, corrections officers and security guards.

But the highest risk job category of all in Washington state is that of nurses’s aid, followed closely by RN. The highest risk place to work is Western State Hospital. Nurse’s aids, nurses, and other frontline workers at Western State Hospital are assaulted on the job 60 times more than the average worker in Washington state. Western State is the largest psychiatric facility west of the Mississippi and houses criminal defendants when they are found mentally incompetent to stand trial.  So it is in effect a combination correctional and psychiatric facility with highly volatile and violence-prone patients.

Nationwide, nurses working in Emergency Departments (EDs) are at high risk for workplace violence, generally in the form of physical violence from patients, family members or other visitors. EDs and urgent care centers are where people go for violence-related injuries stemming from domestic violence or gang violence. EDs and urgent care centers are where people go who are intoxicated or having acute psychiatric emergencies—usually accompanied by police. Waiting room overcrowding, long wait times to be seen by a provider, lack of visible security systems, lack of staff training on de-escalation techniques, and understaffing, all contribute to increased risk of violence. Reports from around the country indicate a steady increase in ED violence, most likely stemming from weakening primary care safety net services, forcing more desperate and frustrated patients into EDs for basic health care needs.

The KUOW episode “Violence in the ER” and the accompanying Seattle Times article “Most violent job in Washington? Nurse’s Aid” highlight ED workplace violence in Tacoma General Hospital in Tacoma, and Harborview Hospital in Seattle—the state’s two biggest hospital EDs. Tacoma General Hospital ED uses a metal detector at all times to screen patients and visitors. Harborview Hospital only uses a metal detector in the ED at night, and at other times security guards use a hand-held metal detector on patients and visitors they deem high risk.  Harborview Hospital administrators, like many for hospitals across the country, have chosen not to install permanent metal detectors for fear of slowing down emergency care. According to the KUOW report, on a recent Saturday night a man got into the Harborview ED with a backpack containing a large knife, two cans of pepper spray, a cap gun, and bullets.

Third behind ED and psychiatric hospital settings for workplace violence for nurses is home care/home hospice. Work in these settings is usually done solo, with possible exposure to domestic violence or drug activity.

The Occupational Safety and Health Administration (OSHA), the federal agency charged with ensuring safe and healthful working environments for US workers, has failed to issue federal standards on workplace violence in health care settings. So far, they have only published voluntary guidelines on this topic. California, Washington, Florida, Illinois, New Jersey, Tennessee, and Nevada have passed state laws requiring further protection for health care workers. For instance, in Washington state, all health care settings are required to develop and implement plans to protect employees from violence. State law now makes it a felony for anyone to attack a health care provider—including verbal threat of assault. Washington state law requires all health care settings to keep records of any violent act (including verbal threats) against an employee, patient or visitor.

According to Jeaux Rinehardt, president of the Washington State Emergency Nurses Association, the felony assault charge is mainly enforced for attacks on doctors—rarely for attacks on nurses or other health care providers. He also echoes many nurses around the country in stating that nurses are actively discouraged from reporting and documenting workplace violence by managers or hospital administrators. (KUOW News: Violence in the ER, 7-13-11)

I worked in home health in Richmond and Baltimore for seven years during the height of the crack cocaine epidemic of the late 1980’s/early 1990’s. I worked in a large downtown Baltimore hospital urgent care center for six years. If you have watched any episodes of “The Wire” that’s what it was like to work and live in Baltimore at that time. The worst thing that happened to me during those years was that an intoxicated patient peed on me during a pelvic examination right when we had a power outage. She got scared she said, so it’s not like she meant any harm. The urgent care center I worked for was well staffed, had excellent relations with the community it served, and had a visible, well-functioning security system. We had panic buttons we carried in our pockets at all times, but I never had to use it. All staff received regular training in violence prevention techniques.

By contrast, working at various community health centers in and around Seattle for 15 years, there were at least ten times when patients seeking narcotics verbally or physically threatened me. These clinics were usually poorly staffed, served large numbers of impoverished people, had no security systems in place, and did not have clear protocols or “pain contracts” for use of narcotics. I remember front desk staff calling for police in several of the cases, but I think in only one case was I encouraged to complete an Incident Report.

An aspect of workplace violence in health care settings I had not even thought of appeared as a spin-off of a KevinMD.com guest blog. In 2007 Patricia Allen, RN wrote “Violence in the Emergency Department and how to promote ER safety.” It is a short blog post, mainly advertising her book. What I found more interesting was a reader’s comment. Steve Parker, MD: “Here in Arizona, hospitals are gun-free zones. Most physician and healthcare providers will not carry their guns into the hospital. Risk of getting caught is too high.” I had to read his comment twice before I understood it, because it never occurred to me that health care providers would carry concealed weapons to work. I thought that was confined to really bad TV shows.