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 Her mother was timid, withdrawn, and depressed, to the point that she spent days and weeks in bed.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.

Nurses Go Where Doctors Don’t

Mary Breckinridge Statue
Mary Breckinridge Statue (Photo credit: jimmywayne)

One of the most e-mailed NYTarticles/blog posts over the past twenty-four hours was Tina Rosenberg’s Opinionator/Fixes post “The Family Doctor, Minus the M.D.” (10-24-12). In her online article, Ms. Rosenberg focuses on the expanding role of nurse practitioners in providing cost-effective, accessible, comprehensive, and quality primary health care—especially in rural and underserved urban areas of the U.S. where physicians typically do not want to work. There is already a severe shortage of primary care physicians in the U.S., a shortage slated to grow with the ‘perfect storm’ of the aging/chronic disease-challenged population combined with Obamacare’s expanded coverage of previously uninsured patients.

Ms. Rosenberg, who is a journalist and contributing writer for the NYT Magazine (and not a nurse), points out that nurses “take a different approach to patient care than doctors(…)”—and that nurses’ more holistic approach to patient care is particularly useful in the management of chronic disease, especially in patients with complex socio-economic barriers to care. She included organized physician resistance to nurse practitioner-run clinics, citing a recent position statement by the American Academy of Family Physicians in which they oppose independent practice by nurse practitioners. Ms. Rosenberg points out that in sixteen states plus Washington, D.C, nurse practitioners have complete independence. (Of course, what she left out is the fact that nurse practitioners have to maintain their RN license; as RNs they are independent practitioners within commonly accepted nursing functions.)

It is a well-researched and well-written article. Perhaps equally interesting are the reader comments—all 295 of them. Unlike local newspapers, the NYT carefully moderates all reader comments. They screen them before allowing posting of only the “thoughtful, civil and articulate” ones. Most of the comments to this article were on-topic. There were the usual vitriolic negative comments by some physicians about care by nurse practitioners being “second rate care,” and how nurse practitioners were dangerous unless “under the direction of a fully trained and clinically seasoned M.D. or D.O.” There were the physician assistants weighing in with “what about me?!” and saying that since they were trained under the medical model they provided superior health care compared with nurse practitioners. There were patient testimonials (for and against) care they received by nurse practitioners. There was an off-topic comment about how all nurses are into narcotic diversion and are addicted (Nurse Jackie, you brought on this misconception). And there were more than a few comments about how professional “turf wars are only hurting the patients and the nation.” I agree with that sentiment. I also am glad to see a healthy debate about the need for more primary care providers in the U.S., as well as about the important role that nurses can (and do) play in our health care system.

Happy (#192) Birthday Flo!

Cover of "Notes on Nursing"
Cover of Notes on Nursing

Happy International Nurses’ Day and happy end of National Nurses (no apostrophe, I don’t know why) Week, celebrated May 6-May 12th every year since 1990, thanks to the American Nurses Association—seemingly in conjunction with Hallmark. Is it a strange coincidence that National Nurses Week, National Administrative Professional’s (or Secretary’s) Day, National Teacher Day, and National Mother’s Day are all clustered around the same weeks?

In the interest of research, I recently bought and watched Season Three of the TV show, Nurse Jackie. According to Nurse Jackie (Episode 11: Batting Practice), “(Nurses) Appreciation week is patronizing. It’s for the overworked and underpaid.” To which her co-worker, male nurse Thor chimes in, “Secretaries. Teachers. Us.” Jackie responds, “It’s bullshit and we don’t celebrate it.” And my favorite character on the show—the pink Crocs and teddy bear scrubs wearing new nurse Zoe—says, “That’s crazy! It’s our week, and if we don’t celebrate it, who will?”

Florence Nightingale, the somewhat tarnished icon of modern nursing, was born 192 years ago today. Of all that has been written about Florence Nightingale, Lyton Strachey’s is my favorite. He calls Florence’s Notes on Nursing, “… that classical compendium of the besetting sins of the sisterhood…”  Here is what Lyton Strachey writes about Florence Nightingale in his entertaining book Eminent Victorians (1918/The Albion Press/Oxford England):

“Every one knows the popular conception of Florence Nightingale. The saintly, self-sacrificing woman, the delicate maiden of high degree who threw aside the pleasures of a life of ease to succour the afflicted, the Lady with the Lamp, gliding through the horrors of the hospital at Scutari, and consecrating with the radiance of her goodness the dying soldier’s couch—the vision is familiar to all. The Miss Nightingale of fact was not as facile fancy painted her. She worked in another fashion, and towards another end; she moved under the stress of an impetus which finds no place in the popular imagination. A Demon possessed her. Now demons, whatever else they may be, are full of interest. And so it happens that in the real Miss Nightingale there was more that was interesting than in the legendary one; there was also less that was agreeable.” (pg 73)

Roxanne Nelson, in her Washington Post (4-29, 2003) article entitled “Good Night, Florence,” reports that Unison, Britain’s largest trade organization representing nurses, declared they were ditching Florence Nightingale because she “represents the negative and backwards elements of nursing.” (during their 1999 annual conference). In her article, Ms. Nelson reminds us that Miss Nightingale worked as a nurse for less than three years, including the time she managed a British hospital in Turkey during the Crimean War. After the war—and for the last fifty years of her life—she basically took to her bed with what historians now suspect was a combination of Malta Fever (brucellosis—probably from infected milk products) and depression. While an invalid, she wrote Notes of Nursing, oversaw the opening of the Nightingale Training School for nurses, and worked on hospital reform of the British military. Florence insisted that nursing was a calling and not a profession.

Those funny Brits across the pond. They know how to celebrate the history and influence of Florence Nightingale. They have the Florence Nightingale museum in London, complete with a stuffed owl—the remains of her pet owl Athena—and a Turkish lantern like the one used during the Crimean War. In their online store you can buy a teddy bear dressed as a nurse and holding a Turkish lantern, or a resin bust of the Iron Maiden, or a hot pink lapel pin with the interesting statement, “Nursing is an art.”

Nursing and the Media

I recently received an e-mail invitation to a free one-hour webinar entitled, “How the Media Portrays Nursing: Does it Really Matter?” The speaker was Sandy Summers, RN, MSN, MPH, the Executive Director of The Truth About Nursing blog and website. As her billing says, “Since 2001 she has led the effort to change how the world views nursing by challenging damaging media depictions of nurses.” I would have signed up to participate in this webinar, but I was working in clinic during the time it aired. Here is the promotional blurb for the webinar:

“Ever watch Grey’s Anatomy, Nurse Jackie, House, or other television shows that seem to portray an inaccurate depiction of a nurse?  How often do you personally experience the misconception that nurses ‘do what doctors tell them to’? The nursing shortage is a public health crisis that is one of the biggest dangers for patients and the public at large. Media products have long shaped and reinforced inaccurate perceptions about the nature of nursing work. Public health research shows that even entertainment media products have a significant effect on how people think and act with regard to health care. By reconsidering how our society thinks and acts toward nursing, we can empower nurses to improve safety for patients, reduce turnover, and enhance public health. Explore some overlooked roots of the nursing crisis and its effects, and learn ways you and other nurses can help.”

A few things I find interesting about her description and that I disagree with. One is contained in the last sentence and that is that media’s (implicitly stated ‘bad’) depiction of nursing leads directly to the nursing crisis. The “nursing crisis” is, of course, that oft-quoted “the sky is falling” alarm statement about how we don’t have enough nurses in the US to take care of all the aging baby-boomers. People have been screaming “nursing crisis” since before I went to nursing school, and I believe it is a largely manufactured problem. If there is a real shortage, it is not for lack of nurses, but for lack of decent working conditions for nurses. They leave nursing. And I doubt it is the fault of the media. “The nursing shortage is a public health crisis that is one of the biggest dangers for patients and the public at large.” Also inaccurate. Yes, adequate nurse staffing levels in hospital settings are clearly related to good patient outcomes. No one who has ever spent time in hospitals, as patient, family or staff, would disagree with this conclusion. But at a population health level, the number of nurses, doctors and hospitals in a country is not well correlated with good population health outcomes. In fact, it can start to have an inverse relationship, with more health care workforce/hospitals seeming to lead to a decline in overall population health—the effects of iatrogenics at work. I know they cover this in the MPH program at Johns Hopkins where Ms. Summers received her public health degree.

So that leads me to consider the overall issue of the media portrayal of nursing. That, after all, is what Ms. Summer’s Truth About Nursing is about. TV is only one segment of media, but an important one on a national level. I have watched episodes of Grey’s Anatomy, ER, Nurse Jackie, and HawthoRNe, both to see if they had any entertainment value, and to see how nurses were portrayed. I haven’t owned a TV—well—ever, so I watched all of these on DVD or streaming video. They are all TV shows, so they have really bad scenes involving resuscitation of deer, ferry crashes, helicopter crashes, and the usual soap opera hospital romances. Nurse Jackie and HawthoRNe at least have flawed but strong, smart and almost believable main characters who are nurses. TV drama shows like these are not reality TV. I still have faith that most Americans know this difference and don’t form their opinions about nursing from these TV portrayals. They form their opinions more from interactions with nurses they know as family members or as health care providers.

Ms. Summers and other nurse media watchdogs need to lighten up. The sexy nurse and the angelic nurse motifs are never going away completely. Having more men in nursing will help change the public’s perception of nursing more than trying to battle the media. And having a sense of perspective—and of humor—is needed.

It reminds me of other negative stereotypes of female-dominated professions, such as librarians. The Nancy Pearl Librarian Action Figure sits here beside me at my desk. Nancy Pearle is a real-life Seattle librarian extraordinaire. Seattle, as one of the most literate cities in the country, would have a librarian as a local celebrity. Our Seattle-based crazy toy-maker and seller Archie McPhee made an action figure of her several years ago that was a big seller. The librarian is dressed in dowdy clothes, a mid-shin length skirt, a loose-fitting jacket, and flat puffy comfort shoes. She is holding an index finger to her pursed lips, permanently ‘shushing’ people. Many librarians around the country were outraged by this action figure, complaining that it reinforced a negative stereotype of the anti-fashion, stern, matronly librarian. Nancy Pearle’s response was that it separated librarians who had a sense of humor from those who needed to check one out of their local library (OK—this is not a direct quote, I added the last part).  I checked today and Archie McPhee’s doesn’t have a nurse action figure. I plan to recommend they come up with one—and not of Florence Nightingale. That reminds me of the Halloween costume I wore one year to a party at Hopkins. I went as sexy Flo and it was a hit…. Luckily I wasn’t in the same class as Ms. Sommers.

In my next blog entry I will continue this discussion, but will focus on nursing’s attitudes towards and interactions with the media, especially the news media.