Paradoxes in Nurses' Identity, Culture and Image

The Shadow Side of Nursing

Margaret McAllister, Donna Brien

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781351033404
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

This book examines some of the more disturbing representations of nurses in popular culture, to understand nursing's complex identities, challenges and future directions.

It critically analyses disquieting representations of nurses who don't care, who kill, who inspire fear or who do not comply with laws and policies. Also addressed are stories about how power is used, as well as supernatural experiences in nursing. Using a series of examples taken from popular culture ranging from film, television and novels to memoirs and true crime podcasts, it interrogates the meaning of the shadow side of nursing and the underlying paradoxes that influence professional identity. Iconic nursing figures are still powerful today. Decades after they were first created, Ratched and Annie Wilkes continue to make readers and viewers shudder at the prospect of ever being ill. Modern storytelling modes are bringing to audiences the grim reality that some nurses are members of the working poor, like Cath Hardacre in Trust Me, and others can be dangerous con artists, like the nurse in Dirty John.

This book is important reading for all those interested in understanding the links between nursing's image and the profession's potential as an agent for change.

1 Transgressive texts about nursing

Introduction

Popular culture texts can be categorised into the conventional and the transgressive (Fiske, 2010). A conventional text offers a normative view on an issue, a view which is generally acceptable and expected. Many television hospital dramas and soap operas are conventional texts. They typically feature nursing characters who draw heavily from the “good nurse” trope. Such stereotyped portrayals ensure the (female) nurse is placed in the position of assistant to the (male) doctor and that she is caring and selfless. Transgressive texts, on the other hand, violate those norms of the good nurse trope.

As transgressive texts are by nature non-conformist, they can be so subversive as to be shocking. When they are effective, they can challenge restrictive thinking. This is because recognising such representations can lead to better portrayals in the future, and a wider understanding of the complexities of the issue (Ellis, 2014). An example of this is the representations of disabled crime fighters on television. The 1960s series Ironside (Young, 1967–1975) featured a detective, played by Raymond Burr in a wheelchair. In television shows like Law and Order SVU (Wolf, 1999), when disability prejudice was portrayed and discussed (Zalla, 2008), wide commentary on the issue followed, which in turn inspired more television shows to cover a wider range of disabilities.

Storey (2003) explains that more examples of transgressions about a particular issue in mass culture indicate that a dominant ideology is beginning to waiver in its authority. The notion of being a transgendered individual, for example, transgresses the belief that there are two discrete genders in human biology. Thus, an increasing representation of transgendered characters in popular culture may suggest that the idea of only two genders is, first, under challenge and, then, in the process of being superseded. Transgressions can also be seen as a site of resistance to dominant ideology, where accepted truths are subverted, allowing new thinking on a topic to emerge, possibly eventually prompting change in ideology. Mallett (2009) argues that such moments of transgression are important to identify because, in indicating where conventions have been defied, new ideas and possibilities are also presented for consideration. This can be seen in popular culture, for example in how The Simpsons (Groening, 1989–current) lampoons many accepted truths about contemporary society. In doing so, it calls into question everyday thinking about the nuclear family and the wisdom of authority figures such as teachers, doctors and church officials. It has been remarked that few previous television shows had ever so boldly and iconoclastically made fun of so many sensitive topics (Alberti, 2004). The Simpsons provides a vivid demonstration of how transgressive texts can play with conventions and test the status quo. Consumers of transgressive texts often find pleasure in engaging with such narratives.

This pleasure is described by Lacan (1994), as jouissance – an intense feeling produced when evading and transgressing the social order – and even, sometimes, gaining pleasure from (others’) pain – when the individual is freed, even if only momentarily, from cultural and hierarchical restrictions (Manga, 2003). Jouissance is important because it lightens situations that might otherwise be unbearably painful and exposes absurdities of oppressive ideologies (Lacan, 1994; Zizek, 2009). This is why fans and scholars of popular culture find transgressive texts fun, pleasurable and exciting. One such revealing transgressive story, which provides a clear exception to the good nurse trope, is found in the British television series Getting On (BBC, 2009–2011).

Getting On

Getting On is set in an English National Health Service (NHS) hospital, in the geriatric ward. The series provides darkly comedic insights into class hierarchies and power inequities between health care workers, and between them and their patients. Written by its core cast, Jo Brand (an ex-nurse turned comedian), Vicki Pepperdine and Joanne Scanlan, the series ran for three seasons in the UK and has been adapted for the American market (HBO, 2013).

The initial episode of the first series opens with an extreme close-up of an old woman’s mottled and bandaged hand, setting in place the promise of intimate close-ups of nursing and health care. The hand-held camera glides up to the patient’s anguished face, and down to her other hand, which viewers see is being held. The camera pans slowly outward revealing that the person holding the old woman’s hand is the Ward Sister, Denise Flixter, who is also known as Den. Den holds a smartphone in her other hand. This is capturing her attention and she is giggling. In this moment, and in stark contrast to Nurse Tallis in Atonement (discussed in the Introduction), she clearly defiles a sacred moment and transgresses the trope of the good nurse. While, like Nurse Tallis, she is attending to someone in their final hours, using human connection so that the patient does not have to die alone, her demeanour is totally unlike this paragon’s. Den’s attention is elsewhere and, despite the solemnity of the scene, she cannot suppress her childish delight at what she is reading on her phone. Then, something makes Den look up from her reverie. The viewer is unsure if this is intuition, or whether she can no longer feel the pulse or hear the breathing of her dying patient. This example from the first few seconds of this series illustrates the shocking power of transgressive texts. It clearly lampoons nursing stereotypes and political correctness. This chapter explores such patent transgressions of the good nurse stereotype and, in doing so, considers what these texts reveal about nursing’s place within health care, its on-going struggles for identity and value, and anxieties related to health care. It also illuminates some paradoxes inherent in nursing and its representation.

Aware that her indulgence needs to stop, Den’s nursing knowledge comes to the fore and she steps into action as Sister Flixter begins the serious business of caring for the deceased. Before, however, she can make much headway, she is interrupted by a nursing assistant, Kim Wilde, whose statement underscores the transgressive nature of Getting On.

“Den, there’s a shit on a chair”, Kim states in a deadpan voice.

Den answers, in an exasperated tone, “It’s faeces, not shit”.

Kim rallies with, “There’s faeces on a chair”.

Den, finishing the repositioning of the deceased patient, refocuses and states, “Okay. Right. Where’s this shit? Err … faeces”.

Together the nurses assess the “deposit” on the chair and confirm that it is indeed faeces. Kim volunteers to clean it up, but Den overrules her, saying, “No, Kim. No. That constitutes a critical incident. So, I’m going to call CERIUM [the infection control services] and get them to come and clean the chair. Can you fill in the critical incident form?” The faeces remain on the chair all day, cordoned off with hazard tape, as the nursing team awaits the staff whose job it is to clean up “contaminants”. This irreverent scene mocks the irrationality and hypocrisy embedded within nursing culture, in the process calling attention to the politically correct language – “deposit”, “hazard”, “contaminants” – that serves to separate those who make policy from those who have to implement it (Johnson, 2016).

Sitting with the dying and laying out a deceased body are two rituals that are normally taken very seriously in nursing. But in the plotting, action and dialogue of this episode, these rituals are seen as commonplace and tedious, and also on a par with dealing with faeces and other quotidian, but often disgusting, bodily secretions. The show exposes the nature of nursing work as mundane and unglamorous and, in addition, draws attention to ridiculous policies and bureaucratic dictates that make nurses’ work overly complicated and, in some cases, ineffective. The show also reveals how, sometimes, the unrelenting expectation for nurses to be compassionate, attentive and selfless is not always met – whether through human failings or the need to deal with competing demands. In this geriatric ward, mortality is a routine fact of life and faeces on a chair attracts more comment and drama than a patient’s death. The nursing staff, like the ward and its patients, are marginalised elements of the hospital system, and it is clear that they realise their work has low status. Thus, in the words of the programme’s title, the staff of the unit are simply “getting on”; getting on with work, life, ageing, dying and death.

Kim, the general “dogs-body” nursing assistant is overweight, slow and tired, but she is also kindly and empathic. She does not, however, appear able to make any autonomous decision, no matter how trivial. Her supervising colleague, Sister Flixter, manages the ward competently and appears quite skillful, but is also overweight and slow and shows little empathy for anyone, appearing to be more preoccupied with her troubled personal life than work on the ward. In contrast, the lithe, impeccably dressed Dr. Pippa Moore, with her upper-class accent and unfinished sentences, is helplessly reliant on the nursing staff for direction. Despite her obvious incompetence, she exudes a superior air and strives to make her daily work more interesting by pursuing scientific challenges. In this episode, this involves her trying to improve upon the Bristol Stool Chart – a national tool that classifies human faeces. Meanwhile, she neglects to make the more practical decisions the nursing staff are expecting – and need – from her.

Getting On also comments critically on the supposed policy of equality driving the NHS, the ideology that all UK citizens have a right to access health care. As many reports have revealed, however, elderly patients experience substandard care, neglect and even abuse (Gorman, 2017; MacKenzie, 2017), and many struggle to even access basic medical care (Cohen and Brown, 2013). When those elderly are also members of a racial minority, they are further marginalised. This is reflected in another scene from the second episode of Getting On. In this scene, Den, Kim and Dr. Moore, together with her medical students, investigate what is distressing an old Asian-looking woman, who is rambling loudly in a language that no one in the care team can understand. Eventually, Kim is able to contact the hospital’s translation service but they cannot attend to consult until the next day. Den suggests that if the nurses convey to the translator over the phone what the old woman is saying, then perhaps he can complete the translation. This results in a farcical interaction. The patient speaks. Den mimics this to Kim: “Gooly-gale-genema”, and Kim conveys it to the translator on the phone, “Gooly-gale-genema”. The patient continues to speak and Den again attempts to mimic this: “Adga-mortichai”. Kim again conveys it: “Adga-mortichai”, and then tells the nurse in the room, “He says that first one doesn’t mean anything”. They persist, relaying “Hannibal-ja-chi” and then being told that this did not mean anything either. Ever-industrious, Den suggests, “Well, listen, what about if you bring the phone up, hold it out there, and he can hear and see if he can translate over the phone?”. The patient speaks again. Kim asks, “Hello, did you get that?”. This time, however, she has an answer and replies, “Oh, you did? Oh, fantastic. Let me get a pen. Blimey, okay, thanks ever so much. Cheers”. When Den asks “Well?”, Kim advises that the woman is saying, “I want to die, please kill me.” Den, without missing a beat, advises, “Put it in her notes”. The jouissance in this scene derives from the politically incorrect way the nurses act in their attempt to try to help their elderly patient. At one level, this is simply a beautifully paced comedy of errors. But on another level, it is a radically subversive narrative that exposes the difficulties of ageing and the functional attitude that nurses, many of them female in this area of health care, bring to their work. The nurses are not unkind, but they do not approach their labour as a natural extension of their female identity (Johnson, 2016).

In this scene, Getting On poignantly confronts the real and tragic issue of many ageing patients in over-stretched public hospitals. These patients are doubly marginalised; they are frail-aged as well as isolated because of language and ethnicity. At the end of the excruciatingly awkward relay of words, viewers expect to finally understand the ramblings of a confused old lady. What they hear instead is truly shocking. The patient is suicidal and begs the nurses to engage in an act of mercy killing. But rather than acknowledge her extreme emotional state, Den’s way of dealing with this drama is to swiftly defuse it with officious action. “Put it in her notes”. Again, a functional attitude to nursing is revealed as the nurses proceed to “get on” with their work. Johnson (2016, p. 192) explains that the significance of scenes such as this in the series are to provide an insider’s perspective of the “messy, ugly, yet crucial work” completed by the carers in aged care. This and many other scenes throughout the series raise the suggestion that contemporary nurses do not always act, or speak, in ways that conform to the stereotype of “the good nurse”. That is, nurses today are not always composed, deferent or compliant. Sometimes they are disengaged, flippant and self-preserving.

Other scenes in Getting On allude to unproductive game-playing, class divisions and professional hierarchies, as well as tension between the nurses themselves. In one such scene, the nurses learn that a new “modern matron”, Hilary Loftus, has commenced work in the hospital. When he arrives, Den and Kim are taken aback to find that the matron is a man. Overweight, tightly coiled and sexually ambiguous, Hilary does not appear congenial or likely to mix well with the other nurses and he is immediately embroiled in struggles in the ward. He sees an empty bed and claims it for a patient, only to learn that Dr. Moore has already requested it. This pits nurse against doctor. Then, Hilary notices that Den is not wearing regulation footwear, instead sporting ankle boots that he says makes him think of strip clubs. This pits nurse against nurse. Finally, Hilary spies the faeces on the chair and can barely contain his anger, ordering Kim to clean it up immediately. At the bottom of this hierarchy, Kim is caught in a dilemma, knowing she will earn the wrath of Dr. Moore, as well as everyone in the nursing pecking order, whatever action she chooses. Both Kim and Den, the working nurses in the ward, are summarily punished and put in their place, and the matron concludes his visit with one final insult. He suggests that this ward, that the nurses work so solidly to keep in order, has “MRSA [an antibiotic-resistant bacteria] written all over it”!

Figure 1.1 The Getting On team – barely tolerating each other and the dema...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• Acknowledgements
• Introduction: Disquieting images of nurses
• 1. Transgressive texts about nursing
• 2. Nursing’s dark past and secret knowledge
• 3. Objects of desire
• 4. Nursing and the abject
• 5. Apparitions, lost souls and healing spaces
• 6. Mighty, mean, monstrous nurses
• 7. Murdering nurses
• 8. Nurses and sick health care systems
• 9. Growing from adversity
• Conclusion: Out of the shadows, into the light
• Index