Nurse Jackie says goodbye
The Showtime comedy’s final seasons had flaws, occasionally suggesting that nurses report to physicians. But there was still a lot of expert care and creative advocacy from the brilliant Jackie Peyton and her protegee Zoey Barkow.
June 2015 – Showtime’s Nurse Jackie could have been named Addict Jackie, since that aspect of the emergency nurse character’s life was probably as important as her nursing. (Yes, we know that label has been questioned, but Experiencing Addiction Jackie might be a little awkward.) Jackie Peyton still managed to save plenty of lives, even during the personal crises of the show’s final three seasons. Those confirmed the show’s place, along with the BBC’s Call the Midwife, as arguably the best drama for nursing in television history. In particular, the show offered many examples of nursing expertise, innovation, and advocacy by Jackie and her gifted protegee Zoey Barkow. The nurse character Thor, while witty and well-meaning, remained fairly weak and never displayed much skill. But the show did have impressive male nurses in the first season’s Mo-Mo de la Cruz and the third season’s Kelly Slater. Jackie’s relationship to Zoey generally reflected the professional mentoring model that is familiar from countless other hospital shows’ portrayal of physicians. By the seventh and last season, Zoey had become a head nurse pursuing a masters degree to become a nurse practitioner. That kind of bond between nurses was rarely seen before Jackie and its less successful contemporaries Mercy and HawthoRNe appeared in 2009. Jackie even trained junior physicians, especially Fitch Cooper and, in these last seasons, Carrie Roman. By contrast, even today, other hospital shows tend to have at most one competent major nurse character, fully formed to assist the expert physician leads. Nurse Jackie’s depiction of emergency care was less about blood and guts than it was about how the patients—often quirky, desperate, or sad—ended up at All Saints Hospital and how their experiences there may have changed their lives going forward. The show generally avoided stereotypes, repeatedly rejecting the angel. Autonomy was always the weakest point. The show had repeated suggestions that the nurses reported to senior physicians like Eleanor O’Hara and Ike Prentiss. Still, there were plenty of plotlines in which physicians played no significant role and the nurses were clearly the primary care givers. And despite the personal issues that put many real nurses off the Jackie character—especially her addiction–the show was a landmark in popular depictions of nursing.
The fifth season of Nurse Jackie, which aired in the spring of 2013, probably had less of a clinical focus than previous ones. And despite some good nursing, on balance it was somewhat worse for the profession, in light of troubling suggestions that physicians directed nursing care.
The season still included real clinical expertise and creative patient advocacy by Jackie and Zoey. In the season premiere, Jackie intubated a head trauma patient, almost casually, when no physician was available. A family member then called her an “angel,” but she demurred. In the same episode, Jackie manipulated a wealthy football player into donating a new $425,000 CT scanner the hospital badly needed by threatening to disclose his drug possession following a vehicle crash (he said the drugs were for friends and he did not seem to have been altered at the time of the crash). In the fifth episode, Zoey took the lead in expertly delivering the baby of a gunshot victim. And in that same episode, manager Gloria Akalitus, also a nurse although the show rarely mentioned it, made an astute clinical intervention: She diagnosed a serious leg problem in a patient who was a dancer, something the highly skilled physician ED “chief” Ike Prentiss had missed.
Jackie herself at times acted as a check on poor physician care, as she had from the beginning of the show. This season she tried to train, or get physician Fitch Cooper to train, the pretty but inept new ED physician Carrie Roman. Jackie repeatedly caught Carrie in dangerous errors, protecting patients when possible, as she did with a sepsis patient in the second episode and in diagnosing appendicitis that Roman had missed in the seventh episode. In the season finale, Jackie was part of a team—along with Akalitus, Cooper, and Prentiss—that tried to fire Roman. But that did not fly; Carrie was able to use the fact that the senior Cooper was also having sex with her. Oops.
Unfortunately, the season also sent damaging messages about nurses’ autonomy and their positions relative to physicians. There were implications that the nurses reported to Prentiss, as in the seventh episode in which he was impatient about temporary nurses not preparing his suture material fast enough. In such scenes, nurses played handmaiden roles for physicians that we hoped we would never see on Nurse Jackie. Also in the seventh episode, the show had Zoey transcribing dictation by Cooper. In the eighth episode, she was seen re-organizing Prentiss’s office, something Akalitus did eventually disavow in the ninth episode, but still—that is not something a strong nurse would waste time doing. And the fact that Zoey turned out to be dating Prentiss didn’t exactly make it better. The season also included some of the reflexive overcrediting of physicians for care that is common on other shows, as occurred in the seventh episode.
The vein whisperer
The sixth season, airing in 2014, had fine examples of clinical expertise and advocacy from Jackie and Zoey, even as Jackie relapsed in a major way and her drug abuse seemed to affect her nursing care significantly for the first time. One plotline found Jackie very supportive of Zoey’s plans to become a nurse practitioner. And there were some good plotlines about educating physicians, marred somewhat by a few more suggestions that nurses report to them.
Viewers were again treated to the experience of seeing nursing expertise and authority on a U.S. hospital show. In the season premiere, Jackie was disrespected by a young patient’s mother, who only seemed to accept the nurse’s assurance that the ED staff had to draw blood to check for tetanus after physician Prentiss confirmed it. Jackie then expertly located a difficult-to-find vein, prompting Zoey to call her “the vein whisperer.” In a priceless plotline from episode 3, a patient arrived at the ED having adverse reactions to a combination of different drugs apparently prescribed by a number of different physicians, with no coordination among them. Jackie tried to contact these physicians, but they all blew her off. So she called again, this time claiming that the physicians’ mothers were in the ED. They showed up for that and were rewarded with a stern lecture from Prentiss. In that same episode, Zoey traveled to a gay bar to vaccinate men for bacterial meningitis, a fine public health measure. In episode 4, only Jackie among all the ED staff realized that a screaming baby indicated an emergency. After Cooper intubated, Jackie pushed Carrie to explain to the worried mother what they were doing, a good example of a nurse teaching a junior physician (although in reality a nurse would likely have been doing that family education). In that same episode, Zoey pushed the reluctant Prentiss to tell an old friend of his that he had cancer, which was good patient advocacy. And in episode 7, after Prentiss had departed the show, Akalitus moved to appoint Cooper as the new ED “chief” (we never did understand how the show thought ED management worked). But Jackie still played a key role in coaching Cooper through the care of a sick toy inventor, which was made far more challenging by the patient’s disruptive personal physician.
One of the season’s more interesting plotlines was that of Zoey as an aspiring nurse practitioner (NP). In episode 10, Zoey told Jackie that she was thinking of getting a masters degree and becoming an NP. Jackie was very supportive and agreed to write a recommendation, which she later did. Jackie also advised Zoey to write her application essay about a case they had that day in the ED, suggesting one with primary care overtones. Then, being Jackie, she told the patient that Zoey already was an NP and that she would be giving him a full exam. Zoey did that successfully, counseling the patient on dealing with his high blood pressure and putting him on what seemed to be a wellness program, assuring him that he could call her later if needed.
The season gave clear indications of how Jackie’s drug abuse might affect her nursing, which the show did not do enough of in earlier seasons. In the season premiere, Jackie provided expert emergency care to a man who had overdosed at her AA group, escorting him to the ED. But there, working with Carrie, Jackie was too distracted by her own impairment to hear Carrie call “clear” when preparing to defibrillate, and Jackie got shocked. The remarkable episode 8, entitled “The Lady with the Lamp,” featured a dream sequence in which Jackie imagined she saw a host of nurses from the past, including Akalitus dressed as a nurse from the World War I era, spouting ethical mantras, and Carrie, no less, seemingly as a 1960s nurse with a too-short dress. The sequence appeared to revolve around Jackie’s insecurity about her job status—rational in light of her addiction struggles—and her troubled relations with her older daughter Grace, who appeared in the sequence as an ED patient. And in a later June episode, with Jackie starting to spiral out of control, she made a potentially deadly error, giving a patient far too much insulin.
Fortunately, Zoe caught that error, and she also eventually figured out that Jackie was using again, leading to Jackie’s downfall—and some terrible messaging about nursing autonomy. In the season finale, Zoey told Akalitus of her suspicion. Akalitus then told Jackie she had to either submit to a drug test or agree to a diversion program, under which she could keep her job but would need to submit to treatment, random testing, a pay cut, and other degrading features. Desperate for a way out, Jackie told Cooper that it was Carrie’s insulin mistake, suggesting that Jackie herself had no responsibility to ensure what she was giving was correct. When confronted, Carrie took responsibility for the mistake of the nurse “working under” her. In this plotline all the characters, even Jackie, seemed to wrongly believe that Jackie reported to Carrie in the clinical setting. In fact, nurses like Jackie are responsible for the medications they give and they have an obligation to evaluate them. By the end, Jackie had burned too many bridges. Zoey told her she had to do the diversion program or Zoey would reveal an ID scam Jackie had used to procure drugs. Jackie fled toward the airport with drugs and money, but on her way there, she could not resist stopping to expertly save a car crash victim. Pulling away from the scene, the altered Jackie crashed into an arriving ambulance. The last thing we saw was Jackie’s mug shots.
Jackie was trapped: Her addiction would not allow her to practice the nursing at which she excelled, and her need to practice nursing prevented her escape from the fallout of her addiction.
Saying a little prayer
The final season, airing in 2015, followed Jackie’s efforts to reclaim her place at All Saints. It was a long way back, through jail, detox at Bellevue Hospital, a criminal case, a fight to get her nursing license back, a bitter war with Akalitus, regular drug testing, and a position as a nurse’s assistant, working for Zoey. But as Jackie remarked in the season premiere, “I can’t not be a nurse.” Meanwhile, Akalitus offered a “head nurse” position to Zoey—something that the characters themselves noted the ED had never had before. Meanwhile, Jackie’s lawyer was skeptical about her chances of recovering her professional life at all, until she cleverly showed up to work at All Saints as if nothing had happened, prompting a furious Akalitus to publicly fire her and accuse her (falsely) of being high. Now, evidently, she had a case.
Even with all this going on, Jackie managed to shine clinically. Unable at first to practice at All Saints, Jackie appeared to be engaged in home health nursing. The season’s first episodes found her helping an overmedicated elderly patient become far more functional despite the resentment of the patient’s daughter, who seemed more inclined to institutionalize her burdensome mother.
After Jackie’s lawyer negotiated her way back to All Saints as a nursing assistant, everyone seemed to struggle with her more limited role, especially Zoey, who was in charge of monitoring her. But Jackie deployed her skills to help people regardless. In episode 3, she noted the pain of a patient in the waiting room. Jackie subtly motivated the marginal nurse Thor, who was working at triage, to see the patient soon. Jackie also pointed out the patient’s blue toes to Zoey, who then alerted Cooper, and generally got the patient into the system. That patient ultimately died, but others had better results. Among them was the motorist Jackie had saved on her way to the airport at the end of the previous season, someone Jackie’s lawyer cleverly used to help get her criminal case dismissed in episode 4. In the middle of the season, it appeared that the hospital would be sold to a Norwegian company that wanted to turn it into condominiums. Jackie tried some bold and creative strategies to prevent that, which could be seen as an effort to help the patients, although they were also consistent with Jackie’s own goal of regaining her lost status there—so many of Jackie’s clever moves over the years seemed to serve patients and her own addiction. In episode 5, Coop left All Saints, but not before paying tribute to Jackie for making him a better physician. His replacement as chief ED physician, the wise older physician Bernard Prince, immediately saw Jackie’s gifts and became the main booster for her full return. Unfortunately, Jackie also felt compelled to sell drugs to pay her expensive lawyer, aided by pharmacist Eddie, her enduring friend with benefits, who now worked as a drug company rep. In episode 7, while the two of them were trying to sell a large quantity of drugs at a “pill mill,” Jackie identified a woman in the waiting room undergoing withdrawal. Jackie managed to browbeat the sleazy physician in charge of the pill mill into calling an ambulance, perhaps saving the woman’s life.
Mid-season episodes also saw Zoey growing into her new role, and it was understood that Jackie’s mentoring over the years was a key reason. Even so, in episode 7, Zoey lost a patient she thought Jackie would have saved. Meanwhile, Zoey had gotten closer to Carrie—who had improved as a physician—and Carrie actually offered to pass along all her physician knowledge to help Zoey with her NP coursework. Of course, Carrie would presumably have at least some helpful information about disease pathology. In any case, Carrie’s help turned out to consist of buying Zoey a research paper online and then getting wasted with her on mushrooms.
Unfortunately, the show never did manage a season without suggestions that nurses report to physicians, and that was true here, even with Zoey ostensibly as the new ED “head nurse.” In episode 5, when the ED staff was handling multiple patients, ED chief physician Prince invited Jackie to be involved in a case despite her limited status, and he also directed Thor to take over for a flailing new nurse. Those elements both suggested that physicians direct nurse staffing in the clinical setting. In episode 11, Prince himself was in decline because of a terminal illness, and one symptom was lashing out irrationally. He tried to fire Zoey; she responded that he lacked the authority. That is correct and we’re glad the show did not suggest otherwise. But given all of its other problematic treatments of this issue, that was not enough.
[spoilers coming – to avoid, stop reading now]
In the end, even the extraordinary Jackie Peyton could not keep all of these balls in the air. In the series finale, All Saints was finally closing, despite the efforts of Jackie and the union. Things were looking up for Jackie: reinstated as an RN, she already had a new job at Bellevue. She urged Zoey to come with her, but Zoey resisted, eventually admitting that although she had learned a lot from Jackie, now she had go on without her—meaning without worrying about her. In this episode, the main patient was addicted to heroin and on the run from a man who wanted to kill him. At one point, we saw Jackie wash his feet a la Mary Magdalene and Jesus, while admitting that she was addicted herself. Jackie gave the patient such good care that she had to fend off another “you’re a saint” comment from him. The patient left All Saints so reinvigorated that he declined to take his things—including his drugs—with him. But that left Jackie with the last temptation of several lines of heroin. She proceeded to snort them, then hallucinate an adventure in Times Square. In reality, we saw, she was lying on the floor in the middle of the All Saints farewell party, overdosed. Since All Saints had now closed, the staff would have to transfer Jackie to Bellevue–where she would presumably no longer have a job, assuming she even survived. The show closed with Jackie looking upwards from the floor, surrounded by Eddie, Akalitus, and Zoey, who repeatedly tried to comfort her by saying, “You’re good, Jackie, you’re good”–in part a reference to the show’s first episode, in which Jackie herself had mused over Saint Augustine’s request: “Make me good, God, but not yet.”
The brilliant Nurse Jackie saved countless lives, but not her own. Did she have more in common with Mary Magdalene or Jesus?
For analyses of the previous seasons, see our Nurse Jackie review page.
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