The code

The incident

“I was in the emergency room (E.R) of the hospital one afternoon. E.Rs use a colour coding system for emergencies, assigning a colour between white, green, yellow and red (in order of severity) to the patients who walk in. Precedence is thus given to more severe cases.

A couple entered and asked me how long they would need to wait to receive medical attention. Before answering their question, I tried to gather more information about their situation and why they needed medical care and treatment – in order not to be unprepared. I realised that the patient’s health was under control. He only needed a medical check. The emergency code assigned to him was the correct one. I tried to explain that the waiting time is linked with the code patients are assigned and that there were many other patients waiting.

It was a rather busy afternoon at the hospital, and these patients were trying to break the rules and find someone who will let them in before others, regardless of the colour code they have been assigned.

The patient and the woman complained loudly to me. The male patient and his female companion felt a need for urgent treatment, but I was aware of their assigned code and wanted to enforce the normal hospital practice.”

1. Identities of the actors in the situation

The situation involved three people:

The narrator is an educated nurse and professor at the University of Palermo. When the incident takes place, the nurse is working in the emergency ward of a hospital in Palermo, Italy. She is 52 years old, Italian. She could be described as an idealist, who is very much dedicated to basic values like family life, social justice and togetherness.

An Italian woman in her 50s. The woman is accompanying a male patient also in his 50s, waiting his turn at the hospital.

They are both from a low social background, uneducated, and share the mainstream idea in Italy that rules can be bent and exceptions can be made even at institutions that are supposed to follow specific rules.

2. Context of the situation

There is a professional nurse-patient link between the actors, and they share the Italian background and the language. The social status is different, in that the nurse is educated and a professor at the university, while the two other actors are uneducated from a low social status.

The narrator is as a nurse responsible for a flow where the patients have access to the doctors and to treatment in the right order in according to the severity of their illness. The level of tension is exacerbated by the stress that is caused by the actors involved. The nurse is usually occupied in the examination rooms with the doctors, but in this situation, she is at the front door of the ER when the patient and his wife started complaining, so she decided to manage the situation and listen to their needs and complaints.

3. Emotional reaction

The nurse was stressed and under pressure because of the many patients and the long waiting time in the emergency ward. The nurse felt a sense of frustration and helplessness facing the rudeness of the couple involved in the incident. It was hard for the nurse to control the situation. She tried to calm down the patient and his companion by explaining the system of the coloured codes and trying to enforce the rules of the hospital.

4. Representations, values, norms, ideas, prejudice: The frame of references of the person who experienced the shock.

1) Respect of rules/equality:

The narrator emphasises and appreciates that there are uniform rules for all patients, and that existing rules are respected, since rules are also seen as a guarantee that patients are treated equally without any possibilities of obtaining special privileges or benefits at the expense of other patients.

She is loyal to the rules to the point of going “against stream”, i.e. against the mainstream idea that you can skip the queue if you know someone or if you insist enough, and enforcing the rules of the hospital, making sure not to create favouritism and tension between patients.

2) Professionalism:

The narrator acted in a professional manner trying to calm down the patient and his companion, explaining why they needed to wait, but also trying to understand the reasons for complaining to the point of checking whether the colour code assigned was the correct one for the state of health of the patient. The narrator applies the procedures of the hospital and of healthcare by providing professional assistance, which she values highly, as is demonstrated by the fact that she dedicated her life to this. Her professional identity should then be respected.

3) Manners and reciprocity:

The narrator appreciates politeness, especially in public places where sensitivity and calm must be shown, such as in a hospital, and especially in an ER where the medical staff is asked to deal with highly-sensitive situations. In this public space an implicit behaviour code exists, people do not speak loudly; do not move much in order to preserve the calm and not to disturb the doctors.

She would expect the patients to be as polite to her as she is to them, but her expectation is not met by reality and she becomes frustrated. The frustration comes from non-respect of the exchange, when we are polite or kind to someone we expect the same response from others.

5. What image emerges from the analysis of point 4 for the other group (neutral slightly negative, very negative, "stigmatized", positive, very positive, real, unreal) etc?

The narrator´s image of the other group is negative, because their behaviour confirms that people do not necessarily respect the rules about standing in queues and the rules of coexistence in a sensitive environment as a hospital.

The narrator is also bothered by the behaviour of the patient and his companion, as she realises that they are seeking favouritism and are trying to make her bend rules for them.

6. Representations, values, norms, prejudice: The frame of references of the person or group that is causing the shock / that caused the shock in the narrator.

1) Rules can be bended

In opposition to a stick system of rules where everybody complies, we can find in Italy some flexibility of the frame imposed by each institution. The rules can be considered somehow flexible and it is normal that people try to get some benefit of it.

The patient and his companion were expecting a special treatment to skip the queue, even when their colour code for the emergency was confirmed by the nurse. We can make the hypothesis that they are occupied only with their own health and treatment needs on the expense of other patients, even though other patients may be severely ill and in acute need of medical treatment in the emergency ward.

Their behaviour and expectation is in line with mainstream culture in Italy, where corruption and rule-bending are often the rules, especially in the public sector, and especially for people from a lower social status.

2) Conception of Authority and Gender Equality

This is a twofold concept for the couple. On one hand, there is a set of rules of the hospital which they will not abide to. On the other hand, they are probably finding it difficult to trust the judgement of the nurse on the health status of the man, mainly for two reasons. Firstly, the nurse is considered by mainstream society as a subordinate of the doctor, an assistant who is much less qualified and who is not able to offer a proper diagnosis to the patient. Secondly, the nurse, as in most cases in Italy, is a woman, and mainstream culture considers women as less capable than men in many sectors, and especially when they are entrusted with serious tasks, such as that of medical care.

7. Does the situation highlight any problem concerning the professional practice, or in general about the respect of cultural differences in intercultural situations?

Possibly the behaviour of the patient could be justified by a low level of education because in terms of protocol, the nurse has acted consciously checking their code and explaining the situation.

Professional practice has been jeopardised by the patients and their presumption of judging their case more urgent than others (though it was already diagnosed), and expecting a special treatment and a rule-bending attitude from the side of the nurse, as understood in mainstream culture in Italy. The narrator has followed the protocol, which also had the positive consequence of reassuring the other patients in the waiting room about the correct and fair enforcement of the rules of the hospital. However, a nurse in her situation could perhaps be more resolute with the ill-mannered patients, and not expect politeness from their side.