Angelite Nurses

When I set out to observe life inside a major urban hospital for a year, I expected to find heartbreaking, inspirational and possibly alarming medical stories. I anticipated insurance entanglements, technological marvels and cultural conundrums.

I didn't expect, however, to find classes to correct bad behavior. The classes -- at Brooklyn's Maimonides Medical Center in New York -- were designed to enforce the hospital's Code of Mutual Respect, and part of a national trend to help people in the medical field rediscover the value of that old-fashioned virtue called common courtesy.

Among the provisions that these doctors and nurses needed to be reminded of were not to use racial or ethnic slurs, or language that was profane or sexually explicit. Also, to refrain from intimidating behavior, "including but not limited to using foul language or shouting, physical throwing of objects."

Slurs? Throwing things? Was this a hospital or a reform school, I asked one physician, a department chief. He shrugged and told me that such behavior was far more common than I might imagine.

"I've worked in lots of hospitals where surgeons have thrown instruments; they get scissors that don't cut, they fling it across the room," he said. "I was at a hospital where the resident accused the attending surgeon of breaking her wrist."

Broken wrists may be extreme, but the way hospital workers treat one another sets the tone for how they treat patients and their families, who are often frightened and fragile. The simplest form of human communication -- a harsh or caring tone, abrupt or attentive behavior -- can be healing or destructive. So in the past few years, hospitals around the country have begun writing codes similar to the one at Maimonides, to promote respectful behavior all around.

During my year at the hospital, real cases illustrated the relationship between respect and result. In one case I heard about, a patient had been prepped for a knee operation. The operating team had followed the universal protocol called "preventing wrong site, wrong procedure and wrong person surgery." Yet just before the procedure began, someone asked, "How come the knee being prepped isn't marked with a 'yes?' "

Who had dared to speak? It was a medical student, the lowest-ranking person in the room, who had noticed the "yes" was on the other knee.

A physician who was there said, "There has to be enough respect so a medical student can raise his hand and say, 'You're operating on the wrong knee.' "

More often than not, catastrophe isn't in the balance, but rather the opportunity to make a difficult situation easier or more stressful.

Another small but all-too-familiar example I witnessed: A terrified family member followed the medical team into a restricted area where the patient was waiting for surgery. A nurse snapped at him to move and shut the door in his face. The man erupted in fury, until another nurse apologized and explained the restrictions were meant to stop the spread of infection. The anger and helplessness on his face quickly turned to understanding and then gratitude.

At Maimonides, the hospital president, Pamela Brier, became Miss Manners on overdrive because she believes disrespect can result in harm to patients. "Bad behavior ruins communication, and communication problems are what cause mishaps that can harm patients," she told me. "I mean communications between doctor and nurse, nurse and clerk, housekeeper to nurse or doctor, everybody."

The craving for respect is a palpable part of hospital life. Nurses and technicians feel underappreciated and underpaid. "I have nursing attendants who make $28,000 a year working elbow to elbow with these attending doctors who come into work in Jaguars," a senior nurse told me. "I think what beats them down is the hierarchy, the respect they're given or not given. Everyone beats down on the one below."

And patients can feel the reverberations of these wounded feelings.

Things can get better, though. For every act of rudeness, I encountered many, many more examples of compassion and kindness. From housekeepers to department heads, most people were doing what they could to improve care in an over-stressed and inequitable system. They did it by recognizing that the healthcare system, after all, isn't abstract or anonymous; it is the sum of individual human successes and failures, in which small gestures can and do make a difference.

Like minding your manners.

Julie Salamon is the author of "Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids."