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PBDS and Nurse Skill Testing

Posted in Nursing, Nursing Jobs, Nursing News

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If you want to discuss a nursing topic that everyone has an opinion about, just bring up Dr. Dorothy del Bueno’s PBDS testing program among a group of travel nurses or nurse managers.

The testing was designed to be used as a tool to help identify nurses’ weak areas so that they might receive additional training in those areas. The end goal of the testing would be a better equipped nursing staff at a reduced cost to the facility in terms of both time and money. However, some people view the test as a tool to keep licensed nurses from gainful employment even after they have passed all of the state licensing requirements to practice nursing.

According to the National Council for State Boards of Nursing website, “NCSBN Member Board jurisdictions require a candidate for licensure to pass an examination that measures the competencies needed to perform safely and effectively as a newly licensed, entry-level nurse.” But the nurses being subjected to the testing are not always entry-level, but seasoned RN’s who oftentimes have many years of practice and travel nursing experience. In this economy, nothing can strike more fear into one’s heart than the prospect of losing a good employment opportunity because of superfluous testing.

In nursing forums and on nursing blogs, travel nurses have reported having very different experiences with the testing. Some have reported the testing was fairly basic, while others say that it was silly and included unrealistic scenarios. Others complained more generally about being “tested to death”.

Either way, easy or difficult, travel nurses have reported becoming anxious in response to the idea that the testing might be a road block to landing a job. Whether it stems from the litigious nature of society, or the focus on better quality of care, skill testing is not likely to go away. If anything, testing seems to have become more prevalent in workplaces over the last decade.

The PBDS tests three skill areas: interpersonal skills which relate to customer relations, team building, and conflict resolution. These critical thinking skills encompass nursing processes used on medical and surgical floors, in critical care wards, OB and the ICU, along with other technical elements which may include creating and following a variety of care plans, based upon the diagnosis.

PBDS testing, of course, was not created to prevent nurses from working, but to be used as a tool, to keep nurses safe and to help provide the most positive patient outcomes. In response to skill testing, travel nursing companies and other staffing agencies have begun to provide study guides and additional test prep information to their nurses, both to reduce testing anxiety and to present the most qualified candidates to employers.

Nurse Practitioners No Threat To Doctors

Posted in Nursing, Nursing Jobs, Nursing News, Nursing Specialties

History has shown that physicians don’t always appreciate sharing with nurses.

The field of obstetrics, which was once dominated by midwives and lay midwives, has been a battleground for years, with physicians laying claim to the right to attend all deliveries. Physician’s groups in the past went so far as to say that women who were attended by midwives were putting themselves and their babies at risk, although statistically this notion was never proven to be a reality. Midwives fought long and hard and are only now attaining the respect they deserve as non-interventionists who are fully capable of handling low-risk deliveries. Ceding to midwives has been a hard pill to swallow for many physicians.

Some physicians are now uneasy with the expanding role of nurse practitioners. The Institute of Medicine recommended in 2010 that barriers to practicing to their full scope be removed so that nurse practitioners could help to ease the shortage of primary care physicians. To date, 16 states (plus the District of Columbia) have embraced more liberal laws to allow nurse practitioners to practice fully what they have studied and trained for. Other states, such as Nebraska, are currently considering such laws.

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One would think that easing the shortage of primary care physicians would be embraced wholeheartedly by physicians, but this has not been the case. What has been the major concern voiced by primary care physicians? It seems that some physicians are worried that nurse practitioners moving in on their turf will result in lowering of physicians’ incomes. Granted, many primary care physicians earn far below what physician specialists earn, so there may be some justification for their concern.

In the first study to assess the impact of nurse practitioners in states with liberal policies versus states with more restrictive policies, researchers from the George Washington School of Public Health and Health Services found no evidence that using nurse practitioners to their full scope of practice had an adverse effect on earnings of family physicians.

This is good news on two fronts: easing the physician shortage and expanding the roles of nurse practitioners. As of May 30th of this year, the Health Resources and Services Administration stated that there are 5,902 HPSAs (health professional shortage areas) serving 59.9 million people. At a ratio of 2000 patients for every one physician, this means that 16,349 practitioners are needed to meet the primary care needs of the population. Such a vast shortage seems to indicate that there is plenty of room for all, and that nurse practitioners can fill a rather large gap in healthcare services that is not currently being filled.

As with the obstetric field, it will take time before nurse practitioners are recognized for what they alone can offer, a unique set of skills and knowledge that can complement and enhance the skills and knowledge that physicians offer. As health care policy changes in the United States, nurse practitioners are entering into a new era, one in which they will be permitted to practice to the fullest extent possible.

UC-Davis Graduating First Class of Nurses

Posted in California, Nursing, Nursing Jobs, Nursing News, Nursing School

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Five years ago, philanthropist Betty Irene Moore donated $100 million to the University of California – Davis, moving the School of Nursing from dream to reality. This week, the first group of nurses will graduate from the program.

25 students who were recruited for their talent and whose education was fully funded by scholarships will be graduating. The hope is that they represent a new breed of well-educated nurses who will transform the health care system.

In this article in the Sacramento Bee, the School of Nursing Dean Heather Young said, “Our goals and priorities are to improve the health care system and advance the health of our communities. We realize that nurses can, and should be, the catalysts of change.”

Young called this year’s class of graduating nurses “just a beginning.” Already another 25 students are queued up for the next two years, with more than 30 percent of them coming from underrepresented ethnic communities. The school also enrolls doctoral students in a four-year program.

In a seminal 2010 report on the future of nursing, the Institute of Medicine concluded that health care reform meant “nursing education must be fundamentally improved both before and after nurses receive their licenses.”

With the population growing older and chronic diseases taking center stage, the IOM report, which Young endorses, determined that “nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”

Young said she was drawn to the position of dean because she, too, was inspired by the vision of Betty Moore.

The story of how Moore decided to commit $100 million over 11 years to a new school of nursing is a tale of personal belief in change.

Moore had been in a hospital and experienced a medication error. A nurse had insisted she take a shot, but Moore objected. The nurse gave her the shot anyway.

It turned out the shot of insulin was meant for a neighboring patient and potentially put the health of both patients at risk.

Says nurse Johnston, “What impresses me most is that Betty Irene Moore, a person with a lot of money, didn’t go blaming the individual or the system, she did the opposite. She decided she could do something positive about the problem of medical errors, make change for the better and build a better nurse.”

Specifically, Johnston’s job, which he says is a project of the Gordon and Betty Moore Foundation, is to be an educator, a monitor and a resource to prevent patients from getting hospital-acquired infections from improper use of ventilators, intravenous tubes, catheters and the like.

In the status-quo health care system, such infections have come to be seen as somewhat of a statistical inevitability – even to the point where patients’ rights groups routinely tracked and reported their occurrence in various hospitals.

“The culture and belief that infections are a part of a hospital stay needs to change,” Johnston said.

In an interview at the UC Medical Center where he works, Johnston said his job is called “nurse champion.”

He works as part of a collaborative system for higher quality by advising and teaching medical staff on ways to curb hospital infections.

It’s a challenging and new role for Johnston, who’s worked as a nurse for 5 1/2 years.

“We are colleagues with physicians and nurses and aides,” he said. “We are change agents in the system.”

To be sure, Johnston’s gotten some push back already in his new job in the UC Davis Medical Center’s burn unit. But he’s prepared to tap into the communication and leadership skills he’s learned to overcome the skepticism.

“I was seen as an outsider, someone to audit them and get them in trouble,” Johnston said of his colleagues. “There was some question of my credibility and credentials both from nurses and the physician side. It’s a challenge. It takes time to get that buy-in.”

School Nurse Visits Up

Posted in Nursing, Nursing Jobs, Nursing News, School Nurses

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Visits to school nurses have significantly increased, likely because of the difficult economy. People often lose health care when they lose their jobs, meaning that they will sometimes send their kids to the school nurse before their primary care doctor.

In Rhode Island, increases in the last five years total in the thousands, according to this article on in the Valley Breeze.

Linda Newbury, a school nurse, provided figures that indicated that visits doubled at one school (3,800 visits to 7,554 visits) and increased significantly at almost all schools. Only one school had a decrease, from 11,000 to 10,930.

Newbury acknowledged that an increase in population is a contributing factor, but not the only one. Parents will ask school nurses, “Before I spend money, what do you see?”

School nurses also are expected to address a much wider range of medical issues, from standard sore throats and fevers to allergies and diabetes.

Cumberland school nurse Margaret Wharton said while the district had not compiled specific figures, she has also noted a similar increase in visits as the neighboring town.

“All I can say is that student visits to the nursing offices appear to continue to increase each year as many families have lost health coverage due to economic issues,” she told The Breeze.

“School nurse teachers, in many cases, have become the first person to see a child for a health issue because they provide free interim nursing care until they are able to refer the child for appropriate medical care.”

Wharton said she is “very concerned” for the next school year, when there will be one fewer nurse in the schools due to budget cuts.

The illnesses seen are cyclical, Villeneuve reported at the meeting. While strep was prevalent several years ago, this year saw more cases of pneumonia, she said.

The nurses all spoke about the increase in number and types of food-related allergies.

Wharton said when she started in the schools 21 years ago, she had about five EpiPens for children with allergies. Now she said she has “a wall full” with about 35.

Newbury said food restrictions, like not allowing peanut butter in the cafeteria, “change the climate of the classroom.”

Newbury said more “medically fragile” students are enrolled in school with more cases of autoimmune diseases and diabetes in children as young as 3.

On Discouraging Unnecessary Medical Tests

Posted in Nursing, Nursing Jobs, Nursing News

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Recently, the American Board of Internal Medicine (ABIM) Foundation, working in conjunction with numerous medical specialty boards and Consumer Reports, instituted an initiative to decrease the number of medical tests ordered unnecessarily by physicians. It also has contributed to new recommendations for annual exams. The initiative is called “Choosing Wisely.” The following are some of the pros and cons of this initiative.

Pros:
Reduction in healthcare spending: An article appearing in Kaiser Health News reported that $6.8 billion dollars were spent in 2009 on twelve unnecessary tests and treatments, such as ordering routine blood work during yearly physicals on healthy patients, performing Pap smears on teens who were unlikely to have cervical cancer, and ordering drugs for children with sore throats that were caused by viruses. Some experts estimate that up to 1/3 of every health care dollar spent in the U.S. is wasted on unnecessary tests, treatments and medications. A McKinsey report states that “health care spending reached record levels in 2009, both in absolute terms and as a share of GDP” . Few people will disagree that we need to spend less money on healthcare and reduce waste where possible; therefore, cutting out unnecessary tests and treatments may be a good place to start.

Reducing the risk to patients: First, do no harm. Performing unnecessary medical tests or prescribing unnecessary treatments to patients could be potentially harmful. For example, performing an unnecessary x-ray exposes the patient to harmful radiation. Prescribing antibiotics that aren’t clearly indicated (i.e. for viral infections) could result in an unforeseen drug reaction or antibiotic resistance. In addition, ordering unnecessary tests and procedures may result in increased patient anxiety.

Cons:
Missing a diagnosis: One concern about discouraging tests is it might result in missing a diagnosis that otherwise may have been caught through routine testing. Some physicians may feel uncomfortable about the new initiative for this reason. A big part of the reason that physicians order multiple tests is due to the fact that doctors are vulnerable to being sued when they miss a diagnosis. Fear of litigation is a driving force behind physicians’ ordering practices. Until this fact changes (or the laws do) some doctors may be reluctant to Choose Wisely.

Removing autonomy: Some might argue that physicians go to school for many years and should be able to practice as they see fit. If insurers and payers determine that certain tests and treatments will not be reimbursable, this can be seen as a challenge to physicians’ autonomy and decision-making ability. Many doctors will be less than appreciative of this kind of oversight. On the patient side, such an initiative might not be met with favor by patients who have become used to certain treatments and test. These patients may also feel that money is being given a higher priority than their health.

As nurses, it will be our job to explain to patients why tests and treatments that they have grown accustomed to receiving are no longer being offered. Rather than confronting their physician, patients may choose to confront nurses instead. Researching “Choosing Wisely” can help us prepare for these questions.

Helping New Moms Achieve Success

Posted in Nursing, Nursing Jobs, Nursing News

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The Nurse-Family Partnership in Virginia assigns a nurse to visit low-income, first-time mothers at home every week, starting early in pregnancy and not ending until the child’s second birthday.

This article in the Virginian-Pilot followed nurse Glenda Asterilla-White as she visited a pregnant 24-year-old named Crystal Stewart in her home.

They discuss things like nutrition, what to expect from each doctor’s appointment, and the need to decrease caffeine intake.

The nurses in the program offer information about how to achieve a healthy pregnancy and also help the mothers prepare for the child. Then after the baby is born, they help offer guidance and information for successful parenting strategies.

Nurse-Family Partnerships have been shown to be extremely successful, when done right. (Especially, the more skilled the nurses, the better the outcomes.)

“This technique that they have really focused on in the Nurse-Family Partnership is intended to help the family be empowered rather than simply supplying them the information,” said Dr. Nancy Welch, acting director of the Western Tidewater Health District.

More than a dozen studies have documented the Nurse-Family Partnership’s impact over three decades.

Researchers say the program improves prenatal health, reduces the number of subsequent pregnancies for the mother, and increases the number of months she is employed. The children experience fewer injuries and are better prepared for starting school.

The program’s success comes from the trust that nurses inspire and the long-term bonding between the nurses and the mothers, said Lauren Baker, chief marketing and communication officer for the partnership.

The results impressed Welch, who also is the director of the Chesapeake Health District. In that capacity, she had evaluated a similar nurse home visiting program in Chesapeake.

Her conclusion: Over a five-year period, families supported by the Baby Care program had lower infant mortality rates, a smaller percentage of low-birth-weight babies and fewer premature births than families in a control group. If the program was expanded to cover all of the city’s premature births, it could save $1.34 million in hospital costs annually, a 129 percent return on the original investment, according to her estimates.

That analysis, along with the Nurse-Family Partnership studies, reinforced Welch’s conviction that home visiting programs work.

Some already existed in Western Tidewater, including one that focuses on parenting education and one for teens who are pregnant or parents.

When the national health law provided more money to the state for such programs, Welch applied for a grant. Relatively high poverty, dropout rates, unemployment rates and pre-term deliveries put Suffolk and Southampton County families at higher risk for unhealthy children, she wrote. Both localities could benefit from another home visiting program.

The health district was awarded a combined $450,000 from the government and Obici Healthcare Foundation. The grant allows five nurses to serve a total of 100 families for four years in Isle of Wight, Franklin, Suffolk and Southampton.

A nurse for more than 30 years, Asterilla-White decided to join the program for a new challenge and because she had been a teen mother herself.

“I’m getting a kick out of being able to make sure that the resources are known by the mothers and that I’m making a contribution,” she said.

Stuart signed up because she wanted as much support as she could get.

“It’s not like a business coming to you,” Stuart said. “It’s more like family.”

Effective Communication and Patient Safety

Posted in Nursing, Nursing Jobs, Nursing News

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Communication has a direct impact on patient safety, according to a new report which found that hospitals where physicians and nurses scored highest on communication also had fewer patient safety events.

The report from HealthGrades is summarized in this article on Nurse.com. The report analyzed patient safety data for hospitalizations between 2008 and 2010.

They found that during that time period, 254,000 patient safety events among Medicare patients could have been prevented, and that 56,367 Medicare patients who died experienced one or more of these events. Data was also taken from Medicare patients’ satisfaction scores. The better the communication, the better the care.

Among the report’s key findings:

• 27% more overall patient safety events occurred in hospitals performing in the bottom 10% for nursing communication, compared to the top 10;

• 15% more overall patient safety events occurred in hospitals performing in the bottom 10% for physician communication, compared to those in the top 10%;

• 13% more patients at hospitals performing in the top 10% for patient satisfaction reported they received instructions on what to do when they left the hospital, compared to the bottom 10% — key guidance that underscores the importance of communication, according to the report.

HealthGrades conducted the analysis as part of its process for identifying the HealthGrades Patient Safety Excellence Award and HealthGrades Outstanding Patient Experience Award recipients. This year, 263 hospitals received the Patient Safety Excellence Award (http://bit.ly/JDRf3e) and 332 received the Outstanding Patient Experience Award (http://bit.ly/JIHBly), with 47 receiving both.

“We have reached a point where Americans must acknowledge the connection between communicating with their healthcare provider and their own safety and satisfaction as patients,” Kristin Reed, MPH, the author of the study and vice president of clinical quality programs for HealthGrades, said in a news release. “Our research revealed some shocking disconnects.”

For example, Reed said, catheter-related bloodstream infections were about 56% more common in hospitals with poor nursing or physician communication.

Nurses Play a Crucial Role in American Health Care

Posted in Nursing, Nursing Jobs, Nursing News, Pennsylvania

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In an editorial, the Reading Eagle says that the community should take a moment to salute its nurses.

Noting that pretty much everyone has been cared for by a nurse, a nurse practitioner, or a licensed practical nurse, the editorial recognizes “all in the nursing profession who have come so far since Florence Nightingale founded the modern nursing movement.”

Nurses have always been important but are becoming even more important for a variety of reasons, including changes in the law and industry trends. Nurses are an integral part of a patient’s medical team and are consulted along with the primary care doctor, physical and occupational therapists, pharmacists, and more. Nurses are also increasingly taking on an advocacy role, studying patient histories and catching mistakes in medications.

They’re also doing more in-home care, due to health insurance trends towards shorter hospital stays.

And nurse practitioners can write prescriptions and do some of the more routine tasks that doctors usually do, thereby easing some of the pressures on the system and filling the gap left by the decreasing number of family doctors and general practitioners.

Nurses aren’t just generalists anymore. All require continuing education, and many require certification in a specialty, such as surgery, pediatrics or trauma. As was recently reported in the Reading Eagle, some nurses even are trained in the specialty of collecting forensic evidence from rape victims to be used by law enforcement in court cases.

Along with all the other changes in the profession, technology has changed nursing in ways that still are being measured.

As The New York Times reported in January: “In just a few years, technology has revolutionized what it means to go to nursing school, in ways more basic – and less obvious to the patient – than learning how to use the latest medical equipment.

“Nursing schools use increasingly sophisticated mannequins to provide realistic but risk-free experience; in the online world Second Life, students’ avatars visit digital clinics to assess digital patients.

“But the most profound recent change is a move away from the profession’s dependence on committing vast amounts of information to memory. It is not that nurses need to know less, educators say, but that the amount of essential data has exploded.”

We hope that the use of technology doesn’t replace the personal care members of the nursing profession are known for and that attracts men and women to the profession.

It is that personal care that we and other members of the health care profession depend on.

The Power of Nurse-Family Partnership

Posted in Nursing, Nursing Jobs, Nursing News

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A single program can cut the number of abused or neglected children in America in half; reduce the number of babies or toddlers hospitalized for accidents or poisonings by more than half; and provide a 5 to 7 point I.Q. boost to children born to the most vulnerable mothers.

This program is the Nurse-Family Partnership program or NFP, founded by David Olds in the early 1970’s. It has been studied carefully and has shown “sizable, sustained effects on important life outcomes which were replicated across different populations,” according to this article by David Bornstein in the New York Times’ Opinionator.

The program arranges for registered nurses to make regular home visits to first-time mothers who are low-income or otherwise vulnerable, starting early in their pregnancies and continuing until the child is two years old. The program has assisted 151,000 families to date and has the potential for even larger impact, due to the Affordable Care Act’s Maternal, Infact, and Early Childhood Home Visiting Program. This provides $1.5 billion for states to expand programs like the NFP.

Bornstein says, “Done well, it could be among the best money the government spends.” The problem is that not all such programs are done well. He encourages policy makers and proponents of home visiting to pay attention to the specific elements of the NFP model that account for its success.

One of the most important elements proved to be nurses. When it came to improving children’s health and development, maternal health, and mothers’ life success, registered nurses got results that were much better than when other, similar programs used paraprofessionals instead.

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin. But there were other reasons nurses were effective. Pregnant women are concerned about their bodies and their babies. Is the baby developing well? What can I do for my back pain? What should I be eating? What birthing options are available? Those are questions mothers wanted to ask nurses, which was why they were motivated to keep up the visits, especially mothers who were pregnant for the first time.

Nurses had more influence encouraging mothers to delay subsequent pregnancies, Olds explained. They could identify emerging complications more promptly, and they were more successful at getting mothers to stop or reduce smoking, drug or alcohol use. This is vital. Prenatal exposure to neurotoxicants is associated with intellectual and emotional deficits. It can also make babies more irritable, which increases risks of abuse. (A mother who was abused herself is more likely to misinterpret an inconsolable baby’s crying as “bad behavior.”)

“A lot of the young mothers have had some pretty terrible early life experiences,” says Olds. “It’s not uncommon for them to have been abused by partners or never have had support and care from a mother. Their lives haven’t been filled with much success and hope. If you ask them what they want for themselves, it’s not uncommon for them to say, ‘What do you mean?’”

A big part of NFP’s work is helping them answer this question.

Consider the relationship between Rita Erickson and Valerie Carberry. Rita had had a methadone addiction for 12 years and was living from place to place in Lakewood, Colo. She found out she was pregnant; a parole officer told her about NFP. “I’d burned bridges with my family,” Rita told me. “I was running around with the wrong people. I didn’t have anyone I could ask about being pregnant.” In the early months, Valerie had to chase her around town, Rita recalled. “I was worried she might say, ‘This is too much hassle. Come back when you have your act together.’ But she stuck with me.”

Over the next two years, they embarked on a journey together. “I had a zillion questions,” Rita recalled. “I was really nervous at first. I had lived most of my adult life as a drug addict. I didn’t know how to take care of myself.” On visits, they discussed everything: prenatal care, nutrition, exercise, delivery options. After Rita’s daughter, Danika, was born, they focused on things like how to recognize feeding and disengagement cues, remembering to sleep when the baby sleeps, how to manage child care so Rita could go back to school. For Rita, what made the biggest impression was hearing about how a baby’s brain develops — how vital it was to talk and read a lot to Danika, and to use “love and logic” so she develops empathy. Once Valerie explained that when babies are touching their hands, they’re discovering that they have two. “To me that was really amazing,” Rita said.

This month, Rita is graduating from Red Rocks Community College with an associate degree in business administration. She’s going to transfer to Regis University to do a bachelors degree. Her faculty selected her as outstanding graduate based on leadership and academic achievement — and she was asked to lead the graduation procession and give one of the commencement speeches. Danika is thriving, Rita said. Recently, she came home from preschool and announced: “Mommy, I didn’t have a good day at school today because I made some bad decisions and you wouldn’t be proud of me.” (She had pushed another child on the playground.) As for the NFP, Rita says that it helped her recover from her own bad decisions. When Valerie came along, she needed help badly. “I didn’t care about my life. I didn’t care about anything. I never ever thought I would have ended up where I am today.”

“When a woman becomes pregnant whether she’s 14 or 40, there’s this window of opportunity,” explained Valerie, who has been a nurse for 28 years and hasworked with more than 150 mothers in NFP over the past seven. “They want to do what’s right. They want to change bad behaviors, tobacco, alcohol, using a seat belt, anything. As nurses, we’re able to come in and become part of their lives at that point in time. It’s a golden moment. But you have to be persistent. And you have to be open and nonjudgmental.”

Beyond the match between nurses and first-time moms, there are multiple factors that make NFP work. (NFP has identified 18 key elements for faithful replication.) The dosage has to be right: Nurses may make 50 or 60 visits over two and a half years. The culture is vital: It must be non-judgmental and respectful, focusing on helping mothers define their own goals and take steps towards them. The curriculum should be rigorous, covering dozens of topics — from prenatal care to home safety to emotional preparation to parenting to the mother’s continuing education. Nurses need good training, close supervision and support, and opportunities to reflect with others about difficult cases. And, above all, data tracking makes it possible to understand on a timely basis when things are working and when they are not.

With the government making such a large investment in home visiting, it’s crucial for programs to get the details right. Otherwise, society will end up with a mixed bag of results, and advocates will have a hard time making the case for continued support. That would be a terrible loss. “When a baby realizes that its needs will be responded to and it can positively influence its own world,” says Olds, “that creates on the baby’s part a sense of efficacy — a sense that I matter.” It’s hard to imagine higher stakes.

Blame The Nurse, A Time-Honored Tradition

Posted in Nurse Safety, Nursing, Nursing Jobs, Nursing News

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Theresa Brown, an oncology nurse, describes a situation in which an entire medical team on its morning rounds stands in a patient’s room, waiting for a test result. The patient, a friendly middle-aged guy, jokingly asked his doctor whom he should yell at. The doctor turned and pointed at the patients’ nurse and replied, “If you want to scream at anyone, scream at her.”

In this article on the New York Times’ Well blog, Brown notes that this bullying didn’t happen 30 years ago and it didn’t happen on a TV show like “House” — it happened to her, just a few months ago.

Brown later asked the doctor if she could quote him for the article, and he nonchalantly said “Sure, it’s a time-honored tradition — blame the nurse whenever anything goes wrong.”

While Brown was stunned and insulted, she also was concerned about the problems such attitudes pose to patient health. Nurses are the hospital’s front line, and such attitudes can create a hostile and even dangerous environment in a setting where “close cooperation can make the difference between life and death.” While many hospitals have anti-bullying policies, the seriousness of the issue is too rarely recognized.

While most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

When a doctor thoughtlessly dresses down a nurse in front of patients or their families, it’s not just a personal affront, it’s an incredible distraction, taking our minds away from our patients, focusing them instead on how powerless we are.

That said, the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.

And because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

Such an uncomfortable workplace can have a chilling effect on communication among staff. A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.

The result, not surprisingly, is a rise in avoidable medical errors, the cause of perhaps 200,000 deaths a year.

Concerned about the role of bullying in medical errors, the Joint Commission, the primary accrediting body for American health care organizations, has warned of a distressing decline in trust among hospital employees and, with it, a decline in the quality of medical outcomes.

What can be done to counter hospital bullying? For one thing, hospitals should adopt standards of professional behavior and apply them uniformly, from the housekeepers to nurses to the president of the hospital. And nurses and other employees need to know they can report incidents confidentially.

Offending parties, whether doctors or nurses, would be required to undergo civility training, and particularly intransigent doctors might even have their hospital privileges — that is, their right to admit patients — revoked.

But to be truly effective, such change can’t be simply imposed bureaucratically. It has to start at the top. Because hospitals tend to be extremely hierarchical, even well-meaning doctors tend to respond much better to suggestions and criticisms from people they consider their equals or superiors. I’ve noticed that doctors otherwise prone to bullying will tend to become models of civility when other doctors are around.

In other words, alongside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.

This shouldn’t be hard: most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them. But unless we can change the overall tone of the workplace, doctors like the one who insulted me in front of my patient will continue to act with impunity.

I wish I could say otherwise, but after being publicly slapped down, I will think twice before speaking up around him again. Whether that was his intention, or whether he was just being thoughtlessly callous, it’s definitely not in my patients’ best interest.

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