For decades, there was a dirty little secret in healthcare. Everyone knew it existed, but no one wanted to talk about it. The secret was that bad behavior and bullying were rampant. In a supposedly caring profession, some caregivers were not caring at all, to the point that they made lives miserable and disrupted patient care. Kathleen Bartholomew's strong voice shone a light on the problem. She has made it her life's work to end bullying and bad behavior by physicians and nurses. [Sponsored by McKesson]

In October, the Institute of Medicine released its landmark report, sponsored by the Robert Wood Johnson Foundation, The Future of Nursing: Leading Change, Advancing Health. The report outlines how nurses are crucial to meeting the country's healthcare needs and says that to handle the increasing complexity of care and greater responsibilities, nurses will need higher levels of education and training.

The report calls for 80% of RNs to have BSNs by 2020 and for the number of nurses with doctorate degrees to have doubled in the same timeframe.

Recently, the IOM took the first step in outlining how to make this happen. The National Summit on Advancing Health through Nursing, held November 30 — December 1, in Washington, DC, brought decision makers and thought leaders—including Don Berwick—together to discuss how to implement the report's recommendations.

"The Foundation is committed to using the IOM Future of Nursing report as it is intended to be used, as a roadmap for future direction and action," said Risa Lavizzo-Mourey, president and CEO of RWJF said in a statement."We are doing this by convening leaders from all sectors, both public and private to join us as partners in this national movement to make these recommendations a reality."

The Future of Nursing: Campaign for Action, is working on five main areas:
• Preparing and enabling nurses to lead change
• Improving nursing education
• Removing barriers to practice
• Creating an infrastructure for interprofessional healthcare workforce data collection
• Fostering interprofessional collaboration

To begin with, the campaign has enlisted five states to work on developing best practices and programs that can be replicated elsewhere. These Future of Nursing Regional Action Coalitions (RACs) are located in New Jersey, New York, Michigan, Mississippi, and California. They have been tasked with capturing best practices, determining research needs, tracking lessons learned, identifying replicable models, connecting with the other RAC programs, and monitoring progress.

The stewards of the IOM report have a huge task on their hands. Some of their recommendations seem positively Herculean, such as the call for 80% of the country's RNs to have baccalaureate degrees by 2020. As I wrote in the summer, this issue has been argued about in nursing for decades and no topic has the capacity to divide the rank and file of the profession quite like this one.

Yet evidence shows that higher-educated nurses produce better patient outcomes. We also know that to fulfill the recommendations of the committee, and meet the future healthcare needs of the country, we need a well-educated, well-trained nursing workforce.

Another Herculean battle to overcome is the recommendation that scope of practice barriers be removed. The state-by-state differences in the regulations regarding advanced practice nurse practitioners are absurd. That one state considers nurse practitioners competent to see patients and prescribe medications independently while another requires physician oversight to do the same is ludicrous.

Meeting the needs of our aging population is going to require multitudes of healthcare providers of varying levels and specialties, and it only makes sense to use our limited resources to the extent of their capabilities and to find ways for everyone to work together for the good of patients.

It will be interesting to follow what happens as the real work begins.

"Our patients will never be safe until all caregivers feel safe enough to communicate—to challenge, question, advocate, and ask for clarification."
— Kathleen Bartholomew

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Kathleen Bartholomew's story.

For decades, there was a dirty little secret in healthcare. Everyone knew it existed, but no one wanted to talk about it. The secret was that bad behavior and bullying were rampant. In a supposedly caring profession, some caregivers were not caring at all, to the point that they made lives miserable and disrupted patient care.

Today, the secret is out. Everyone has heard that bad behavior, bullying, and poor communication are serious safety concerns that lead to medical errors, poor patient care, and high staff turnover. Even The Joint Commission has issued a mandate for organizations to have a policy in place to deal with bad behavior.

One of the people who exposed the secret is a nurse named Kathleen Bartholomew, RN, MN. Her hard work and strong voice shone a light on the problem, focusing attention on its critical impact on patient safety. She has made it her life's work to end bullying and bad behavior by physicians and nurses.

Bartholomew first encountered physician bad behavior as a brand new nurse in the early 1990s. No stranger to difficult situations, she would not conform to the culture of submissiveness that pervaded nursing, and instead challenged the behavior and found her calling.

This was not a road she expected to find herself traveling. The journey began in 1991, when she was out of a job, separated from her husband, and the mother of five children, all younger than 11. She was introduced to a lawyer who offered to handle her divorce for free—if she agreed to become a nurse. Never one to turn down a good deal, and recognizing her dire straits, Bartholomew accepted the deal.

She packed her five kids into the car and drove to North Carolina so family could watch the children while she attended school and studied. Eventually, her hard work paid off and she started her first position as a nurse. Almost immediately, she witnessed the perverse hierarchies involved when physicians and nurses talk to each other.

"Every time the nurse would call to report a temperature, the physician would slam the phone down, even though we had guidelines to call if the patient's temperature was above 102 degrees," says Bartholomew.

She knew that the belittling, demeaning, and hostile behavior she witnessed throughout healthcare was a serious problem.

"I realized it was something that carried over" and affected patient care, because a person cannot perform cognitive tasks when his or her emotional state is compromised, says Bartholomew. "No human being can think clearly when they are upset. When you create healthy relationships, you are providing a safety net. Our patients will never be safe until all caregivers feel safe enough to communicate—to challenge, question, advocate, and ask for clarification."

As Bartholomew progressed in her career, becoming manager of a 57-bed orthopedic unit in a downtown Seattle hospital, she worked on improving nurse-physician communication and she experienced amazing results.

She turned her attention outside her organization and began to talk about the issue to others. What she was saying struck a nerve. As she presented to hospitals and conferences, nurses would come up to her, weeping, and tell her their stories. She added the need to improve nurse-to-nurse horizontal hostility to her mission and became a celebrated author, speaker, and educator on the topic of bad behavior and the patient safety imperative for changing culture.

"It's just absurd that the two people who are providing the care are not required or expected to communicate on a daily basis," says Bartholomew, noting that poor communication "is the No. 1 cause of errors."

When she started talking about this dirty little secret, no one else was acknowledging that healthcare culture could and should change. And yet the Institute for Healthcare Improvement clearly stated that the greatest barrier to patient safety is culture.

"At the time, there were only a few articles on this topic," she says. "It was not at all a priority anywhere. No one saw the impact and no one had demonstrated the impact."

Bartholomew focuses on the critical importance for healthcare to learn how to create collegial teams, just as has been done in other professions, such as aviation and nuclear power.

"Until we get there, patients will never be safe," says Bartholomew. "Allowing one person to behave badly undermines trust. You can't have collegial teams without trust and everyone on board. An institution cannot have integrity when there are different rules for different roles."

"We will look back in 20 years and wonder how we possibly thought we could deliver care when the physician doesn't think it's necessary to read the nurse's notes or even speak to the nurse," she says. "It's absurd that two people delivering care are not required to communicate."

Bartholomew now works on delivering her message to all levels across healthcare, from staff nurses to boards of directors.

"Right now, I'm thrilled to be able to have an impact on a much larger scale," she says. "I speak to boards of directors at hospitals and get to spend a whole day explaining culture and the impact of that culture on quality and safety. I teach them about nurse-to-nurse and physician-to-nurse communication and it's been profound. Boards are now adopting behavior rules. Now senior nurses are being given the clout they need from the boards of directors. They are saying, 'It doesn't matter how much money that physician brings in, he screamed at and demeaned the nurse!'"

Karen Hill started out at Central Baptist Hospital in Lexington, KY, as a teenage candy striper. Today, she's a visionary vice-president and chief nurse executive and winner of the 2010 HCPro Nursing Image Awards: Image of Nursing in Leadership.

Hill's career at Central Baptist has spun 26 years, and through her exemplary leadership, she has created a vision for caring and nursing excellence that has twice been recognized with ANCC Magnet Recognition Program® designation.

As a visionary leader, Hill has empowered staff nurses and leaders with the creation of staff-managed professional RN and LPN career models, a five-level leadership development program, and the development and adaptation of a peer-based staff interview model for every nursing leadership position. The hospital exhibits an enviable nurse vacancy rate and has been named one of the top 10 large employers in the state of Kentucky every year from 2005.

A recent employee engagement survey found that more than 90% of the nursing staff reported they were in agreement with the mission and values of the organization.

Hill supports nursing professional development through such hands-on endeavors as providing mentoring support to nurses interested in being published, the construction of "quiet rooms" on various nursing units for staff and families to meditate and reflect, and an annual graduation/certification celebration to celebrate staff who have achieved new degrees and/or professional certifications.

In contrast to the all-too-common practice of promoting nurses into management positions and watching them sink or swim, Hill created a leadership orientation plan to ensure new nurse leaders receive the support they need. New leaders are given the opportunity to meet with various content experts to learn more about how nursing works with other disciplines and they spend part of orientation shadowing staff members and clinical house supervisors to gain a better understanding of operations in their particular unit.

Through the support of the leadership development curriculum and mentorship opportunities, 60% of the leadership positions within nursing in the last two years have been filled by internal candidates.

 "Karen is a visionary leader who mentors all, shares knowledge through writing and speaking engagements, achieves terrific clinical outcomes and creatively communicates them to her team, and focuses on leadership development and caregiver safety," says judge Melissa Fitzpatrick, vice president and chief clinical officer for Hill-Rom.

"Karen is a leader, mentor, educator and change agent for multiple initiatives," says judge, Bonnie Clair, retention project manager, human resources/recruitment and retention at CoxHealth in Springfield, MO. "She is an exceptionally well-rounded RN who exemplifies visionary nursing leadership at its finest."

As well as visionary leadership, the awards also recognize clinical excellence. This year's winner of the Image of Nursing in Clinical Practice Award is Rebecca Schorn, nurse clinician level 4 in the PICU at Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE.

Schorn practices exemplary evidence-based nursing in the PICU, where she serves as a role model for professional practice to both novice nurses and more experienced peers. She serves in a direct care role providing evidence-based, hands-on nursing care, while at the same time ministering to the emotional and spiritual needs of her patients and their families, and she also serves as a preceptor and mentor to new nurses. 

In addition, her dedication to healing has taken her to Uganda, Honduras, and Mongolia as part of her work Samaritan's Purse Children's Heart Project, transporting children with congenital heart defects from their homelands to hospitals in the United States for treatment.

 "Rebecca combines extraordinary nursing care while ministering to emotional and spiritual needs," says judge Clair. "She is smart, caring, compassionate, and artful, and serves both locally and internationally. This nurse, to me, embodies the very essence of professional nursing: Equally skilled in both science and art with a heart to serve."

"It was a difficult choice, but in the end, it was the reality that this nurse's reach of excellence goes far behind the walls of her facility," says Mike Briddon, executive editor at HCPro. "Along with skillfully guiding the next generation of nurses, she gives presentations, publishes her experiences, and works with foreign countries to spread her love of nursing."

Please join me in congratulating this year's winners and thanking them for all they bring to nursing.