The research always has been clear on the key role of physician/nurse communication in patient safety, but it wasn’t until the Institute of Medicine published its 1999 report on medical errors that a national debate was triggered about those so-called "C words": communication, collegiality and collaboration.

Suddenly, hospital administrators, nurses and physicians began to ask the kinds of questions that demand serious change.

"Questions such as, ‘Why are we working in such parallel play?’ ‘Why aren’t we communicating better?’ ‘Why aren’t we writing more and writing legibly?’ " said Rhonda Anderson, MPA, RN, FAAN, senior administrator of Desert Samaritan Medical Center in Mesa, Ariz.

In the last couple of years, many hospitals have set up hotlines and channels for complaints about harassment and disrespect by physicians and nurses. They’ve established zero-tolerance policies for "anything that breaks down the trust between the patient and nurse," Anderson said.

At some hospitals, physicians have been suspended and required to attend counseling or anger management classes after an investigation by a peer review committee. The threat of peer review has been a powerful incentive for physicians to change.

At Thunderbird Samaritan Medical Center in Phoenix, a labor and delivery nurse recently "wrote up" a physician after he humiliated her in front of a patient. Colleen Hallberg, MSN, RN, senior administrator and chief nursing officer, describes what happened next:

"The nursing director told the doctor that he had a chance to turn this around before it went to his peers and he was very interested. She said, ‘In my opinion, an apology is in order, and you might consider something to go along with the apology. Like flowers.’ He needed to be coached through it, but the outcome was that he learned how to deal with a problem immediately and solve it."

Thunderbird Samaritan has offered training seminars by lawyers who have addressed the question of harassment in monetary terms. "That was really attention-getting," Hallberg said.

With the growing nursing shortage, most hospitals have made staff retention a priority. When the 30-hospital Banner Health System in Arizona established a "service excellence initiative" three years ago, it quickly became apparent that patient satisfaction went hand in glove with nursing satisfaction.

A month ago, Banner hired Jay Kaplan, MD, an authority on emergency services also known for his expertise on collegiality. Kaplan leads retreats for physicians and hospital administrators on the subject of collaboration, and he uses the language of business to make his pitch.

"I’m not an MBA and I have never taken a business course, but what I’m saying is we’re going to utilize some business concepts to make hospital service less businesslike," he explained.

"Everyone I work with—on a department level and a personal level—everyone is my customer. The nurses are my customers, the receptionist is my customer, the technician … We are each other’s customers. If I look at them as my customers, then I say to them, ‘What can I do to help you take better care of the patients and enjoy your day more?’ "

But if you’re going to ask people to change, Kaplan said, "you have to answer a key question for them: What’s in it for you?"

That question clinched it for Rick Kirshner, MD, a hotheaded young cardiovascular and thoracic surgeon at Thunderbird who had a reputation for lashing out at nurses. It was at a retreat led by Kaplan six months ago that Kirshner finally got it.

"I got back from this retreat Sunday night and I went directly to the hospital to talk to the nighttime nurses about this," Kirshner recalled. "Essentially, they just wanted a forum to be heard. They felt like a forgotten group.

"It’s been a real help to all of us … What Dr. Kaplan said was you want to do everything in life for altruistic reasons, but that’s a lie; it’s always ‘What’s in it for me?’ And what’s in it for me is that the nurses have a better feeling dealing with me. The amount of energy I have to put into the system is a lot less than ever before, because the nurses put more care into dealing with my patients ... It’s a win-win-win situation—for patients, nurses and doctors."

In fact, the research has long proved that patient outcome—as measured by pain control, length of stay and survival rates—benefits as well. A groundbreaking study in 1985 by William Knaus at George Washington University found a 50 percent higher mortality rate in hospitals marked by poor collaboration. It shouldn’t come as a surprise.

According to Ginger Malone, MSN, RN, leader of care innovation at Children’s Hospitals and Clinics in Minneapolis/St. Paul, nurses typically withhold information from physicians who are oppositional and derogatory in their behavior—with potentially disastrous consequences.

"I think the greatest barrier to collaboration is the hierarchical model we’ve inherited from the military," said Kathleen Dracup, DNSc, NP, RN, dean of the University of California, San Francisco School of Nursing. "It reminds me very much of changes that occurred in marriages and family structure in the 1960s, and I think that as nurses change their view of what nursing is as a career, as they become more educated, it will change."

UCSF is trying to develop collaborative practice by bringing medical and nursing students together in classes and hospital rotation. At Thunderbird Samaritan in Phoenix, emergency room nurses are required to rate physicians on their efficiency, courtesy and organizational skills. A poor evaluation is taken seriously.

Like everything else in medicine today, communication has been affected by managed care. For example, the industry often relies on hospitalists, a new specialty of physicians given responsibility for a patient after he or she is admitted to the hospital. Because hospitalists typically have no history with the patient, they are especially dependent on good communication to do their job.

"One of the most important things in my job is to communicate—both with patients and with nurses," said Robert Enguidanos, MD, a hospitalist at Thunderbird Samaritan. "We’re in the hospital all the time, compared to some doctors who come in and do clinic for a third of their day.

"As we’re pressed to see more patients, as patients in hospitals are sicker than they used to be, it becomes more important to get information from the nurse."

Despite all the institutional incentives, however, many nurses feel discouraged.

"I get concerned because sometimes it seems like we really have a passive staff," Anderson said. "There are people who take it and take it and take it—and feel they’re victims because they don’t set boundaries in their interactions. And then, all the way on the other side, there are individuals who are so aggressive that they are more the cause than the recipient.

"We need to do a better job of preparing our professionals for the interdisciplinary relationship with all health care providers," she said.

"If they don’t have a workplace that helps them deal with this, or is supportive of the concept of collaboration, then we’ve socialized them into nursing without the right tools or techniques. I just think we have a long way to go."