NURS FPX 4005 Assessment 2 Interview and Interdisciplinary Issue Identification

Student Name

School of Nursing and Health Sciences, Capella University

NURS-FPX4005: Nursing Leadership: Focusing on People, Processes, and Organizations

Professor Name

Submission Date

Interview and Interdisciplinary Issue Identification

Introduction

Healthcare organizations increasingly rely on interdisciplinary collaboration to address complex patient needs and improve healthcare outcomes. Effective communication, coordination, and teamwork among healthcare professionals are essential for delivering safe, efficient, and patient-centered care. However, communication breakdowns and fragmented workflows continue to challenge healthcare organizations and can negatively affect patient outcomes, staff satisfaction, and organizational performance.

The purpose of this assessment is to summarize an interview conducted with a healthcare professional, identify an interdisciplinary issue within the organization, and analyze evidence-based leadership, collaboration, and change management strategies that could contribute to an effective solution. Understanding how organizational challenges impact healthcare delivery allows nurse leaders to develop interventions that promote collaboration and improve patient care outcomes.

Interview Summary

An interview was conducted with a nurse manager employed at a 250-bed community hospital that provides acute care, surgical services, emergency care, and outpatient specialty services. The organization serves a diverse population consisting primarily of adults and older adults with chronic and acute medical conditions.

The nurse manager supervises nursing operations on two medical-surgical units and collaborates regularly with physicians, case managers, social workers, therapists, and administrative staff. During the interview, the participant identified several organizational challenges affecting patient care; however, ineffective discharge planning and poor communication during care transitions emerged as the most significant concerns.

According to the interviewee, communication gaps frequently occur between nursing staff, physicians, case managers, and outpatient providers during discharge planning. Critical information regarding follow-up appointments, medication reconciliation, patient education, and community resources is often delayed or inconsistently communicated. As a result, patients occasionally experience confusion after discharge, delayed follow-up care, medication errors, and preventable readmissions.

The interviewee explained that previous attempts to address the issue included staff education sessions, electronic reminders within the electronic health record (EHR), and informal interdisciplinary meetings. Although these interventions produced temporary improvements, they failed to create sustainable change because communication processes remained inconsistent across departments.

The nurse manager emphasized that successful discharge planning requires coordinated efforts from multiple disciplines. Therefore, solving the problem requires an interdisciplinary approach rather than isolated departmental interventions.

Identification of the Interdisciplinary Issue

The primary interdisciplinary issue identified during the interview is ineffective discharge coordination caused by inconsistent communication among healthcare professionals involved in patient transitions of care.

Discharge planning is inherently interdisciplinary because it requires collaboration among nurses, physicians, pharmacists, case managers, social workers, rehabilitation specialists, and outpatient providers. Each discipline contributes unique expertise that supports safe and effective patient transitions from the hospital to the community.

When communication failures occur during discharge planning, patients may receive incomplete information, experience delays in care, misunderstand medication instructions, or fail to attend follow-up appointments. These outcomes increase the risk of hospital readmissions, adverse events, and decreased patient satisfaction.

The interview findings indicate that no single department can independently resolve the issue. Effective discharge planning depends on shared accountability, coordinated workflows, and timely information exchange among all healthcare professionals involved in patient care. Therefore, an interdisciplinary solution is necessary to address the root causes of the problem.

Organizational Impact of the Issue

Poor discharge coordination affects multiple aspects of organizational performance. First, ineffective communication contributes to increased hospital readmission rates. Readmissions place financial burdens on healthcare organizations and may negatively affect quality performance metrics.

Second, communication breakdowns increase workload demands for nursing staff. Nurses frequently spend additional time clarifying discharge instructions, coordinating services, and resolving information gaps that could have been prevented through effective interdisciplinary communication.

Third, patient satisfaction can decline when discharge processes are disorganized or confusing. Patients who do not understand their care plans often feel less confident managing their health conditions after discharge.

Finally, fragmented communication can contribute to staff frustration and decreased team effectiveness. Healthcare professionals may experience difficulties coordinating care when expectations, responsibilities, and communication pathways are unclear.

Addressing this issue has the potential to improve patient outcomes, reduce readmissions, enhance workflow efficiency, and strengthen interdisciplinary collaboration throughout the organization.

Change Theories That Could Support an Interdisciplinary Solution

Implementing sustainable improvements in discharge coordination requires a structured change management approach. Two evidence-based change theories particularly applicable to this issue are Lewin’s Change Theory and Kotter’s Eight-Step Change Model.

Lewin’s Change Theory

Lewin’s Change Theory consists of three stages: unfreezing, changing, and refreezing. During the unfreezing stage, organizational leaders help stakeholders recognize the need for change by presenting evidence regarding communication failures, readmission rates, and patient outcomes.

The changing stage involves implementing new interdisciplinary communication processes such as standardized discharge checklists, structured interdisciplinary rounds, and communication tools. Staff receive education and support as they adopt new practices.

During the refreezing stage, successful practices become integrated into organizational culture through ongoing evaluation, accountability measures, and policy development. This phase helps ensure long-term sustainability of improvements.

Kotter’s Eight-Step Change Model

Kotter’s model expands upon change implementation by emphasizing leadership engagement and stakeholder involvement. The model begins by establishing urgency and creating a guiding coalition composed of representatives from multiple disciplines.

Leaders then develop a shared vision, communicate goals, empower employees, generate short-term successes, and institutionalize improvements. Because discharge planning requires participation from numerous healthcare professionals, Kotter’s framework provides an effective structure for promoting interdisciplinary engagement and organizational commitment.

Research supports the effectiveness of structured change models in healthcare settings where complex workflow changes require collaboration across departments (Zomorodi et al., 2024).

Leadership Strategies That Could Lead to an Interdisciplinary Solution

Transformational leadership represents the most appropriate leadership strategy for addressing the discharge coordination issue identified during the interview.

Transformational leaders inspire employees through a shared vision, encourage innovation, foster collaboration, and support professional development. Rather than relying solely on authority, transformational leaders motivate team members to actively participate in organizational improvement efforts.

For discharge planning initiatives, transformational leadership can encourage nurses, physicians, case managers, pharmacists, and social workers to collaborate toward common goals. By creating an environment characterized by trust, transparency, and mutual respect, leaders can improve interdisciplinary communication and strengthen team relationships.

Research demonstrates that transformational leadership positively influences employee engagement, communication quality, teamwork effectiveness, and patient outcomes (Ystaas et al., 2023). Additionally, transformational leadership promotes psychological safety, allowing team members to openly discuss concerns, identify barriers, and contribute innovative solutions.

The nurse manager interviewed identified inconsistent participation across departments as a major obstacle. Transformational leadership can address this challenge by promoting accountability, shared ownership, and active involvement from all disciplines.

Evidence-Based Collaboration Approaches

Several evidence-based collaboration strategies can support improvements in discharge planning and interdisciplinary communication.

SBAR Communication Framework

The Situation, Background, Assessment, Recommendation (SBAR) framework provides a standardized communication method that improves information exchange among healthcare professionals. SBAR reduces ambiguity and ensures that critical information is communicated clearly and consistently.

Studies have shown that SBAR improves patient safety, communication effectiveness, and clinical decision-making (Ghosh et al., 2021).

Interdisciplinary Rounds

Regular interdisciplinary rounds allow healthcare professionals to discuss patient care plans, clarify discharge goals, identify barriers, and coordinate interventions. These meetings promote real-time communication and improve collaboration among team members.

Interdisciplinary rounds also help establish accountability by ensuring that responsibilities are clearly assigned and progress is regularly monitored.

TeamSTEPPS

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based teamwork framework developed to improve communication, leadership, situation monitoring, and mutual support within healthcare teams.

TeamSTEPPS training equips healthcare professionals with standardized communication tools that enhance teamwork and reduce errors during patient care transitions.

Implementation of TeamSTEPPS can improve coordination between inpatient and outpatient providers, thereby reducing communication failures during discharge planning.

Conclusion

The interview identified ineffective discharge coordination as a significant interdisciplinary issue affecting patient outcomes, staff efficiency, and organizational performance. Communication breakdowns among healthcare professionals contribute to delayed care transitions, increased readmissions, and reduced patient satisfaction.

Evidence-based change theories such as Lewin’s Change Theory and Kotter’s Eight-Step Model provide structured approaches for implementing sustainable improvements. Transformational leadership can further strengthen interdisciplinary collaboration by promoting communication, trust, and shared accountability.

Finally, evidence-based collaboration strategies including SBAR, interdisciplinary rounds, and TeamSTEPPS offer practical solutions for improving discharge planning processes. Through effective leadership and interdisciplinary teamwork, healthcare organizations can enhance patient safety, improve care transitions, and achieve better overall healthcare outcomes.

References

Ghosh, S., Ramamoorthy, L., & Pottakat, B. (2021). Impact of structured clinical handover protocol on communication and patient satisfaction. Journal of Patient Experience, 8(1), 1–6. https://doi.org/10.1177/2374373521997733

Persson, M. H., Søndergaard, J., Mogensen, C. B., Skjøt-Arkil, H., & Andersen, P. T. (2022). Healthcare professionals’ experiences and attitudes to care coordination across health sectors: An interview study. BMC Geriatrics, 22(1), 509. https://doi.org/10.1186/s12877-022-03200-6

Warren, J., & Warren, J. (2023). The case for understanding interdisciplinary relationships in health care. Ochsner Journal, 23(2), 94–97. https://doi.org/10.31486/toj.22.0111

Ystaas, L. M. K., Nikitara, M., Ghobrial, S., Latzourakis, E., Polychronis, G., & Constantinou, C. S. (2023). The impact of transformational leadership in the nursing work environment and patients’ outcomes: A systematic review. Nursing Reports, 13(3), 1271–1290. https://doi.org/10.3390/nursrep13030108

Zomorodi, M., Ciarrocca, K., Neal, M., & Rodgers, P. (2024). Step by step: Utilizing Kotter’s model to design and implement a strategic plan for institutionalizing interprofessional education and practice. Journal of Interprofessional Education & Practice, 37, 100720. https://doi.org/10.1016/j.xjep.2024.100720