Student name

School of Nursing and Health Sciences, Capella University

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

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Submission Date

Interview and Interdisciplinary Issue Identification

The multidisciplinary teamwork has become an essential aspect of modern healthcare because complex patients are likely to require expertise and abilities of multiple disciplines working together in the direction of a shared configuration (Warren and Warren, 2023). As a nurse who is ready at the baccalaureate level, the ability to determine the problems that the organization is struggling with, arrange the solutions as a team, and make sure the evidence-based strategies are implemented is the most significant in improving the patient and the system outcomes. Such an assessment is the initial step in the process when an interview with a healthcare professional is carried out to explore real-life issues related to communication, workflow, or coordination that are present in an organization.

Interview Summary

The interviewed nursing leader worked in a 200-bed community hospital providing acute medical-surgical care, obstetrics, and outpatient specialty clinics to a city and suburban community of patients. The heterogeneous population of adults and older adults with a wide range of chronic and acute illnesses characterizes the organization; the recent tendencies in the services are the high turnover rates in the inpatient area and the growth of the pressure on the outpatient follow-up. On the list of operational stressors presented by the participant in the interview, insufficient discharge coordination between nurses, case management, and outpatient services stood out, which causes delays in the patient flow and even readmission (Cadel et al., 2022). Such system pressures were put in the environment of a system where staffing variability and conflicting priorities make communication and transition of care on time challenging.

The interviewee is a nurse manager in two inpatient units of the medical-surgical unit who identified daily activities that include the responsibilities of nursing staff supervisors, interaction with case managers and physicians, length of stay outcomes, and readmission rates. Referring to organization-related issues, the interviewee said that the lack of interdisciplinary communication (discharge plans, a lack of information about outpatient appointments) became an obstacle to the working process, increased nursing workload, which negatively affected patient satisfaction and their treatment continuation. Some of the fixes that had already been made by leadership included short interdisciplinary huddles, ad hoc electronic reminders, and specific staff education, but were temporary fixes due to poor engagement and not standardized processes (Girnius et al., 2024).

On the issue of culture, the interviewee indicated that there was an overall positive disposition towards teamwork, but there was a lack of consistency in various departments working on engaging in formal interdisciplinary processes; past experiences of interdisciplinary teams revealed that the key to success was centered on the use of formal communication tools in addition to leadership support. The interview was facilitated using open-ended questions, reflective probing, and active listening because a broad scope of information can be collected to be explored further.

Issue Identification

The key issue discussed in the interview is that discharge coordination has never worked, and there was a lack of communication among the nursing staff, the case managers, the physicians, and the outpatient service provider. It is a problem in interdisciplinary nature too because effective discharge planning requires coordination of different departments, joint decision making, as well as sharing of information on time to facilitate the effective transition of patients. The interdisciplinary approach is thus unusual since no department has all the information or authority to maximize discharge, and the experience of individual departments, such as individual nurse-led education or case management alerts, did not result in permanent improvement (Tseng et al., 2025). The remarks of the interviewee about the slowness of communication, incoherent workflow, and inconsistency in discharge participation help to understand that the problem is interdisciplinary, and teamwork and collaboration are the only ways out.

Change Theories That Could Lead to an Interdisciplinary Solution

A potent model to facilitate an interdisciplinary intervention and create a discharge coordination improvement is the Change Theory by Lewin and the 8-step change model of Kotter. The Lewin model has emphasized three phases, which include unfreezing, changing, and refreezing, that are very natural in supporting the team-based practice change by making the stakeholders realize the importance of the change, adopt new collaborative behavior, and standardize the communication process among the disciplines.

Kotter’s model provides extensive attention to steps, such as creating a sense of urgency, a guiding coalition, shared vision, and empowering action on a large scale, which were also found in collective leadership, which is the coordinated effort that is required in interdisciplinary teams. Both theories endorse the systematic communication, shared ownership, and progressive assimilation of new workflow, which are crucial in correcting the communication failures as seen in the interview. The peer-reviewed sources present the same evidence that these models can be successfully applied in a medical setting, especially in situations when the change that was to be implemented comprises the coordination of work of the members of different professional groups (Persson et al., 2022).

The theories can be applied to the discharge coordination issue, especially because they provide systematic methods of offering resistance, ensuring staff participation, and integration of new communication practices among the different departments. The unfreezing phase presented by Lewin can help the organization to understand that the existence of disjointed communication is leading to poor patient outcomes, and the change phase can be proposed to implement systemic interdisciplinary discharge huddles or standardised communication tools.

Kotter’s steps also enable the leaders to create interdisciplinary champions and entrench new behaviors by identifying and training individuals and creating feedback loops (Zomorodi et al., 2024). The cultural, behavioral, and organizational determinants of such problems are directly mentioned in the two theories due to the inconsistent participation and non-standardized processes that the interviewee mentioned, which hindered the effective discharge planning. In addition, the specified sources are current, evidence-based, and featured in credible peer-reviewed healthcare journals, and, therefore, the theoretical backgrounds applied to address the issue in question are not only valid but are also balanced with the current best practices.

Leadership Strategies That Could Lead to an Interdisciplinary Solution

One of the most effective approaches to building interdisciplinary cooperation and working as a driving force behind the organizational change is transformational leadership. Transformational leaders can encourage and inspire the staff members by spreading a shared vision, empowering the staff members, and promoting the free flow of information across professional borders. Such a leadership is centered around relationship building, trust, and psychological safety, of the critical factors that enable the nurses, physicians, case managers, and other colleagues involved in the field to open up in their problem-solving and collective decision-making.

The existing body of knowledge proves that transformational leadership improves the unity of teams, the level of communication, and readiness to change, which is why it can be particularly relevant in addressing multi-departmental and complex issues (Singh et al., 2024). As the transformational leaders introduce the inclusive behaviors and engage various disciplines so that the specialists offer their input, the transformational leaders have a fair chance to guide the staff through the process of learning the new communication working processes and interdisciplinary types of work. The relevance of transformational leadership to the discharge coordination issue is most evident when referring to the problem of inconsistent participation and fragmented communication presented by the interviewee.

Perhaps, a transformational leader will be able to share a joint vision of interdisciplinary rounds during the regular discharge planning, motivate employees to engage in interdisciplinary rounds regularly, and support the teams in developing the standardized communication tools, such as formal handoff protocols. The mentioned leadership style would help in silo-busting and make all disciplines feel empowered and devoted to achieving outcome improvement due to the established trust and responsibility in the departments (Bakewell, 2024). Moreover, the sources about transformational leadership in healthcare are current, peer-reviewed, and have a positive reputation for improving the quality of care and interdisciplinary interaction, which suggests that the strategy is also credible and evidence-based.

Collaboration Approaches for Interdisciplinary Teams

It could be extremely important in the context of improving the level of communication and collaboration between the healthcare teams; evidence-based collaboration strategies should be considered, such as Situation, Background, Assessment, Recommendation (SBAR) communication, interdisciplinary rounds, and TeamSTEPPS. SBAR is a structured form of communication with significant patient information that can reduce ambiguity and offer the same information to all fields that might be needed when reaching a decision. The interdisciplinary rounds and huddles would enable nurses, physicians, case managers, and allied healthcare professionals to have face-to-face access regularly to organize the goals, explain the discharge plans, and anticipate patient demand.

TeamSTEPPS is an evidence-based, teamwork-oriented program aimed at enhancing communication, other departmental support, and understanding by training them to use standardized instruments and responding behaviours to promote collaboration. The available literature indicates that the practices and the electronic health record (EHR) adoption encourage reduced errors, effectiveness, and improved patient outcomes, particularly in the settings that include two or more professionals who are engaged in the transition of care (Alharbi, 2025).

These collaboration strategies directly address the discharge coordination issue that was noted in the interview, since they have developed reliable solutions to give real-time information and expectations to all team members. SBAR may be the basis of standardization in changes in nursing and case management to prevent miscommunication in discharge preparation or for follow-up care. The interdisciplinary rounds would encourage frequent participation and interdisciplinary interaction, which would result in the absence of delays and work overload. It would establish accountability and ownership of the discharge process by the department through the application of the strategies of TeamSTEPPS that entail check-backs, briefs, and cross-monitoring.

Conclusion

The interview revealed that discontinuous communication and interdisciplinary coordination are some of the challenges that could be important in achieving discharge planning and quality outcomes in patients. The identification of this issue adds to the need for a team-based, evidence-based intervention that could be improved using the relevant models of change and effective leadership. The implementation of the Lewin Change Theory and transformational leadership can make the staff undergo long-term changes, whereas SBAR, interdisciplinary rounds, and TeamSTEPPS were applied to facilitate communication and workflow.

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