Student name

Capella University

NURS-FPX4005

Professor Name

Submission Date

Interview and Interdisciplinary Issue Identification

The concept of multidisciplinary teamwork has become a mandatory part of contemporary healthcare due to the high likelihood that complex patients will need the skills and competencies of several disciplines collaborating in the direction of the common arrangement (Warren and Warren, 2023). The willingness to identify the issues that the organization is grappling with, organize solutions as a team, and ensure that the evidence-based strategies are applied is the most critical at the baccalaureate level as a ready nurse in enhancing the evidence-based strategies of patient and system outcomes. This kind of assessment is the first case in the process when an interview with a medical worker is conducted to investigate real-life problems regarding communication, workflow, or coordination that exist in an organization.

Interview Summary

The interviewed nursing leader practiced in a 200-bed community hospital that offers acute medical-surgical care, obstetrics, and outpatient specialty clinics to a city/suburban community of patients. The heterogeneous population of adults and older adults with a broad spectrum of chronic and acute illnesses defines the organization; the recent trends in the services are the high turnover rates in the inpatient area and the increase in the pressure on the outpatient follow-up. Among the list of active stress factors noted by the interviewee, the lack of discharge coordination between nurses, case management, and outpatient services was the most remarkable one, which leads to delays in the flow of patients and even readmission (Cadel et al., 2022). These pressures on the system were placed within the setting of a system where staffing fluctuation and competing priorities make communication and care transfer on time difficult.

The interviewee is an inpatient nurse manager in two units of the medical-surgical unit who provided information about routine daily activities, consisting of the role of nursing staff supervisors, collaboration with case managers and physicians, length of stay, and readmission rates. Using terms that are related to the organizational aspects, the interviewee stated that the absence of communication across disciplines (discharge plans, the deficiency of information concerning outpatient appointments) turned out to impede the working process, and it predisposed the nursing workload, which adversely influenced patient satisfaction and their persistence with treatment.

Leadership had already implemented some of the fixes, such as short interdisciplinary huddles, ad hoc electronic reminders, and specific staff education, but these were temporary fixes since they were poorly engaged and not standardized processes (Girnius et al., 2024). Regarding issues of culture, the interviewee stated that the overall attitude to teamwork was positive, yet there was no consistency in the work of different departments to participate in formal interdisciplinary processes; prior experiences of interdisciplinary teams demonstrated that the major success was based on the application of formal communication tools along with the assistance of leadership. Open-ended questions, reflective probing, and active listening were used to facilitate the interview since a large amount of information can be gathered and discussed later.

Issue Identification

The major problem highlighted in the interview is that discharge coordination has never been effective, and there was no communication between the nursing staff, the case managers, the physicians, and the outpatient service provider. It is also an issue of an interdisciplinary nature since a successful discharge planning involves coordination of various departments, joint decision making, and sharing of information in a timely manner to ensure an effective transition of patients. The interdisciplinary approach is therefore bizarre as no department possessed all the information or authority to optimize the discharge, and the experience of individual departments, including an individual nurse-led education or case management alert, did not lead to permanent improvement (Tseng et al., 2025). The comments of the interviewee concerning the slowness of communication, incoherent workflow, and lack of consistency in discharge participation can be used to realize that the issue is interdisciplinary, and the only way to escape is to work as a team and collaborate.

Change Theories That Could Lead to an Interdisciplinary Solution

One effective model that can be employed to enable an interdisciplinary intervention and develop a discharge coordination improvement is the Change Theory developed by Lewin and the 8-step change model of Kotter. By highlighting three stages, namely unfreezing, changing, and refreezing, which are extremely natural in facilitating the team-based practice change, the Lewin model has made the stakeholders understand the significance of the change, embrace new collaborative behavior, and streamline the process of communication among the disciplines. The model by Kotter gives much consideration to the steps, which include a sense of urgency, guiding coalition, shared vision, and empowering action on a large scale, which was also present in collective leadership, which is the coordinated effort needed in interdisciplinary teams.

These two theories support the systematic communication, collective ownership, and gradual assimilation of the new workflow, which plays a major role in overcoming the communication breakdowns as observed in the interview. The peer-reviewed sources provide the same evidence that such models may be effectively implemented in a medical facility, particularly in situations where the change to be adopted involves the coordination of the work of the representatives of various professional communities (Persson et al., 2022).

The discharge coordination problem can be subjected to the theories, particularly due to the fact that they offer steps in offering resistance, staff involvement, and intertwining of new communication practices across the various departments. The unfreezing phase offered by Lewin may assist the organization to realize that the existence of fragmented communications is resulting in poor patient outcomes, and the change phase could be suggested to introduce systemic interdisciplinary discharge huddles or standardized communication tools. These steps are also important because, following Kotter, the leaders can produce interdisciplinary champions and can make the new behaviors too permanent by finding and educating individuals and designing feedback loops (Zomorodi et al., 2024).

The two theories directly refer to the cultural, behavioral, and organizational determinants of such issues as the inconsistent participation and non-standardized processes that the interviewee identified did not contribute to the effective discharge planning. Moreover, the mentioned references are recent, evidence-based, and published in reputable peer-reviewed healthcare publications, so the theoretical frameworks used to tackle the problem under consideration are not only legitimate but are equalized to the existing best practices.

Leadership Strategies That Could Lead to an Interdisciplinary Solution

Transformational leadership is one of the best strategies to establish interdisciplinary cooperation and act as a force towards organizational change. Transformational leaders are capable of motivating and inspiring the personnel staff by disseminating a common vision, empowering the staff members, and facilitating the free flow of information across professional boundaries. Relationship building, trust, and psychological safety are some of the key elements of such leadership that facilitate the nurses, physicians, case managers, and other professionals involved in the field to open up when problem-solving and making decisions as a team. The available body of knowledge confirms that transformational leadership enhances the cohesiveness of teams, the degree of communication, and change readiness, which is why it might be specifically helpful in treating the issues of multi-departmental and complexity (Singh et al., 2024).

When the transformational leaders introduce the behaviors of inclusiveness and the various disciplines are all motivated to participate in a way that the specialists contribute their own part, there is a justifiable opportunity that the transformational leaders would direct the staff in the process of learning the fresh communication functioning and interdisciplinary character of work. It is possible to note that the application of transformational leadership to the discharge coordination problem is best applied in connection to the problem of uneven participation and lack of unity in communication, as demonstrated by the interviewee.

Possibly, a transformational leader will have a chance to present a joint vision of interdisciplinary rounds into the regular discharge planning, encourage employees to participate in interdisciplinary rounds regularly, and assist the teams in the creation of the standard communication tools, including formal handoff procedures. The above leadership approach would assist in silo-busting as well as ensure that all disciplines are empowered and committed to attaining outcome improvement owing to the developed trust and responsibility within the departments (Bakewell, 2024).

Collaboration Approaches for Interdisciplinary Teams

It may be highly relevant against the backdrop of enhancing the quality of communication and collaboration among the medical teams; one should take into consideration the evidence-based collaboration strategies, including Situation, Background, Assessment, Recommendation (SBAR) communication, interdisciplinary rounds, and TeamSTEPPS. SBAR is a stacked type of communication that involves a considerable amount of patient information that may help eliminate ambiguity and provide the same information to all disciplines that may be needed in reaching a decision. The interdisciplinary rounds and huddles would allow the nurses, physicians, case managers, and other allied healthcare professionals to routinely have face-to-face access to plan the goals, explain the discharge plans, and predict patient demand.

Team stepps is an evidence-based and team-based program that is designed to improve communication, other departmental support, and understanding through training them on how to use standardized instruments and responding behaviours to encourage collaboration. The literature that is available suggests that the practices and the adoption of electronic health record (EHR) promote a decrease in errors, efficacy, and improved patient outcomes, especially in the settings involving two or more professionals that are involved in the transfer of care (Alharbi, 2025).

Such kinds of collaboration strategies are the direct solution to the problem of discharge coordination that was identified in the interview, as they have created effective solutions to provide all the team members with real-time data and expectations. SBAR can be the foundation of the standardization of the change in nursing and case management to avoid miscommunication during discharge preparation or follow-up care. Interdisciplinary rounds would promote regular involvement and interdisciplinary interaction that would lead to the non-existence of delays and work overload. It would create a sense of accountability and ownership of the discharge process by the department by implementing the strategies of TeamSTEPPS that involve the use of check-backs, briefs, and cross-monitoring.

Conclusion

As noted in the interview, discontinuous communication and interdisciplinary coordination are among the challenges that might be significant in the realization of discharge planning and quality outcomes in patients. The discovery of this problem contributes to the necessity of an evidence-based intervention in the team, which can be enhanced with the help of the corresponding models of change and efficient leadership. The staff can be subjected to long-term changes with the implementation of the Lewin Change Theory and transformational leadership, but SBAR, interdisciplinary rounds, and TeamSTEPPS were implemented to support the process of communication and workflow.