Capella FPX 4005 Assessment 4

Name

Capella University

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

Prof. Name

Date

Stakeholder Presentation

Hello, my name is ——, and I am here to present a critical initiative designed to address the elevated readmission rates at Cedar Valley Health Center, particularly among patients with diabetes and hypertension. These increasing rates indicate the urgent need for an interdisciplinary solution that reduces care fragmentation and strengthens transitional support across all patient populations. This proposal presents an evidence-based, collaborative approach aimed at enhancing care coordination, improving discharge planning, and promoting effective communication among healthcare teams. We strive to reduce avoidable readmissions, improve patient outcomes, and raise our facility’s overall quality of care.

Issue Identification

Cedar Valley Health Center’s challenge is the high rate of patient readmissions resulting from fragmented care, inadequate discharge planning, and poor coordination of care settings. The current strategies, isolated discharge instructions, and limited post-discharge follow-up have failed to address the problem. Therefore, patients encounter preventable complications and repeated hospital visits, which result in increased healthcare costs and poor patient satisfaction (Brown et al., 2021). This challenge is particularly critical to healthcare providers and administrators because care quality and organizational efficiency are undermined.

Relevance of the Issue

Hospital readmissions and better patient outcomes depend on effective care transitions and interdisciplinary coordination. Fragmented communication and the absence of structured follow-up result in care gaps and adverse events following discharge in studies (Ibrahim et al., 2022). Cedar Valley Health Center can enhance its reputation as a high-quality, patient-centered facility by implementing integrated care strategies and improving team collaboration to strengthen transitional care and reduce unnecessary readmissions.

Relevance of an Interdisciplinary Team Approach

Addressing High Readmission Rates

It is essential to reduce hospital readmissions among patients with diabetes and hypertension at Cedar Valley Health Center to enhance patient safety and overall quality of care. Among these patient groups, fragmented care transitions are particularly prone to deteriorating health and recurrent hospitalization due to inadequate discharge planning and insufficient follow-up protocols. This problem hinders patient well-being and adds to the burden and stress of healthcare personnel responsible for handling complex cases. A comprehensive interdisciplinary approach is implemented, with nurses, physicians, social workers, and care coordinators working together as a team, to ensure that patients receive comprehensive discharge planning and adequate post-discharge support. Collaboration is essential in addressing the complex needs of patients with diabetes and hypertension to preventable readmissions (Hayes et al., 2024).

Enhancing Transitional Care Through Collaborative Strategies

Improving transitional care for patients with diabetes and hypertension is dependent on adopting an interdisciplinary team model at Cedar Valley Health Center that is specifically tailored for this patient population. This approach brings together the expertise of many healthcare professionals, enabling thorough patient assessments, cohesive care planning, and tailored follow-up procedures to address the specific challenges associated with managing these chronic conditions (Hayes et al., 2024). Interprofessional rounds are conducted regularly and utilize Collaborative Care Models, which facilitate communication among all members of the interprofessional team and promote joint decision-making to ensure that all aspects of a patient’s health, including medication management and lifestyle modifications, are well-coordinated (Harrison et al., 2021). 

Failure to address the high readmission rates at Cedar Valley Health Center could lead to continued patient harm, increased healthcare costs, and penalties from value-based reimbursement programs. Fragmented care may lead to preventable complications, decreased patient satisfaction, and erosion of trust in the facility. Additionally, the organization risks staff burnout and inefficiencies due to repeated hospitalizations and poorly coordinated care. Over time, this could damage Cedar Valley’s reputation and ability to compete in a quality-driven healthcare landscape. A structured collaboration will optimize resource use and reinforce a culture of safety and accountability within the organization (Karam et al., 2021).

Interdisciplinary Plan Summary

Objective

The approach at Cedar Valley Health Center focuses on reducing elevated readmission rates by implementing a comprehensive, interdisciplinary transitional care strategy for patients with diabetes and hypertension, with a particular emphasis on readmission rates. Early discharge planning, coordinated care, and structured post-discharge support are emphasized for this initiative to ensure continuity of care and to prevent avoidable hospital readmissions.

Likelihood of Success  

This approach is likely to succeed, and strong evidence supports this. Karam et al. (2021) demonstrate that early discharge planning, interprofessional communication, and structured follow-up have a significant impact on patients’ outcomes and readmissions. Incorporating these evidence-based strategies into Cedar Valley’s care model, especially for high-risk patients, positions them well to achieve measurable improvements in patient satisfaction and clinical outcomes.

Actions 

Cedar Valley will plan a targeted transitional care protocol using the Plan-Do-Study-Act (PDSA) model. Patients identified as high risk, especially those with diabetes or hypertension, are discharged with a plan initiated upon admission by the nurse case manager. The plan will outline team roles: pharmacists will conduct medication reconciliation and education, social workers will assess social determinants of health and arrange post-discharge services, and attending physicians will make medical decisions. Clear communication and alignment of care team members will be maintained through daily interprofessional rounds and weekly case reviews. This plan will be piloted in the “Do” phase with a select patient group, and the social worker will follow up with the patient in 48 hours post-discharge to address immediate barriers.

During the “Study” phase, monthly readmission rates, medication adherence, and patient satisfaction will be reviewed, and staff feedback will be collected to assess the effectiveness of the strategy (McKenna et al., 2023). The final “Act” phase will involve using the collected data to refine the process further and expand the intervention throughout all units, institutionalizing interprofessional rounds and collaborative care models as a standard part of Cedar Valley’s patient care. By working in this manner, structuring and collaborating, Cedar Valley Health Center aims to establish a safer and more efficient care transition process that better serves patients and reduces unnecessary readmissions (McKenna et al., 2023).

Implementation and Resource Management

A carefully structured framework is necessary for an interdisciplinary plan to reduce hospital readmissions at Cedar Valley Health Center, especially for patients with chronic conditions, including diabetes and hypertension. The scope of the intervention will be defined first, including clearly assigned roles and responsibilities for each team member. Upon admission, a full-time nurse case manager will initiate discharge planning for high-risk patients. At the same time, a part-time social worker will coordinate social determinants of health and post-discharge support. Estimated to cost $60,000 and $35,000 a year, these staffing adjustments would allow the center to run with current staffing levels at a minimal financial outlay.

Medication reconciliation responsibilities will be integrated into the clinical pharmacist’s existing workflow, eliminating the risk of medication misunderstandings for patients. Daily interprofessional rounds will include structured discussion among nurses, physicians, pharmacists, and social workers. We estimate $5,000 to support this model, covering staff communication and care coordination training. While most technological infrastructure is in place at Cedar Valley, a small EHR system upgrade (approximately $10,000) will enhance real-time documentation and team communication, particularly during care transitions.

The estimated cost of staffing adjustments, training, and technological improvements is $110,000. Nevertheless, they are outweighed by the potential savings from reduced hospital readmissions. The national burden of readmission-related costs is $17.4 billion, and considering the national burden of $17.4 billion, Cedar Valley could recoup its investment by preventing as few as 10 readmissions annually (Agube, 2023). Care coordination programs, such as those in managed care, have reduced readmissions and improved patient outcomes and organizational efficiency (Fu et al., 2023). Cedar Valley can proactively address discharge planning and transitional care through a well-resourced, interdisciplinary model, thereby improving care quality, maintaining financial sustainability, and protecting the organization’s long-term reputation.

Evidence-Based Criteria for Evaluation

Evaluating the outcomes of the care coordination initiative at Cedar Valley Health Center can be done using evidence-based metrics such as reduced hospital readmission rates, improved care plan adherence, increased patient satisfaction, and enhanced interprofessional collaboration. A 25% reduction in 30-day readmissions among high-risk patients with diabetes and hypertension within six months of implementation would be a key success indicator, aligning with the outcomes of similar interventions in coordinated care models (Thyagaturu et al., 2021). Through standardized surveys, a 10% improvement in satisfaction scores regarding discharge planning and care continuity can be measured for patient satisfaction, as reported by Agube (2023).

Staff surveys and structured feedback will measure communication and collaboration, aiming to achieve at least 80% of team members reporting improved coordination and clarity during interdisciplinary rounds (Karam et al., 2021). EHR audits can track adherence to care plans (medication and follow-up visits) to increase adherence by 20% in the intervention group. In addition, monthly outcome monitoring will include rates of completing post-discharge follow-up within 48 hours, a minimum of 90%.

These metrics blend quantitative and qualitative evaluation methods. For instance, if readmissions go from 40 to 30 per quarter, that represents a 25% improvement. At the same time, patient and staff feedback will complement the numbers, helping pinpoint successes and further refine the program. Integrating these outcomes allows Cedar Valley to hold itself accountable, continually improve the quality of care and operational effectiveness, and measure the improvements.

Conclusion

A conclusion is drawn that the proposed interdisciplinary care coordination initiative at Cedar Valley Health Center offers a viable, evidence-based solution to reducing avoidable readmissions and improving patient outcomes. This approach strengthens transitional care for high-risk populations by improving communication, discharge planning, and post-discharge support. Resources are utilized strategically and continually evaluated for both clinical and operational benefits. Ultimately, this initiative is putting Cedar Valley at the forefront of providing high-quality, patient-centered care.

References

Agube, K. (2023). How provider education on identification and referral of eligible patients to a care management program affects readmission rates: An evidence-based project. https://digitalcommons.pvamu.edu/dnp-projects/1 

Brown, C. S., Montgomery, J. R., Neiman, P. U., Wakam, G. K., Tsai, T. C., Dimick, J. B., & Scott, J. W. (2021). Assessment of potentially preventable hospital readmissions after major surgery and association with public vs private health insurance and comorbidities. JAMA Network Open, 4(4), e215503. https://doi.org/10.1001/jamanetworkopen.2021.5503

Fu, B. Q., Zhong, C. C., Wong, C. H., Ho, F. F., Nilsen, P., Hung, C. T., … & Chung, V. C. (2023). Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies. International Journal of Health Policy and Management, 12, 7089.

Capella FPX 4005 Assessment 4

Harrison, R., Fischer, S., Walpola, R. L., Chauhan, A., Babalola, T., Mears, S., & Le-Dao, H. (2021). Where do models for change management, improvement, and implementation meet? A systematic review of the applications of change management models in healthcare. Journal of Healthcare Leadership, 13(2), 85–108. https://doi.org/10.2147/JHL.S289176

Hayes, C., Manning, M., Fitzgerald, C., Condon, B., Griffin, A., O’Connor, M., Glynn, L., Robinson, K., & Galvin, R. (2024). Effectiveness of community‐based multidisciplinary integrated care for older adults with general practitioner involvement: A systematic review and meta‐analysis. Health & Social Care in the Community, 2024(1). https://doi.org/10.1155/2024/6437930

Ibrahim, H., Harhara, T., Athar, S., Nair, S. C., & Kamour, A. M. (2022). Multi-disciplinary discharge coordination team to overcome discharge barriers and address the risk of delayed discharges. Risk Management and Healthcare Policy, Volume 15(15), 141–149. https://doi.org/10.2147/rmhp.s347693

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon, C. (2021). Nursing care coordination for patients with complex needs in primary healthcare: A scoping review. International Journal of Integrated Care, 21(1), 16. https://doi.org/10.5334/ijic.5518

Capella FPX 4005 Assessment 4

McKenna, A. L., Carter, L. E., Kase, A. M., McCain, J. D., Fitzgerald, P. J., Kesler, A. M., Varma, S., & J. Colt Cowdell. (2023). Closing the gap in direct admissions: A quality improvement project. Quality Management in Health Care, Publish Ahead of Print. https://doi.org/10.1097/qmh.0000000000000412

Thyagaturu, H. S., Bolton, A. R., Li, S., Kumar, A., Shah, K. R., & Katz, D. (2021). Effect of diabetes mellitus on 30 and 90-day readmissions of patients with heart failure. The American Journal of Cardiology, 155, 78–85. https://doi.org/10.1016/j.amjcard.2021.06.016 

Capella FPX 4005 Assessment 3

Name

Capella University

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

Prof. Name

Date

Interdisciplinary Plan Proposal

Nurse burnout is a state of physical, emotional, and mental exhaustion caused by prolonged stress and irresistible job demands in healthcare settings. According to the Centers for Disease Control and Prevention (CDC), 46% of U.S. health workers felt frequent or extreme burnout in 2022, up from 32% in 2018 (CDC, 2023). This proposal addresses nurse burnout at Texas Children’s Hospital, a leading pediatric facility in Houston, Texas. This plan proposes an interdisciplinary team approach to reducing burnout. 

Objective

This plan will execute an interprofessional team approach to reduce nurse burnout at Texas Children’s Hospital by fostering interdisciplinary collaboration. It enhances emotional and organizational support and promotes equitable workload distribution. Achieving this goal is expected to improve organizational outcomes by increasing staff retention, reducing turnover, and cultivating a culture of teamwork and mutual accountability. Improved nurse health will improve pediatric patient outcomes by supporting consistent, compassionate care delivery and building a resilient, engaged nursing workforce.

Questions and Predictions

How will the implementation of an interdisciplinary team impact nurses’ workloads?

Initially, interdisciplinary collaboration may need extra meeting time. However, enhanced communication and collective decision-making will rationalize workflows, decreasing task repetition and facilitating nurse workloads.

What resources are vital to provide mental health support for pediatric nurses facing burnout?

Resources should include on-site access to trained psychologists for counseling, weekly resilience workshops tailored to the demands of pediatric care, and peer support forums. Collaborating with mental health specialists and providing confidential support will help nurses deliver complete care.

How will supportive scheduling for pediatric nurses impact patient care delivery?

Flexible scheduling will enhance nurses’ health and decrease fatigue. It will promote better focus and reliable patient care, and sufficient staffing will uphold patient safety.

What are the key measures to evaluate the plan’s success?  

Success will be evaluated by monitoring nurse burnout levels, staff retention rates, patient outcomes, and the efficiency of interdisciplinary collaboration through constant surveys and performance appraisals over six to twelve months.

Change Theories and Leadership Strategies

Kurt Lewin’s change management model offers a structured framework for addressing pediatric nurse burnout at Texas Children’s Hospital by methodically going through three stages. It includes unfreezing, changing, and refreezing (Stanz et al., 2021). In the unfreezing stage, leadership will highlight how burnout adversely affects pediatric care quality and nurse retention. It creates urgency for collaborative action. During the changing stage, interdisciplinary teams will introduce supportive scheduling practices.

This expands access to mental health resources and promotes standardized communication tools like SBAR (Situation, Background, Assessment, Recommendation) to improve team coordination. In the refreezing stage, these strategies will be integrated into hospital policy through constant evaluation, staff involvement, and feedback loops. This model guarantees sustainable development by empowering nurses. It fosters interdisciplinary collaboration and reinforces a healthy and quality care culture.

Transformational Leadership (TL) addresses nurse burnout at Texas Children’s Hospital by fostering collaboration, motivation, and a unified vision (Ystaas et al., 2023). Nurse managers can apply personalized thought to meet pediatric nurses’ emotional and professional needs by providing access to mental support services, such as peer-support programs and counseling, and ensuring equitable workload distribution. Through inspirational motivation, leaders can communicate the goal of reducing burnout and enhancing the work setting. This promotes staff engagement, trust, and long-term commitment (Ystaas et al., 2023).

For instance, the University of California, San Francisco (UCSF) Benioff Children’s Hospital implemented TL strategies. UCSF’s Magnet recognition highlights its excellence in nursing, with nurses experiencing less burnout and greater job satisfaction compared to most hospitals (UCSF Benioff Children’s Hospitals, 2025). This resulted in a measurable drop in reported burnout symptoms and improved department communication. Intellectual stimulation empowered these teams to develop innovative clinical strategies, such as rotating rest breaks and flexible scheduling. These changes boosted morale and improved patient care quality and staff retention. By valuing staff input and modeling transparency, TL fosters a culture of trust and collaboration. At Texas Children’s Hospital, this leadership style will continue to enhance nurse well-being, improve retention, and elevate the overall quality of pediatric care.

Team Collaboration Strategy

Texas Children’s Hospital’s interdisciplinary team addressing nurse burnout includes nurse managers, pediatric nurses, mental health specialists, and hospital administrators. Nurse managers will lead the execution of the burnout reduction plan. It offers constant support and monitors nurses’ health through regular surveys while coordinating supportive scheduling. Pediatric nurses will provide feedback and engage in peer support programs to foster emotional resilience. Mental health specialists will facilitate weekly wellness workshops and offer confidential counseling services (Flaubert et al., 2021). Hospital administrators will regularly assess staffing levels. It optimizes resource allocation and analyzes burnout and retention data quarterly to safeguard sustainable improvements in nurse well-being and patient care quality.

The collaboration approach will incorporate SBAR to standardize communication and Solution-Focused Brief Therapy (SFBT) to support nurses’ emotional resilience. SBAR will enhance clarity and accuracy during patient handoffs among pediatric nurses, physicians, and other healthcare team members, minimizing miscommunication. It contributes to nurse stress and burnout (Lo et al., 2021). SFBT will equip nurses with effective coping strategies by emphasizing solutions and strengths rather than dwelling on problems. It promotes positive emotional well-being (Kong et al., 2024). For instance, the SBAR communication tool at the Mayo Clinic is integrated into interprofessional teamwork training to enhance clarity, patient safety, and team collaboration (Wingo et al., 2024). These approaches will foster open dialogue and reinforce collaboration. This outline aims to sustain nurse health and the quality of care.

Required Organizational Resources

The plan to address nurse burnout at Texas Children’s Hospital requires resources for execution. Key staffing includes pediatric nurse managers, bedside nurses, mental health experts, and hospital managers who will dedicate time to monitor stress levels. They conduct wellness sessions and optimize scheduling practices. Existing resources such as private counseling rooms and digital communication platforms will facilitate mental support and SBAR execution. Extra costs involve partnering with mental consultants, $150–$180 per session, and delivering peer support and resilience training programs, $500–$1,000 annually. Required data access includes patient records, nurse scheduling, and burnout survey results.

It will leverage existing hospital systems without incurring extra costs. The estimated financial impact of implementation, including staffing time and external mental health services, ranges from $15,000 to $20,000 annually. It supports sustainable improvements in nurse well-being and pediatric care delivery. At Texas Children’s Hospital, similar wellness initiatives have reduced nurse turnover by 15% over a year. For example, integrating peer support groups in the pediatric ICU led to measurable decreases in reported stress and improved teamwork.

If the plan is not executed, nurse burnout can intensify. It leads to higher staff attrition and diminished care quality. This would require increased recruitment, onboarding, and training costs, which places extra strain on organizational resources. Burnout-induced fatigue can elevate the risk of clinical errors, which exposes the facility to legal repercussions and potential accreditation issues (Jun et al., 2021). Inconsistent care delivery erodes patient satisfaction and trust. It damages Texas Children’s Hospital’s reputation and weakens community confidence in its services.

References

CDC. (2023, October 24). Health Workers Face a Mental Health Crisis. Centers for Disease Control and Prevention. https://www.cdc.gov/vitalsigns/health-worker-mental-health/index.html

Flaubert, J. L., Menestrel, S. L., Williams, D. R., & Wakefield, M. K. (2021). Supporting the Health and Professional Well-being of Nurses. In www.ncbi.nlm.nih.gov. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK573902/ 

Jun, J., Ojemeni, M. M., Kalamani, R., Tong, J., & Crecelius, M. L. (2021). Relationship between nurse burnout, patient and organizational outcomes: Systematic review. International Journal of Nursing Studies, 119. https://doi.org/10.1016/j.ijnurstu.2021.103933

Kong, Y., Zhang, Y., Sun, P., Zhang, J., Lu, Y., Li, J., & Zheng, Y. (2024). Interdisciplinary cooperation with solution-focused brief therapy to reduce job stress, burnout, and coping in Chinese nurses: A randomised controlled trial. Heliyon, 10(22), e40138. https://doi.org/10.1016/j.heliyon.2024.e40138 

Lo, L., Rotteau, L., & Shojania, K. (2021). Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. British Medical Journal Open, 11(12). https://doi.org/10.1136/bmjopen-2021-055247

Capella FPX 4005 Assessment 3

Stanz, L., Silverstein, S., Vo, D., & Thompson, J. (2021). Leading through rapid change management. Hospital Pharmacy, 57(4), 422–424. https://doi.org/10.1177/00185787211046855 

UCSF Benioff Children’s Hospitals. (2025). Magnet Recognition. Ucsfhealth.org. https://www.ucsfbenioffchildrens.org/about/magnet-recognition

Wingo, M. T., Halvorsen, A. J., Leasure, E. L., Wallace, J. A., Huber, J. M., Mathias, T. R., & Thomas, K. G. (2024). Enhancing team development in an internal medicine resident continuity clinic. Medical Education Online, 29(1). https://doi.org/10.1080/10872981.2024.2430570

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 

Capella FPX 4005 Assessment 2

Name

Capella University

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

Prof. Name

Date

Interview and Interdisciplinary Issue Identification 

In a healthcare setting, many interdisciplinary issues exist, impacting patient care. This assessment focuses on an interview with a medical professional to identify a problem in Gifford Medical Center that can benefit from a multidisciplinary solution. It outlines the change models, leadership, and cooperation methods to overcome the concern identified.

Summary of Interview

I interviewed with the nurse manager at Gifford Medical Center, a critical access hospital offering surgical and transitional care. She has over eight years of experience as a nurse manager, directing nursing staff, liaising with departments, and regulating patient flow. One critical issue she discussed is higher readmissions due to poor communication among the team and the patient during discharge, leading to adverse outcomes. Previously, to address this issue, the facility implemented an Electronic Health Record (EHR) to improve communication and documentation during patient discharge.

Still, it did not work due to a lack of standardized protocol. Leadership conducted discharge education workshops and integrated follow-up calls. However, it failed due to non-compliance. The nurse manager told that organization has a positive culture however, units operate in silos. She underlined the significance of adopting standard communication methods like teach-back and interprofessional collaboration between nurses, physicians, and management to better patient results through efficient discharge planning. Gledhill et al. (2023), stated that shared goals and collaborative interaction among the primary stakeholders facilitate effective subacute care discharge planning. 

I used active listening approaches and took notes where necessary. The conversation was thorough to gain a complete understanding of the issues and investigate the limitations of using interdisciplinary techniques. I also used the open-ended inquiry strategy to obtain detailed responses. I asked questions to better comprehend the problem, like “How can interdisciplinary collaboration solve this issue? Adopting this approach is also supported by evidence. Dunwoodie et al. (2022), asserted that open-ended interview questions allow respondents to speak freely about a topic without direction, enabling rich data production on distinctive aspects of a topic.

Issue Identification

During the interview, the problem was recognized as increased readmissions at Gifford Medical Center due to improper discharge planning and patient management due to poor communication among care team members and the patient. According to the literature, poor communication among stakeholders, including the care team and patients, led to greater confusion and lower trust in medical providers (Gledhill et al., 2023). An interdisciplinary strategy is appropriate to solve this issue because it encourages collaboration among stakeholders to address the multifaceted causes of readmissions, like communication and patient interaction.

Nurses’ collaboration with case managers, physicians, and pharmacists ensures comprehensive patient care at the time of discharge. Each team member has a particular duty in the patient discharge, like offering education, communicating with patients, and drug reconciliation. Shared goals and collaborative interaction among stakeholders promote effective discharge planning and readmission reduction (Gledhill et al., 2023). Structured interdisciplinary discharge meetings help improve the release process and patient management. Adopting a multidisciplinary method at Gifford Medical Center can improve patient services upon discharge and reduce readmissions.

Change Theory and an Interdisciplinary Solution

Lewin’s Change Theory is a well-known and widely accepted model for organizational change. It has three stages: unfreezing, transforming, and refreezing (Amina et al., 2022). This theory can help create a multidisciplinary approach since it defines the hospital’s sequential transformation process and is most appropriate for addressing the patient readmission concern at Gifford Medical Center. During the unfreezing stage, leadership can involve staff in a discussion to acknowledge the need for improved discharge practices and a coordinated strategy to reduce readmission. During the transformation phase, the hospital can deploy a team of specialists to coordinate actions, such as planned team meetings for patient release and follow-up care.

Implementing standardized discharge guidelines and the teach-back method will also help to improve staff-patient communication. The refreezing stage focuses on sustaining new routines with ongoing monitoring, input, and managerial assistance. Lewin’s approach has strong evidence. Amina et al. (2022), recognized its usefulness in introducing change and assisting organizations in meeting their goals. The study found that using Lewin’s change theory assists nurses in efficient discharge planning. The teach-back method helps boost communication between the care team and the patients. The resource’s credibility is established, and it underlines the applicability of this theory in facilities via a quasi-experimental study.

Leadership Strategy and an Interdisciplinary Solution

To address the higher readmission and related communication problem, an efficient leadership approach like Transformational Leadership (TL) can be adopted. According to Nnate et al. (2021), the TL strategy has been recognized as a crucial method for leading change in organizations. The leader collaborates with every teammate based on expertise and knowledge, instilling trust and commitment to the set targets. TL can motivate nurses, physicians, pharmacists, and social workers to work towards the common goal of reducing readmissions, creating an interdisciplinary solution.

They make a clear vision for improved discharge planning, delegating responsibility to team members and building a trust and collaboration culture. Evidence showed that TL inspires and motivates team members to collaborate and develop relationships toward a common goal, generating a supportive setting to address issues (Ystaas et al., 2023). The resource of Nnate et al. (2021), is credible and relevant as it offers evidence on the role of TL in promoting multidisciplinary teamwork for discharge planning to reduce readmissions and lead to improved organizational culture.

Collaboration Approach for Interdisciplinary Teams

Interprofessional collaboration is critical for addressing complicated clinical difficulties such as patient readmission owing to ineffective communication among the care team. Adopting a Multidisciplinary Teamwork (MDT) model based on forming a multidisciplinary discharge coordination team panel aids in improving interaction and cooperation. Diverse specialists are involved in enhancing patient care and addressing issues. They can recognize and identify difficulties in effective discharge through weekly meetings. Ibrahim et al. (2022) state that face-to-face contacts improve medical teamwork and care quality. Further, TL is critical for improving interprofessional collaboration. It boosts confidence and helps teammates share their issues, resulting in better teamwork (Nnate et al., 2021).

This ensures that all perspectives are considered when resolving the causes of readmissions. Integrating an empathic communication approach aids in improving team interaction and collaboration. Team empathy is related to listening actively, comprehending, and acknowledging team members (Lobchuk et al., 2020). It leads to better teamwork, patient relations, and care practices.  Lastly, adopting a novel EHR- based departure readiness communication system allows staff to communicate about discharge and patient release readiness status and boosts team interaction in real time (Keniston et al., 2021). Adopting the MDT framework based on a team panel is ideal to increase cooperation. Ibrahim et al. (2022), evidence is credible since it validates the utility of team meeting, indicating that collaboration helps to improve care practice and resolve patient discharge issues.

Conclusion

Addressing patient readmission and discharge-related issues, efficient communication, and teamwork help to improve patient management and outcomes. Integrating tools and adopting standardized communication methods like the teach-back method can improve staff-patient communication, while team collaboration resolves patient discharge and readmission issues. Efficient leadership, such as the TL, Lewin Model, and MDT models, for collaborative teamwork is crucial to a positive workplace, addressing issues and boosting results.

References

Amina, A., Kassem, A., & Sleem, W. (2022). Applying Lewin’s change management theory to improve patient’s discharge plan. Mansoura Nursing Journal, 9(2), 335-348. https://doi.org/10.21608/mnj.2022.295591

Dunwoodie, K., Macaulay, L., & Newman, A. (2022). Qualitative interviewing in the field of work and organizational psychology: Benefits, challenges and guidelines for researchers and reviewers. Applied Psychology, 72(2), 863–889. https://doi.org/10.1111/apps.12414

Gledhill, K., Bucknall, T. K., Lannin, N. A., & Hanna, L. (2023). The role of collaborative decision‐making in discharge planning: Perspectives from patients, family members and health professionals. Journal of Clinical Nursing, 32(19-20), 7519-7529. https://doi.org/10.1111/jocn.16820

Capella FPX 4005 Assessment 2

Ibrahim, H., Harhara, T., Athar, S., Nair, S. C., & Kamour, A. M. (2022). Multi-disciplinary discharge coordination team to overcome discharge barriers and address the risk of delayed discharges. Risk Management and Healthcare Policy, 15, 141–149. https://doi.org/10.2147/rmhp.s347693

Keniston, A., McBeth, L., Sr, J. P., Bowden, K., Ball, S., Stoebner, K., Scherzberg, E., Moore, S. L., Nordhagen, J., Anthony, A., & Burden, M. (2021). Development and implementation of a multidisciplinary electronic discharge readiness tool: User-centered design approach. Journal of Medical Internet Research Human Factors, 8(2), e24038–e24038. https://doi.org/10.2196/24038

Lobchuk, M., Bell, A., Hoplock, L., & Lemoine, J. (2020). Interprofessional discharge team communication and empathy in discharge planning activities: A narrative review. Journal of Interprofessional Education & Practice, 23, 100393–100393. https://doi.org/10.1016/j.xjep.2020.100393

Nnate, D. A., Barber, D., & Abaraogu, U. O. (2021). Discharge plan to promote patient safety and shared decision making by a multidisciplinary team of healthcare professionals in a respiratory unit. Nursing Reports, 11(3), 590–599. https://doi.org/10.3390/nursrep11030056

Capella FPX 4005 Assessment 2

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

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Capella FPX 4005 Assessment 1

Name

Capella University

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

Prof. Name

Date

Collaboration and Leadership Reflection

Leadership is important for a collaborative healthcare environment. As a nurse, I have witnessed how effective leadership can enhance teamwork and improve patient outcomes. In this reflection, I will analyze my interprofessional collaboration experience and compare effective and ineffective leadership styles. 

Interdisciplinary Collaboration Experience

During my nursing practice, I collaborated with an interdisciplinary team—including a nurse, physician, dietitian, and social worker—to manage a patient with uncontrolled Type 2 Diabetes. Clear communication, shared decision-making, and a patient-centered method led to enhanced outcomes. However, scheduling conflicts and competing priorities delayed key interventions. Reflecting on this experience helped me analyze both strengths and challenges, reinforcing the importance of proactive coordination and effective communication. This reflection fosters growth, allowing me to adapt and lead in interprofessional settings, ensuring more cohesive teamwork and ultimately better patient outcomes.

Effective vs. Ineffective Leadership in Collaboration

Nursing leadership helps in teamwork, accountability, and patient-centered care. A good leader gives clear instructions, delegates properly, encourages subordinates, and makes the working environment pleasant. For instance, an active listener who addresses concerns and distributes tasks fairly is a charge nurse and an efficient and morale-boosting force in the workplace (Saxena, 2020). On the other hand, ineffective leadership results in confusion, low motivation, and poor patient care. If the supervisor is not good at communicating, does not listen to staff’s input, or does not give instructions, it can be stressful and inefficient. The main difference is adaptability, empathy, and commitment to collaboration, which lead to better patient care and team dynamics (Saxena, 2020).

Best-Practice Leadership Strategies

Interdisciplinary team best-practice leadership strategies involve effective communication, collaborative decision-making, and mutual respect. Transformational leadership helps people collaborate by inspiring and motivating the team to achieve common goals (Labrague & Obeidat, 2021). Conflict resolution and listening improve team cohesion, reducing misunderstandings and improving patient outcomes (Jankelová & Zuzana, 2021). Adopting these strategies allows for building a team that can provide high-quality, patient-centric care.

Best-Practice Interdisciplinary Collaboration Strategies

Interdisciplinary collaboration best practice covers open communication strategies, definite roles, and roles, as well as mutual respect among team members. Having regular team meetings helps establish a shared sense of decision-making and alignment in patient care goals (Lyng et al., 2022). Evidence-based tools such as SBAR (Situation, Background, Assessment, Recommendation) help in reducing communication errors (Adam et al., 2022). Building a psychology of safety encourages team members to present suggestions without fear of judgment. These strategies improve teamwork, patient outcomes, and health professionals’ job satisfaction.

Developing Leadership Style

A transformational leadership style supports best-practice strategies for developing motivation, collaboration, and innovation in interdisciplinary teams. Active participation in the team and leading by example with strong communication and ethical decision-making can be achieved. For example, taking leadership training workshops, seeking mentorship, and practicing active listening can enable one to inspire and lead others. A nurse can be more engaged by embracing transformational leadership, resulting in a high-performing, positive team focusing on patient-centered care and continuous improvement (Labrague & Obeidat, 2021).

Conclusion

Reflecting on my interdisciplinary collaboration experience has reinforced the importance of transformational leadership in healthcare. Nurses can drive meaningful change and improve patient outcomes by inspiring and empowering team members. Developing my leadership skills will allow me to contribute more effectively to patient-focused care.

References 

Adam, M. H., Ali, H. A., Koko, A., Ibrahim, M. F., Omar, R. S., Mahmoud, D. S., Mohammed, S. O. A., Ahmed, R. A., Habib, K. R., & Ali, D. Y. (2022). The use of the Situation, Background, Assessment, and Recommendation (SBAR) form as a tool for handoff communication in the pediatrics department in a Sudanese teaching hospital. Cureus, 14(11). https://doi.org/10.7759/cureus.31998 

Jankelová, N., & Zuzana, J. (2021). Communication skills and transformational leadership style of first-line nurse managers in relation to job satisfaction of nurses and moderators of this relationship. Healthcare, 9(3), 346. https://doi.org/10.3390/healthcare9030346 

Labrague, L. J., & Obeidat, A. A. (2021). Transformational leadership as a mediator between work-family conflict, nurse‐reported patient safety outcomes, and job engagement. Journal of Nursing Scholarship, 54(4), 493–500. https://doi.org/10.1111/jnu.12756 

Capella FPX 4005 Assessment 1

Lyng, H. B., Macrae, C., Guise, V., Driftland, C., Fagerdal, B., Schibevaag, L., & Wiig, S. (2022). Capacities for resilience in healthcare; A qualitative study across different healthcare contexts. Biomed Central Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07887-6 

Saxena, A. (2020). Challenges and success strategies for dyad leadership model in healthcare. Healthcare Management Forum, 34(3). https://doi.org/10.1177/0840470420961522 

NURS FPX 4005 Assessment 5

Name

Capella University

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

Prof. Name

Date

NURS FPX 4005 Assessment 4

Name

Capella University

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

Prof. Name

Date

DEI and Ethics in Stakeholder Presentation

Organizational Issue

At St. Paul Regional Health Center (SPRHC), delays in implementing an integrated diabetes education program have impacted patient adherence to self-management strategies. These delays stem from fragmented care coordination and inconsistent communication among interdisciplinary teams. Additionally, a lack of structured workflows for patient education further exacerbates the issue. The absence of real-time collaboration between primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists leads to misaligned treatment plans, ultimately creating gaps in diabetes management.

These inefficiencies contribute to poor glycemic control, increased hospital readmissions, and higher long-term healthcare costs. Furthermore, inadequate interdisciplinary coordination affects staff morale, as healthcare professionals struggle with unclear roles and ineffective workflows, leading to burnout. The reputation of SPRHC could also suffer, as ineffective diabetes management may deter future patients and hinder the hospital’s ability to attract top healthcare talent. According to Tandan et al. (2024), a systematic review and meta-analysis of team-based interventions in primary care showed significant reductions in systolic blood pressure, diastolic blood pressure, and HbA1C levels when multiple teamwork components were involved. These findings highlight the importance of a structured, interdisciplinary approach to improving diabetes management at SPRHC.

Importance of the Issue

Addressing gaps in diabetes education and interdisciplinary practice at SPRHC is crucial to providing high-quality, patient-centered care. Implementing a structured diabetes education program will enhance workflow efficiency by establishing standardized protocols, shared decision-making, and common electronic health record (EHR) templates. These changes will enable real-time treatment adjustments through weekly interdisciplinary rounds. Improved coordination among primary care providers, nurses, dietitians, pharmacists, and behavioral health professionals will optimize clinical outcomes while fostering a culture of teamwork.

Effective communication and minimized treatment variability will ensure that healthcare providers deliver evidence-based care while enhancing job satisfaction. This initiative aligns with SPRHC’s mission to provide comprehensive diabetes care, build patient trust, and encourage long-term patient engagement. Ultimately, these improvements will contribute to reduced hospital readmissions, decreased healthcare expenses, and enhanced organizational effectiveness, ensuring sustainable excellence in diabetes care.

Importance of an Interdisciplinary Team Approach

Improved care coordination among primary care providers, endocrinologists, diabetes educators, dietitians, pharmacists, and behavioral health professionals is critical to optimizing Type 2 diabetes care. A formalized interdisciplinary approach at SPRHC will include several key strategies:

1. Standardized Communication Protocols – The use of the SBAR (Situation, Background, Assessment, and Recommendation) framework for patient handoffs will enhance communication, ensuring that care plans are consistently followed and adjusted according to patient progress.
2. Real-Time Data Sharing and Integration – Integrating EHR systems with a dedicated diabetes management platform will allow healthcare providers to access real-time patient data, lab results, and medication adherence. This will enable immediate adjustments to treatment plans, ultimately improving glycemic control.
3. Collaborative Decision-Making and Care Pathways – Developing interdisciplinary care pathways, including personalized insulin management, lifestyle interventions, and behavioral support, will facilitate a seamless transition from diagnosis to long-term diabetes management, reducing complications such as neuropathy, nephropathy, and cardiovascular disease.
4. Training and Cross-Disciplinary Education – Ongoing training programs focusing on diabetes management, motivational interviewing techniques, and shared decision-making strategies will enhance collaboration among team members. Joint rounds and interdisciplinary workshops will strengthen communication, improve patient education, and support adherence to self-care behaviors.

Nurchis et al. (2022) found that interprofessional collaboration significantly improved patient satisfaction, psychological well-being, and self-care behaviors. By fostering interdisciplinary teamwork, SPRHC can enhance diabetes care outcomes, improve provider communication, and reduce patient complications.

Table Format Representation

References

American Diabetes Association (ADA). (2024). About diabetes. Diabetes.org. https://diabetes.org/about-diabetes

Colvin, C. L., Akinyelure, O. P., Rajan, M., Safford, M. M., Carson, A. P., Muntner, P., Colantonio, L. D., & Kern, L. M. (2023). Diabetes, gaps in care coordination, and preventable adverse events. The American Journal of Managed Care, 29(6), e162–e168. https://doi.org/10.37765/ajmc.2023.89374

Dhediya, R., Chadha, M., Bhattacharya, A. D., Godbole, S., & Godbole, S. (2022). Role of telemedicine in diabetes management. Journal of Diabetes Science and Technology, 17(3), 193229682210811. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10210114/

NURS FPX 4005 Assessment 4

Nurchis, M. C., Sessa, G., Pascucci, D., Sassano, M., Lombi, L., & Damiani, G. (2022). Interprofessional collaboration and diabetes management in primary care: A systematic review and meta-analysis of patient-reported outcomes. Journal of Personalized Medicine, 12(4). https://doi.org/10.3390/jpm12040643

Tamunobarafiri, G., Aderonke, J., Cosmos, C., None Mojeed Dayo Ajegbile, & None Samira Abdul. (2024). Integrating electronic health records systems across borders: Technical challenges and policy solutions. International Medical Science Research Journal, 4(7), 788–796. https://doi.org/10.51594/imsrj.v4i7.1357

Tandan, M., Dunlea, S., Cullen, W., & Bury, G. (2024). Teamwork and its impact on chronic disease clinical outcomes in primary care: A systematic review and meta-analysis. Public Health, 229, 88–115. https://doi.org/10.1016/j.puhe.2024.01.019

NURS FPX 4005 Assessment 3

Name

Capella University

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

Prof. Name

Date

Interdisciplinary Plan Proposal

Introduction

The increasing prevalence of Type 2 diabetes at St. Paul Regional Health Center necessitates a structured and interdisciplinary approach to patient education and care coordination. Many patients struggle with diabetes management due to a lack of education, inadequate nutritional guidance, and psychological barriers (Adhikari et al., 2021). To address these issues, this proposal suggests the implementation of a diabetes education program within the outpatient diabetes management department. This initiative will integrate an interdisciplinary team to enhance self-care behaviors, reduce complications, and improve long-term patient outcomes.

Objectives and Expected Outcomes

The primary objective of this program is to establish an interdisciplinary diabetes education initiative that involves primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists. This collaboration aims to enhance adherence to self-management strategies, ultimately improving glycemic control, reducing hospital readmissions, and lowering healthcare costs. Research highlights that an interdisciplinary approach leads to better patient outcomes and cost reductions in diabetes care (Nurchis et al., 2022).

Key questions guiding the program include assessing the impact of interdisciplinary collaboration on adherence to diabetes self-management and identifying barriers to implementation. It is expected that patient adherence to medication, diet, and exercise will increase by 20% within six months. Additionally, self-management improvements are anticipated to reduce diabetes-related hospital readmissions by 15% annually (Pugh et al., 2021). Despite potential initial resistance from both healthcare providers and patients, continued education and support will help integrate the program effectively. While the team may experience a 10% increase in workload, structured workflows are expected to enhance efficiency, leading to long-term cost savings and improved patient care (Haque et al., 2021).

Change Theories and Leadership Strategies

Kotter’s 8-step change model will guide the program’s implementation, focusing on creating urgency for better diabetes management, securing staff buy-in, and reinforcing the initiative’s importance through leadership support (Miles et al., 2023). Transformational leadership will be instrumental in motivating healthcare providers, fostering innovation, and encouraging collaboration. Open dialogue and shared decision-making will play a crucial role in ensuring continued team engagement and success (Ystaas et al., 2023).

Team Collaboration Strategy

The success of this program hinges on effective interdisciplinary collaboration. Primary care providers will assess patients, prescribe medications, and monitor progress, while nurses will educate patients, coordinate care, and serve as primary contacts. Dietitians will develop personalized meal plans, and behavioral health specialists will address emotional and psychological factors that impact diabetes management (Segal & Gunturu, 2024). Pharmacists will optimize medication regimens and educate patients on proper usage. Weekly interdisciplinary meetings will facilitate communication, ensuring cohesive care. Additionally, a shared electronic health record (EHR) system will support real-time data exchange, enhancing care coordination and reducing medication errors (Robertson et al., 2022).

Resource Requirements and Potential Impact

Implementing this program requires investments in staffing, training, and technology. Staff will need specialized training in diabetes education, motivational interviewing, and interdisciplinary collaboration (Ng et al., 2023). The program will require educational materials, blood glucose monitoring devices, and telehealth support for virtual consultations. An initial investment of $50,000 will cover training and technology setup, while long-term savings of approximately $100,000 annually are projected due to reduced hospitalizations and emergency visits. Collaboration with the hospital’s IT department will be necessary for EHR integration, and administrative approval will be required for budget allocation (Robertson et al., 2022).

Failure to implement this program may lead to ongoing patient non-adherence, increased hospital readmissions, and higher long-term healthcare costs. Without structured education and support, patients face greater risks of complications such as cardiovascular disease, kidney failure, and amputations—issues that significantly affect quality of life and healthcare expenditures (Nurchis et al., 2022). The proposed interdisciplinary diabetes education program presents a sustainable solution to improve patient care and alleviate the financial burden on St. Paul Regional Health Center.

Conclusion

This interdisciplinary diabetes education program aims to improve patient self-management, enhance collaboration among healthcare providers, and reduce healthcare costs. By integrating primary care providers, nurses, dietitians, pharmacists, and behavioral health specialists, the initiative will deliver patient-centered education and support. Over time, the program is expected to generate cost savings and contribute to better health outcomes for diabetes patients at St. Paul Regional Health Center.

NURS FPX 4005 Assessment 3

References

Adhikari, M., Devkota, H. R., & Cesuroglu, T. (2021). Barriers to and facilitators of diabetes self-management practices in Rupandehi, Nepal—multiple stakeholders’ perspective. BMC Public Health, 21(1). https://doi.org/10.1186/s12889-021-11308-4

Haque, W. Z., Demidowich, A. P., Sidhaye, A., Golden, S. H., & Zilbermint, M. (2021). The financial impact of an inpatient diabetes management service. Current Diabetes Reports, 21(2). https://doi.org/10.1007/s11892-020-01374-0

Miles, M. C., Richardson, K. M., Wolfe, R., Hairston, K., Cleveland, M., Kelly, C., Lippert, J., Mastandrea, N., & Pruitt, Z. (2023). Using Kotter’s change management framework to redesign departmental GME recruitment. Journal of Graduate Medical Education, 15(1), 98–104. https://pmc.ncbi.nlm.nih.gov/articles/PMC9934828/

NURS FPX 4005 Assessment 3

Ng, Y. K., Shah, N. M., Chen, T. F., Loganadan, N. K., Kong, S. H., Cheng, Y. Y., Sharifudin, S. S. M., & Chong, W. W. (2023). Impact of a training program on hospital pharmacists’ patient-centered communication attitudes and behaviors. Exploratory Research in Clinical and Social Pharmacy, 11, 100325. https://doi.org/10.1016/j.rcsop.2023.100325

Nurchis, M. C., Sessa, G., Pascucci, D., Sassano, M., Lombi, L., & Damiani, G. (2022). Interprofessional collaboration and diabetes management in primary care: A systematic review and meta-analysis of patient-reported outcomes. Journal of Personalized Medicine, 12(4). https://doi.org/10.3390/jpm12040643

Pugh, J., Penney, L. S., Noël, P. H., Neller, S., Mader, M., Finley, E. P., Lanham, H. J., & Leykum, L. (2021). Evidence-based processes to prevent readmissions. BioMed Central Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06193-x

NURS FPX 4005 Assessment 2

Name

Capella University

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

Prof. Name

Date

Interview and Interdisciplinary Issue Identification

Interview Summary

This report examines an interview with a charge nurse at St. Michael’s Medical Center to identify an organizational issue that would benefit from an interdisciplinary approach. The charge nurse, who has over five years of experience, highlighted communication breakdowns between nursing staff and physicians during emergency situations and patient handovers. These issues have resulted in care delays, confusion, and potential patient safety risks.

Previous efforts to address this problem included implementing a standardized handoff tool and conducting staff training sessions. However, adherence to these initiatives was inconsistent, and communication gaps persisted. While the organization fosters a supportive culture, healthcare professionals often work independently within their respective disciplines, contributing to fragmented communication. The interview underscored the need for an interdisciplinary solution, emphasizing the importance of structured communication frameworks and engagement strategies to enhance teamwork and patient safety.

The interview process utilized a semi-structured format, allowing for open-ended responses while maintaining a clear focus on key topics. Active listening techniques, such as paraphrasing and clarification, were employed to validate understanding and encourage deeper discussion (Slade & Sergent, 2023). The conversation provided valuable insights into the hospital’s communication challenges, interdisciplinary dynamics, and existing strategies, ultimately reinforcing the necessity of collaborative problem-solving.

Issue Identification

The primary issue identified in the interview is the communication breakdown between nurses and physicians, particularly during critical care interventions. Ineffective communication can lead to care delays, errors, and adverse patient outcomes. Addressing this challenge requires an interdisciplinary approach that fosters collaboration, enhances teamwork, and standardizes communication protocols. Research supports the implementation of structured handoff tools and teamwork training programs to improve communication and build trust among healthcare professionals (Eva et al., 2024).

A multidisciplinary engagement strategy can support the adoption of standardized communication frameworks, such as the SBAR (Situation, Background, Assessment, and Recommendation) tool, which has been shown to enhance clarity and efficiency in healthcare communication. Additionally, fostering a culture of continuous feedback and teamwork can promote sustainable improvements in communication practices (Simons et al., 2022). Implementing these strategies will create a cohesive environment where healthcare teams collaborate effectively, leading to improved patient care and overall hospital efficiency.

Change Theory and Leadership Strategies for an Interdisciplinary Solution

Kurt Lewin’s Change Theory provides a structured approach for addressing communication challenges in healthcare. This model includes three phases: unfreezing, changing, and refreezing (Smith et al., 2022). The unfreezing stage involves identifying communication gaps and educating staff on their impact. The changing phase introduces structured communication protocols and interdisciplinary training programs. Finally, the refreezing stage ensures long-term adherence to new practices through monitoring, feedback, and leadership reinforcement.

Transformational leadership plays a key role in fostering an environment conducive to change. Leaders who adopt a transformational approach inspire teamwork, promote open communication, and encourage continuous learning. By modeling effective communication behaviors and supporting team training initiatives, transformational leaders can drive improvements in interdisciplinary collaboration (Jankelová & Joniaková, 2021). Additionally, implementing frameworks like TeamSTEPPS can strengthen teamwork, clarify roles, and enhance communication efficiency (Hassan et al., 2024). These combined strategies will facilitate a lasting positive impact on interdisciplinary communication and patient care.

Table: Summary of Key Findings

Conclusion

Addressing communication breakdowns in healthcare requires a structured interdisciplinary approach. By applying Lewin’s Change Theory, transformational leadership strategies, and evidence-based frameworks like TeamSTEPPS, organizations can enhance teamwork, improve patient outcomes, and foster a culture of collaboration. Implementing standardized communication tools and continuous training programs will ensure sustainable improvements in healthcare communication and efficiency.

References

Eva, T. P., Afroze, R., & Sarker, M. A. R. (2024). The impact of leadership, communication, and teamwork practices on employee trust in the workplace. Management Dynamics in the Knowledge Economy, 12(3), 241–261. https://doi.org/10.2478/mdke-2024-0015

Hassan, A. E., Mohammed, F. A., Zakaria, A. M., & Ibrahim, I. A. (2024). Evaluating the effect of TeamSTEPPS on teamwork perceptions and patient safety culture among newly graduated nurses. BMC Nursing, 23(1). https://doi.org/10.1186/s12912-024-01850-y

Jankelová, N., & Joniaková, Z. (2021). Communication skills and transformational leadership style of first-line nurse managers in relation to job satisfaction of nurses and moderators of this relationship. Healthcare, 9(3), 346. https://doi.org/10.3390/healthcare9030346

NURS FPX 4005 Assessment 2

Simons, M., Goossensen, A., & Nies, H. (2022). Interventions fostering interdisciplinary and inter-organizational collaboration in health and social care; an integrative literature review. Journal of Interprofessional Education & Practice, 28(28), 100515. https://doi.org/10.1016/j.xjep.2022.100515

Slade, S., & Sergent, S. R. (2023). Interview techniques. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526083/

Smith, T. G., Norasi, H., Herbst, K. M., Kendrick, M. L., Curry, T. B., Grantcharov, T. P., Palter, V. N., Hallbeck, M. S., & Cleary, S. P. (2022). Creating a practical transformational change management model for novel artificial intelligence–enabled technology implementation in the operating room. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 6(6), 584–596. https://doi.org/10.1016/j.mayocpiqo.2022.09.004

NURS FPX 4005 Assessment 1

Name

Capella University

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

Prof. Name

Date

Collaboration and Leadership Reflection

Interdisciplinary Collaboration Experience

Transformational leadership plays a crucial role in fostering a collaborative healthcare environment. In my nursing practice, I participated in an interdisciplinary team focused on reducing medication errors and enhancing patient safety through structured communication among nurses, physicians, and pharmacists. One major challenge our team encountered was ensuring accurate medication reconciliation, which was hindered by inconsistent Electronic Health Record (EHR) documentation. To address this issue, our nursing team implemented team huddles at the start of each shift to discuss medication orders and ensure alignment among all professionals.

A shared documentation process was established to provide real-time updates in the EHR, promoting transparency and reducing errors. Open communication and mutual respect among team members fostered a sense of collaboration and shared responsibility. However, resistance to change was evident, particularly among staff accustomed to traditional workflows. Some nurses expressed frustration due to delays in updating medication orders. Implementing a structured change management approach with clearer role definitions and additional training on the new documentation process could have alleviated these challenges and enhanced collaboration.

Effective vs. Ineffective Leadership in Collaboration

Leadership plays a vital role in guiding interdisciplinary teams and influencing collaboration outcomes. In my experience, I observed two contrasting leadership styles: transformational and transactional. Transformational leadership encouraged open dialogue, innovation, and shared decision-making, fostering a positive and collaborative work environment (Mekonnen & Bayissa, 2023). Leaders using this approach motivated team members, promoted trust, and facilitated problem-solving through collective engagement. Conversely, transactional leadership, which prioritizes task completion, hierarchical control, and immediate issue resolution, was less effective in promoting interdisciplinary teamwork. This rigid approach often led to punitive measures rather than empowerment, resulting in resistance and disengagement from team members.

Transformational leadership proved more beneficial in ensuring sustained improvements, as it enhanced team engagement and adaptability. In contrast, the transactional approach contributed to frustration and limited collaboration due to its emphasis on maintaining strict structures. Encouraging transformational leadership in healthcare can lead to better teamwork, innovation, and improved patient outcomes.

Best-Practice Leadership and Collaboration Strategies

To strengthen interdisciplinary collaboration, transformational leadership principles should be implemented through various strategies. One key approach is fostering a shared vision, where leaders clearly communicate organizational goals to enhance engagement among team members (Liu et al., 2022). Another important strategy is promoting continuous professional development, including mentorship programs and leadership training, which equip nurses with the skills needed to lead and collaborate effectively (Shen & Tucker, 2024).

In addition, structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) can enhance interdisciplinary coordination by standardizing communication and reducing errors. Regular interdisciplinary meetings and technology-driven collaboration, such as integrated EHR systems, facilitate real-time data sharing and alignment of care plans (Calduch et al., 2021). Developing these best practices will foster a more efficient and cooperative healthcare environment.

Table: Leadership Styles and Strategies in Healthcare Collaboration

Conclusion

Reflecting on my interdisciplinary collaboration experience has reinforced the importance of transformational leadership in healthcare. Effective leadership fosters teamwork, communication, and patient-centered care. By adopting transformational leadership strategies such as shared vision, mentorship, and structured communication, healthcare professionals can enhance collaboration and improve patient outcomes. As I continue to develop my leadership skills, I aim to promote interdisciplinary teamwork, advocate for team-based decision-making, and contribute to a more collaborative healthcare environment.

References

Calduch, E., Muscat, N., Krishnamurthy, R. S., & Ortiz, D. (2021). Technological progress in electronic health record system optimization: Systematic review of systematic literature reviews. International Journal of Medical Informatics, 152(1), 104507. https://doi.org/10.1016/j.ijmedinf.2021.104507

Liu, M., Zhang, P., Zhu, Y., & Li, Y. (2022). How and when does visionary leadership promote followers’ taking charge? The roles of inclusion of leader in self and future orientation. Psychology Research and Behavior Management, 15(2), 1917–1929. https://doi.org/10.2147/PRBM.S366939

Mekonnen, M., & Bayissa, Z. (2023). The effect of transformational and transactional leadership styles on organizational readiness for change among health professionals. SAGE Open Nursing, 9(9). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10336755/

NURS FPX 4005 Assessment 1

Samardzic, M., Doekhie, K. D., & Wijngaarden, J. D. H. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(2), 1–42. https://doi.org/10.1186/s12960-019-0411-3

Shen, Q., & Tucker, S. (2024). Fostering leadership development and growth of nurse leaders: Experiences from Midwest Nursing Research Society Leadership Academy. Nursing Outlook, 72(6), 102293. https://doi.org/10.1016/j.outlook.2024.102293