NURS FPX 4005 Assessment 2 Interview and Interdisciplinary Issue Identification

Interview and Interdisciplinary Issue Identification

Student Name

Capella University

NURS-FPX4005

Professor Name

Submission Date

Working as a team helps to enable transition of care, especially inter-professional, or when referrals are made to other sources. Cultivate inter-professional working to improve communication, decrease waiting times, and improve outcomes for patients. However, when an interdisciplinary team is formed, it requires measures to foster teamwork and ensure everyone is on the same page, as well as for patients’ care to remain continuous as they need to transition from one provider to another. The effectiveness of communication techniques and tools that facilitate communication among healthcare teams, decrease delays, and enhance the quality of healthcare will be assessed.

Interview Summary

During the interview, I discovered that one of the challenges relating to the transition of care is the move of the patients from the hospital departments to the outside care management facilities (Khatri et al., 2023). To do this kind of work, one must first be interviewed in order to coordinate the patients, essentially supervise the nursing staff, and finally, ensure adequate communication between the nursing staff.

 Poor communication leads to delays in medical response, inactivity, and dissatisfaction of the patient, according to the charge nurse. It did have electronic health records (EHRs) and had had training for communication, although staff were not always appropriately following the new procedures, and there were no follow-up supervision sessions.

Working as a team is part of a challenge and a key element of Riverstone Medical Center, but it’s hard every day, and it’s done anyway. There is potential for less teamwork outside of meetings and work, as leaders enable interactions between the teams. They outlined the multidisciplinary nature of healthcare professionals and case managers, and how they can work together to create and implement individual plans to better serve patients with multiple health conditions. But there isn’t any linking between these endeavors to make a whole system. During the interview, serious flaws in care coordination were identified, along with the need to have more structured team-based processes to facilitate care and outcomes.

Issue Identification

During my interview with the nurse in the Riverstone Medical Center, I discovered that coordination of scheduling and communication between various departments, as well as setting up a move to another health care facility, could be very difficult. In those situations, the problems encountered result in communication problems and a delay of medical aid. All healthcare providers need to be able to work and coordinate care with each other to ensure the patient is cared for in a seamless manner.

With a team working together, they can then make sure that the medical and rehabilitative needs are all coordinated within a single care plan, reducing care gaps (Phillips et al., 2020). Some of the improvements are providers not making mistakes when communicating, increased collaboration and saving of resources, as well as coordination and planning of patient care during transitions.

Change Theories That Could Lead to an Interdisciplinary Solution

Challenges associated with service transitions, inter-service coordination, and patient care handoff from the clinic are readily addressed using Lewin’s Change Theory. According to Silvola et al. (2024), the model focuses on three steps: unfreezing, changing, and refreezing. To begin, an organization must document the challenges of patient information sharing, the delays of patient handoff, and the barriers to patient care transition protocols.

As described by Silvola et al. (2024), during the changing phase, barriers to communication are addressed, and inter-sectoral teams are convened to create documentation that can be easily accessed by all members of the health care team. These methods are designed to improve the ease of transition and the collaboration and coordination across multiple sectors.

In the refreezing stage, the focus shifts to the sustainability of the gains. Employees are regularly trained, and the policies are updated to reflect the new practices. As noted by Campbell et al. (2020), this model is beneficial to managers and has been employed to varying degrees to improve service delivery and patient outcomes. The application of this model will improve the patient experience during the relocation of the Riverstone Medical Center to the new site.

Leadership Strategies That Could Lead to an Interdisciplinary Solution

According to Simons et al (2022), Collaborative Leadership is a viable way to engage all departments to support each other and coordinate the care of a patient when they are transitioning or being referred to other services. Team-based care is about having everyone on the team involved and allows health care providers to trust and communicate with each other.

Ensuring nurses, doctors, case managers, and rehab providers work as a team will enable leadership to assist in developing seamless handoffs between each team. Having a pre-established patient sharing plan and standardized processes and interfaces between the teams facilitates a better combination of different types of knowledge and reduces the risk of errors and delays in patient care (Craig et al., 2020). Care and support from the various healthcare providers is coordinated, allowing care for patients from the beginning to the end of their healthcare journey.

Collaborative leadership provides a system for transitions with the patient experience at the forefront. Implementation of such an approach will help tackle intermittent communication and ambiguous referral systems, expand the capacities of the center, and consequently improve outcomes for patients (Simons et al., 2022).

These methods promote collaboration and reduce mistakes when moving to and out of care, according to evidence. Silva et al. (2022) reported that collaborative assistance helps to develop the labor force and thus contributes to satisfaction in the workplace, which leads to providing systematic, organized care. A collaborative and accountable management structure will enable the organization to continue to improve care and people’s satisfaction with the services.

Collaboration Approaches for Interdisciplinary Teams

Multidisciplinary collaboration – coordination of care between departments/referral to external services – should be based upon good practice. Some of the important strategies include the implementation of a communication policy, the availability of information to all team members, and the sharing of decisions within the team and in a smooth manner with all providers. When healthcare professionals are working closely together, they can easily share with each other to help set goals and to help make a smooth transition without delay and miscommunication.

The use of EHRs, having standard ways to hand over care and regular meetings that involve various specialists, all aid in communicating key patient information and preventing care problems (Chance et al., 2024). Additionally, patient/family involvement in the transition can help ensure care is more individualized to the patient. They tackle key issues in care coordination and streamline the transition process to be smoother and more effective.

They have proven to be effective and have helped to enhance communication, prevent medical errors, and provide better patient satisfaction (Chance et al., 2024). Interdisciplinary collaboration is said to increase the levels of care continuity and patient safety in organisations that support it (Heip et al., 2020).

Additionally, these sorts of systems enable health care providers to build the expertise needed with teamwork and ultimately come up with an enhanced system that may be handed on to a different staff. With these best practices, Riverstone Medical Center can create a system of care that will ensure patients can seamlessly transition between different care settings and that the team can collaborate and enjoy better outcomes.

Conclusion

Collaborative leadership, communication, and teamwork should be utilized to address care transitions at Riverstone Medical Center. Staff working together to make the decisions and standardization in the approach to connecting patient records together can foster better collaboration, quicker care, and seamless transitions for patients, following the principles of Lewin’s Change Theory.

For the 3rd (next) assessment of this class, NURS-4005 visit: NURS FPX 4005 Assessment 3