Name
Capella University
NURS-FPX4005 Nursing Leadership: Focusing on People, Processes, and Organizations
Prof. Name
Date
Emily Carter is the head of the Emergency Department (ED) at Riverside Community Hospital (RCH), a 542-bed facility specializing in advanced medical care. She had over nine years of leadership experience in her role. She supervises clinical operations, staff management, and regulatory compliance. In a recent interview, Carter highlighted a concerning trend: a rise in readmissions among patients with Coronary Artery Disease (CAD), driven by gaps in communication between staff and patients during discharge. This trend has damaged patient satisfaction metrics and the hospital’s financial performance. Although the hospital previously attempted to update the discharge process by improving scheduling. The initiative fell short due to the absence of organized protocols.
Effective interventions, including discharge education and leadership-supported follow-up calls, are ineffective due to low compliance. Carter noted that despite a collaborative culture, departments tend to operate in isolation. She emphasized the need for Interdisciplinary Rounds (IDRs) and the Situation, Background, Assessment, and Recommendation (SBAR) method to bridge communication gaps. IDRs facilitate real-time collaboration among care providers. It enables unified discharge planning, early identification of patient needs, and consistent messaging across units. It lowers the risk of readmission (Jeemon et al., 2023).
A semi-structured interview approach was employed. It enables in-depth, open-ended dialogue while ensuring that critical topics are carefully examined. The participant was presented with guiding questions such as: What impact does poor discharge communication have on readmissions and patient outcomes? How can leadership support collaboration to decrease avoidable readmissions?”, and What role do standardized communication tools play in enhancing discharge efficacy? These encouraged views on systemic challenges within the setting. The interviewee revealed that unsystematic discharge processes result in suboptimal patient outcomes. She emphasized that these lapses compromise the steadiness of care, strain hospital operations, and affect institutional performance.
Elevated rates of ED readmissions among patients with CAD have appeared as a persistent concern at RCH. It demands evidence-based approaches. This challenge stems from inadequate communication between staff and patients during the discharge process. Gaps in discharge-related discussion compromise patient safety. It contributes to uncoordinated changes of care. Unexpected readmissions are an indicator of diminished care quality. It led to increased costs, morbidity, and erosion of public confidence in the health system (Omonaiye et al., 2024). A team-based approach to discharge planning is vital for mitigating this issue.
Active participation from nurses, physicians, pharmacists, case managers, administrative staff, and patients is critical in formulating customized post-discharge care plans. Implementing joint discharge approaches enhanced adherence to care regimens and decreased readmissions in cardiac surgery patients from 11.6% to 0% (Rahpeima et al., 2022). The integration of Electronic Health Records (EHRs) and communication tools, such as SBAR, streamlined the exchange of data among the team. Strategies such as IDR and collaborative decision-making enhance team-patient engagement, post-discharge compliance (Rehm et al., 2021). Strengthening communication at RCH optimizes discharge workflows and improves patient outcomes.
Lewin’s change management theory offers an outline that supports nurses and healthcare leaders in initiating, executing, and sustaining change. The theory comprises three core phases. It includes unfreezing, changing, and refreezing. It provides a systematic approach to address organizational challenges (Harrison et al., 2021). This model is effective for addressing discharge-related communication gaps at RCH. It enables the growth of an improvement plan. In the unfreezing stage, leadership can cultivate awareness among clinical staff about the need to enhance discharge communication to reduce readmissions. This involves challenging existing norms and nurturing readiness for change. The change phase focuses on executing interventions, including SBAR, organized discharge summaries, and IDRs to facilitate consistent data exchange.
Discharge summaries are an essential communication mechanism that strengthens patient safety, continuity of care, and supports efficient care transitions (Omonaiye et al., 2024). The refreezing phase supports the newly established practices through monitoring, data-driven feedback loops, periodic audits, and strong leadership engagement. This embeds changes into daily routines. The credibility of Omonaiye et al. (2024) findings is published in a reputable, peer-reviewed journal. It strengthens the validity of applying Lewin’s model. Their evidence underlines the impact of discharge communication on reducing readmissions.
The Democratic leadership presents an approach for addressing the rise in patient readmissions linked to inadequate discharge communication. Democratic leadership nurtures a culture of innovation, shared purpose, and active collaboration among interprofessional teams. This leadership approach empowers staff to address challenges such as poor post-discharge compliance and uncoordinated care transitions by fostering solution-focused teamwork. Democratic leadership supports open communication and improvement by encouraging staff to prioritize patient safety and clinical excellence (Olatoye et al., 2024). This emphasizes the importance of clear role delegation, cohesive teamwork, and shared responsibility in optimizing discharge procedures. By inspiring team members to work toward reducing readmissions, democratic leadership strengthens engagement and enhances care quality. The study by
Olatoye et al. (2024) published in a reputable peer-reviewed journal, validating the role of leadership in improving patient outcomes.
The reduction of elevated readmission rates among CAD patients centers on multidisciplinary collaboration to resolve discharge-related communication failures. Implementing the Collaborative Care Model (CCM) rooted in interdisciplinary discharge planning, strengthens coordination across teams. This integrated team comprises cardiologists, physicians, pharmacists, dietitians, nursing personnel, and social workers. They work to streamline transitions of care (Jeemon et al., 2023). The model promotes mutual understanding and synergistic communication between providers and patients.
It enhances treatment adherence. Democratic leadership supports active engagement by cultivating a team-centered culture that encourages regular interaction among diverse experts. This is operationalized through team huddles or multidisciplinary meetings. It fosters mutual accountability and shared decision-making (Olatoye et al., 2024).Structured communication outlines such as I-PASS and SBAR strengthen clarity and define team responsibilities. These tools, proven effective in clinical education and coordination, enhance partnership and drive progress in care delivery (McLellan et al., 2024).
The use of Electronic Discharge Communication Tools (EDCTs) reinforces coordination by streamlining data exchange. These digital platforms enhance patient-centered communication, support post-discharge follow-up, and reduce ED returns (Rehm et al., 2021). Employing a structured discharge model nurtures interprofessional synergy and enhances care transitions. The evidence presented by Rahpeima et al. (2022), a credible peer-reviewed source, confirms the efficiency of collaborative discharge planning in improving patient adherence and reducing hospital readmissions.
The persistent issue of readmissions among CAD patients at RCH highlights the urgent need for improved discharge communication. The integration of strategies such as SBAR, I-PASS, and IDRs promotes collaboration and streamlines patient transitions. Applying Lewin’s change theory safeguards a sustainable execution process. Democratic leadership inspires teamwork and accountability. These combined approaches support patient-centered care, enhance compliance, and reduce the frequency of unplanned hospital returns.
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
Jeemon, Bahuleyan, Javaregowda, Punnoose, E., Rajendiran, Unni, G., Abdullakutty, Balakrishnan, J., Joseph, J., & Gnanaraj. (2023). Team based collaborative care model, facilitated by mHealth enabled and trained nurses, for management of heart failure with reduced ejection fraction in India (TIME-HF): Design and rationale of a parallel group, open label, multi-centric cluster randomised controlled trial. Wellcome Open Research, 8. https://doi.org/10.12688/wellcomeopenres.19196.2
McLellan, M. C., Irshad, M., Penny, K. C., Rufo, M., Atwood, S., Dacey, H., Ireland, C. M., de Ferranti, S., Saia, T., Fisk, A. C., & Saleeb, S. F. (2024). Enhanced safety and efficiency of ambulatory cardiology admissions: A quality improvement initiative. Pediatric Quality & Safety, 9(3), e726. https://doi.org/10.1097/pq9.0000000000000726
Olatoye, F. O., Elufioye, O. A., Okoye, C., Nwankwo, E., & Olakunle, J. (2024). Leadership styles and their impact on healthcare management effectiveness: A review. International Journal of Science and Research Archive, 11(1), 2022–2032. https://doi.org/10.30574/ijsra.2024.11.1.0271
Omonaiye, O., Stockham, K., Darzins, P., Kitt, C., Newnham, E., Taylor, N. F., & Considine, J. (2024). Hospital discharge processes: Insights from patients, caregivers, and staff in an Australian healthcare setting. Public Library of Science ONE, 19(9), e0308042. https://doi.org/10.1371/journal.pone.0308042
Rahpeima, E., Bijani, M., Karimi, S., Alkame, A., & Dehghan, A. (2022). Effect of the Implementation of interdisciplinary discharge planning on treatment adherence and readmission in patients undergoing coronary artery angioplasty. Investigación Y Educación En Enfermería, 40(2). https://doi.org/10.17533/udea.iee.v40n2e08
Rehm, C., Zoller, R., Schenk, A., Müller, N., Nerschbach, N., Zenker, S., & Schindler, E. (2021). Evaluation of a paper-based checklist versus an electronic handover tool based on the Situation Background Assessment Recommendation (SBAR) concept in patients after surgery for congenital heart disease. Journal of Clinical Medicine, 10(24), 5724. https://doi.org/10.3390/jcm10245724
