Think back to your most recent time in the clinical setting when another discipline (respiratory, physical therapy, nutrition, occupational therapy) was utilized.
Describe a form of interdisciplinary collaborative care you’ve seen on your current assigned clinical or work site. Then have a discussion about the following questions:
- Who coordinated that care? What was the nurse’s role in ascertaining that the care was provided?
- Was the patient’s outcome met? How or why not? What would you, a novice nurse-leader, have done differently to achieve the patient’s goals?
One page or less
Let’s imagine a scenario in which an interdisciplinary collaborative care approach was utilized for a patient:
Scenario: Patient: Mr. Smith, a 65-year-old man with chronic obstructive pulmonary disease (COPD).
Interdisciplinary Team:
- Respiratory Therapist
- Physical Therapist
- Registered Dietitian
- Occupational Therapist
- Nurse
Coordination of Care: The coordination of care for Mr. Smith was overseen by the nurse, who served as the primary point of contact for the patient and their family. The nurse assessed Mr. Smith’s condition, communicated with the interdisciplinary team members, and ensured that each discipline’s recommendations and interventions were aligned with the patient’s goals and needs.
Roles and Contributions:
- Respiratory Therapist: Assisted with managing Mr. Smith’s COPD, provided breathing treatments, and assessed his lung function regularly.
- Physical Therapist: Developed an exercise plan to improve Mr. Smith’s mobility and lung function, including breathing exercises and walking routines.
- Registered Dietitian: Assessed Mr. Smith’s nutritional needs and developed a dietary plan to help manage his weight and improve his overall health.
- Occupational Therapist: Evaluated Mr. Smith’s ability to perform activities of daily living (ADLs) and provided interventions to improve his independence in self-care tasks.
- Nurse: Coordinated care, administered medications, monitored vital signs, and provided education to Mr. Smith and his family about COPD management and self-care.
Patient’s Outcome: Mr. Smith’s outcome was positive in this scenario. With the collaborative care provided by the interdisciplinary team and the nurse’s coordination, he experienced improved lung function, increased mobility, better nutritional status, and enhanced independence in ADLs. His COPD symptoms were better managed, leading to an improved quality of life.
Discussion: As a novice nurse-leader, there are a few things I might consider to further enhance patient care:
- Enhanced Communication: I would ensure that communication between team members is seamless and timely, facilitating regular team meetings to discuss the patient’s progress and adjust the care plan as needed.
- Patient and Family Education: I would emphasize the importance of patient and family education, ensuring that they fully understand the nature of COPD, the treatment plan, and the importance of adherence to medications and therapies.
- Goal Setting: I would work closely with the interdisciplinary team to establish clear, measurable goals for Mr. Smith, regularly assessing progress and adjusting interventions to meet those goals.
- Emotional Support: Recognizing the emotional impact of chronic illnesses, I would ensure that Mr. Smith and his family receive emotional support, potentially involving a social worker or counselor if needed.
By focusing on these aspects, I would aim to further improve the patient’s experience and outcomes in a collaborative care setting.