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Difficulty: MediumCollaboration with Interdisciplinary Team

An elderly client who recently stabilized following an acute exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for transfer to a subacute rehabilitation center. The client's family is actively resisting the transfer, exhibiting hostility toward the unit staff, and refusing to sign the necessary transition documents. Which of the following is the most appropriate action for the primary nurse to take?

  1. Coordinating a structured interprofessional meeting with the case manager and attending provider to address the family's concerns regarding the transition of care.Answer
  2. B
    Telling the family members they are required to accept the transfer because acute care beds must be reserved for unstable patients.
  3. C
    Instructing the unlicensed assistive personnel (UAP) to review the discharge teaching materials with the family to alleviate their anxiety.
  4. D
    Delaying the assessment of the client's newly reported chest discomfort to ensure the facility transfer paperwork is completed on time.

Answer

Coordinating a structured interprofessional meeting with the case manager and attending provider to address the family's concerns regarding the transition of care.
Complex discharge barriers involving significant family resistance require a collaborative, interdisciplinary approach. Bringing together the case manager, the attending provider, and the primary nurse provides a united front to comprehensively address the family's anxieties, answer medical and logistical questions, and formulate a mutually agreeable transition plan.

Step-by-Step Solution

1
Identify the primary clinical problem in the scenario.
The family is exhibiting severe anxiety and hostility, creating a barrier to a safe and timely discharge transition.
Recognizing the root cause of the barrier dictates the appropriate intervention.
2
Evaluate the nursing scope of practice and interdisciplinary resources.
The nurse recognizes that resolving complex discharge disputes requires expertise in facility placement, medical stability, and direct patient care.
No single discipline has all the information needed to fully reassure an anxious family during a complex transition.
3
Select the intervention that best utilizes the healthcare team.
A coordinated interprofessional meeting is selected.
This allows the provider to explain medical readiness, the case manager to explain facility resources, and the nurse to address daily care, providing a united and comprehensive approach.

Key Concept

Interdisciplinary Collaboration in Transition of Care
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Topics

Collaboration with Interdisciplinary Team

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