Advocating for the Nursing Role in Program Design and Implementation: Interview Transcript Example (Heart Failure Transitional Care Program)

Advocating for the Nursing Role in Program Design and Implementation

As their names imply, the honeyguide bird and the honey badger both share an affinity for honey. Honeyguide birds specialize in finding beehives but struggle to access the honey within. Honey badgers are well-equipped to raid beehives but cannot always find them. However, these two honey-loving species have learned to collaborate on an effective means to meet their objectives. The honeyguide bird guides honey badgers to newly discovered hives. Once the honey badger has ransacked the hive, the honeyguide bird safely enters to enjoy the leftover honey.

Much like honeyguide birds and honey badgers, nurses and health professionals from other specialty areas can—and should—collaborate to design effective programs. Nurses bring specialties to the table that make them natural partners to professionals with different specialties. When nurses take the requisite leadership in becoming involved throughout the healthcare system, these partnerships can better design and deliver highly effective programs that meet objectives.

In this Assignment, you will practice this type of leadership by advocating for a healthcare program. Equally as important, you will advocate for a collaborative role of the nurse in the design and implementation of this program. To do this, assume you are preparing to be interviewed by a professional organization/publication regarding your thoughts on the role of the nurse in the design and implementation of new healthcare programs.

The Assignment (2–4 pages): In a 2- to 4-page paper, create an interview transcript of your responses to the following interview questions:

• Tell us about a healthcare program, within your practice. What are the costs and projected outcomes of this program?
• Who is your target population?
• What is the role of the nurse in providing input for the design of this healthcare program? Can you provide examples?
• What is your role as an advocate for your target population for this healthcare program? Do you have input into design decisions? How else do you impact design?
• What is the role of the nurse in healthcare program implementation? How does this role vary between design and implementation of healthcare programs? Can you provide examples?
• Who are the members of a healthcare team that you believe are most needed to implement a program? Can you explain why?

Original example for study purposes (about 1,200 words, roughly four double-spaced pages). Program details and costs are illustrative; use your own practice information.

Interviewer: Tell us about a healthcare program within your practice. What are the costs and projected outcomes?

Nurse: Our hospital is launching a nurse-led heart failure transitional care program to reduce avoidable readmissions. Heart failure is one of the most common reasons older adults return to the hospital within 30 days, and Medicare’s Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions, so the issue affects both patients and the organization’s finances (Short, 2022). The program includes standardized heart failure education before discharge using teach-back, a scheduled follow-up appointment within seven days, a nurse phone call within 48 to 72 hours, two home or telehealth visits in the first month, and remote weight monitoring with a scale that transmits daily weights to the care team.

The projected first-year cost is about $310,000. This includes two full-time heart failure nurse navigators, part-time pharmacist time for medication reconciliation, telemonitoring equipment and data plans, and staff education. Our projected outcomes are a 20% relative reduction in 30-day heart failure readmissions, follow-up visits within seven days for at least 85% of patients, improved patient knowledge scores on a validated heart failure self-care tool, and higher patient satisfaction. Systematic reviews have found that nurse home visits and multidisciplinary heart failure clinics reduce readmissions and mortality (Van Spall et al., 2017). If we prevent roughly 40 readmissions a year, at an average cost of more than $10,000 each, the program would offset much of its cost while improving patients’ quality of life.

Interviewer: Who is your target population?

Nurse: Our target population is adults admitted with heart failure, especially those 65 and older with Medicare coverage, multiple chronic conditions, limited health literacy or limited social support. We also focus on patients who live in neighborhoods with limited access to transportation and healthy food, because social determinants such as housing, income and access to care strongly influence whether patients can follow a low-sodium diet, weigh themselves daily and keep appointments (Yelpaala et al., 2025). Family caregivers are a secondary target population because they often manage medications and recognize early warning signs.

Interviewer: What is the role of the nurse in providing input for the design of this program? Can you give examples?

Nurse: Nurses spend more time with patients than any other professionals, so they see the practical barriers that policy documents can miss. In the design phase, nurses on our planning committee reviewed readmission data and conducted chart reviews that showed most readmitted patients had not weighed themselves at home or did not understand their diuretic instructions. That finding shaped the decision to include scales and teach-back education. Staff nurses also tested the discharge education materials with patients and rewrote them at a sixth-grade reading level with pictures. Another example is workflow design: nurses identified that discharge teaching was often rushed at the end of a shift, so the program moved education to begin on admission day. Policy analysis models emphasize defining the problem accurately and evaluating options before choosing a solution (Short, 2022), and nurses’ clinical data were essential to defining the problem correctly.

Interviewer: What is your role as an advocate for your target population? Do you have input into design decisions?

Nurse: My role is to make sure the program is designed around what patients actually need, not only what is convenient for the organization. I serve on the design committee, so I have a direct voice in decisions. For example, I advocated for offering telehealth visits for patients who lack transportation and for providing scales at no cost, because patients with limited income might otherwise go without. I also impact design by bringing patient stories and data to leadership, collecting feedback from patients and caregivers, and connecting the program to community partners such as Area Agencies on Aging and meal programs. Beyond my organization, I can advocate for policies that support transitional care, such as reimbursement for remote monitoring and transitional care management services, through professional organizations such as the American Nurses Association, which supports nurses’ involvement in federal advocacy (American Nurses Association [ANA], n.d.).

Interviewer: What is the role of the nurse in program implementation, and how does it differ from design?

Nurse: In design, the nurse’s role is mostly strategic: identifying needs, contributing evidence and shaping the program. In implementation, the role becomes operational and relational: delivering the intervention, training colleagues, solving problems and monitoring results. For example, our nurse navigators enroll patients, provide education, make follow-up calls and respond to weight alerts by contacting the provider for diuretic adjustments. Unit nurses complete the standardized teaching, and nurse educators train staff on teach-back.

Implementation also requires judgment. Frontline professionals, sometimes called street-level bureaucrats, adapt policies to real situations and therefore shape how programs work in practice (Macena & De Oliveira, 2022). When nurses noticed that some patients did not have reliable phone service, they adapted the program by using text messages and coordinating with home health agencies. Implementation also includes measuring results. Nurses collect process data, such as education completion and follow-up rates, and outcome data, such as readmissions, and they participate in Plan-Do-Study-Act cycles to improve the program. Innovation in health organizations often fails because of implementation barriers such as staff workload and resistance to change (Rauner & Stummer, 2024), so nurse leadership during implementation is critical.

Interviewer: Who are the members of the healthcare team most needed to implement a program, and why?

Nurse: Several team members are essential. Nurse navigators and staff nurses deliver education, coordinate transitions and monitor patients. Cardiologists, hospitalists and nurse practitioners adjust treatment and see patients at follow-up visits. Pharmacists reconcile medications and help patients afford them, since medication errors and cost are common causes of readmission. Dietitians teach sodium and fluid management. Social workers and case managers address transportation, insurance, home support and other social needs. Information technology and data analysts support telemonitoring and outcome tracking, which is increasingly important as health innovation relies on data (Yelpaala et al., 2025). Finally, hospital leaders secure funding and remove barriers. Like the honeyguide bird and the honey badger, each team member contributes a strength the others lack, and the program succeeds only when they work together toward the shared goal of keeping patients healthy at home.

References

American Nurses Association. (n.d.). Federal advocacy. https://www.nursingworld.org/practice-policy/advocacy/

Macena, A., & De Oliveira, V. E. (2022). Discretion and local health policy implementation: Street-level bureaucrats and integrative and complementary therapies in Santos’ local health units. Primary Health Care Research and Development, 23, e12. https://doi.org/10.1017/S1463423622000172

Rauner, Y., & Stummer, H. (2024). Challenges of innovation management in health system organizations: Evidence from Germany. International Journal of Healthcare Management, 1–12. https://doi.org/10.1080/20479700.2024.2424702

Short, N. M. (2022). Milstead’s health policy and politics: A nurse’s guide (7th ed.). Jones & Bartlett Learning.

Van Spall, H. G. C., Rahman, T., Mytton, O., Ramasundarahettige, C., Ibrahim, Q., Kabali, C., Coppens, M., Haynes, R. B., & Connolly, S. (2017). Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: A systematic review and network meta-analysis. European Journal of Heart Failure, 19(11), 1427–1443. https://doi.org/10.1002/ejhf.765

Yelpaala, K., Gibbons, M. C., Vigil, I. M., Leaño, J., McCall, T., Opara, I., Zink, A., Nunez-Smith, M., Mukherjee, B., & Ranney, M. (2025). The role of data in public health and health innovation: Perspectives on social determinants of health, community-based data approaches, and AI. Journal of Medical Internet Research, 27, e78794. https://doi.org/10.2196/78794