Theory description and evaluation paper
Hospital readmission is defined as the admission of a patient within a specified time after discharge. In most cases, readmissions are in-patient admissions that occur within 30 days after discharge from a healthcare facility. Patient readmissions have been linked to several negative outcomes, including increased mortality rates; several studies have suggested that in-patient mortality rates are higher among re-admitted patients compared to those who are not re-admitted. Readmission is also associated with the increased cost of health care services; readmission leads to longer hospital stays and expenditure of more health resources, which lead to higher costs for the care services. It is estimated that hospital readmissions cost about $26 billion annually. Hospital readmissions can be prevented by appropriate case management during the care process (Banerjee et al., 2021).
Case management is a process that involves facilitating collaboration to assess, plan, implement, monitor, and evaluate the health interventions necessary to meet the health needs of a patient. The case manager assesses the various options available for the patient and recommends the most suitable options to ensure the delivery of quality care services with minimal financial implications. Hospital readmissions are affected by the environmental factors within the health care, and these factors can be controlled or manipulated through the case management process. To explore these factors, Bronfenbrenner’s social-ecological model theory would be appropriate. The theory focuses on external factors that influence the development of children and can be applied to nursing practice to evaluate how hospital readmissions can be prevented using the theory (Hertler et al., 2018). This paper will specifically assess the application of Bronfenbrenner’s social-ecological model theory in case management to reduce hospital readmission rates.
Bronfenbrenner’s ecological systems theory was developed by Urie Bronfenbrenner, who was critical of the theories that then explained child development. He believed that the theories were ecologically invalid, and the laboratory features of previous research that contributed to the development of other theories on child development were not representative of the actual environment that a child grew up in. He looked beyond individual development and included other ecological factors that he believed interacted with the child and affected the child’s development. He then developed the theory based on the environment’s interactions with child development. His theory holds that individuals encounter different environments throughout their lifespan, affecting the way they behave in different situations. Bronfenbrenner proposed that a child’s environment comprises nested structure arrangement where each structure is contained within the next. He then described the structures depending on their impact on a child’s development (Guy-Evans, 2020).
The microsystem is the first structure, and it includes things that are in direct contact with the child. This comprises relationships with parents, siblings, peers, and other relatives. The microsystem directly influences the child, and the child can also influence the beliefs and attitudes of others in the microsystem. The mesosystem is the second system, and it involves interactions between the different components in the microsystem, but they affect the child’s development. An example is an interaction between a parent and teacher, if their interaction is positive, the child will be positively impacted, and if it is negative, the child will experience the negative impact. The exosystem includes informal and social structures that indirectly affect the child (Hertler et al., 2018). For example, the work environment can impact the parent’s mood and therefore affect the relationship with the child. The macrosystem focuses on the cultural elements, including socioeconomic status, and how they impact the child’s development. Hospital readmissions can be affected by the macrosystem, and the exosystem of a patient, since components such as socioeconomic factors and hospital environment influence the prevalence of disease and general quality of care services (Tan et al., 2020).
Application to Research
Bronfenbrenner’s social-ecological theory has been extensively used in research. Huang et al. (2021) used the theory to assess the influence of social interactions on adult preferences for palliative care and life-sustaining treatments. The researchers specifically explored the importance of professional support in the community, culture, social interactions, and determinants of adult preferences for palliative care and life-sustaining treatments. Four levels of societal influence were selected, including cultural, interpersonal, community, and intrapersonal. The researchers used these concepts to determine their influence on patient preferences regarding life-sustaining treatments and palliative care. Intrapersonal and interpersonal concepts included fear of death, personal attributes, and knowledge about existing services and support. The community concept included community support resources, and cultural influence involved adherence to cultural values.
Adu & Oudshoorn (2020) utilized Bronfenbrenner’s theory to propose a process that can be used to deinstitutionalize psychiatric services in Ghana and transition to community-based mental healthcare. Deinstitutionalization was defined as a policy initiative that aimed at closing the current large mental health institutions to establish alternative institutions in the community. Four concepts were identified microsystem, mesosystem, macrosystem, and exosystem. The microsystem was defined as the innermost ecological level where the patient resides. Mesosystem was identified as comprising associative relationships between the patient and other factors in the microsystem. These relationships affect the psychosocial well-being of the patients. The exosystem includes the neighborhood, external family, community resources, and mass media. All these factors affect the psychosocial well-being of a patient. Macrosystems included political environment, cultural belief systems, health policies, and economic systems. While the macrosystems are far from the patients, they affect their daily activities and, therefore, are essential in the mental well-being of the patients.
Application to Practice
Hospital readmissions are a common occurrence in the healthcare industry. They are, however, associated with poor patient outcomes, such as higher mortality rates among re-admitted patients, and they also impose a significant economic burden on patients and healthcare providers in general. The causes for hospital readmission can be grouped in different ecological systems identified by Bronfenbrenner. Some of the concepts that will be of interest in hospital readmission include microsystem, mesosystem, and macrosystem (Tan et al., 2020). Microsystem, in this case, will be defined as patients’ immediate interactions and relationships with those surrounding them, which are important in providing basic care assistance after they are discharged from the healthcare facilities. For example, the availability of care providers at home ensures that discharge instructions and prescriptions are followed, therefore minimizing readmissions (Guy-Evans, 2020).
The mesosystem will include relationships between healthcare providers and the patients’ support system. Patient education is required to include patients’ immediate support system to ensure that discharge instructions are followed. When necessary, good relationships between healthcare providers and support providers can facilitate consultations, which is crucial in preventing readmissions for most patients. The macrosystem will be defined as the cultural factors that influence the health beliefs and practices adopted by the patients once they are discharged. The levels of the ecological system identified by this theory can be used in case management to identify factors that affect collaboration between care providers and those factors that lead to frequent hospital readmissions. For example, macrosystem concepts can be used to assess predictors that a patient will be re-admitted (Tan et al., 2020). Based on the theory’s proposition, some of the questions include the influence of cultural and environmental factors on a patient’s health and the likelihood of being re-admitted to a healthcare facility. What is the impact of patient education on readmission rates among patients who have undergone major surgeries? (Hertler et al., 2018).
Bronfenbrenner’s social-ecological theory has been tested empirically by several researchers and is valid and accurate. For example, Lippard et al. (2018) examined children’s experiences in the classroom, specifically the interpersonal interactions between teachers and children and their impact on classroom behavior and academic achievement of the children. The social-ecological theory holds that these interactions uniquely impact children’s development and performance. The researchers showed that the relationship and the interaction were congruent with classroom behavior and the children’s academic achievements. This suggests that the relationships are essential and therefore supports Bronfenbrenner’s social-ecological theory. Erickson et al. (2018) assessed their use in public mental health research and their contribution to public mental health practices and policies. The researchers established that the use of the theory has resulted in the development of the most useful recommendations that guide public mental health practice and policies.
While the theory was primarily formulated to explain child development and ecological factors affecting development, the theory is generalizable to other phenomena. Its framework can be used to guide research in areas that involve behavioral changes. For example, the theory can be used in mental health and health promotion to understand why individuals adopt specific health behaviors and explain the impact of the environment and culture on individuals (Hertler et al., 2018).
Some of the theory’s strengths include its wide application; this theory is not limited to application in children. It can be used in diverse settings, including the corporate world, classrooms, and healthcare settings. It provides a clear breakdown of the ecological factors, which allows for easy formulation and implementation of interventions. However, some of the weaknesses are that testing the theory empirically is usually a challenge since it is hard to determine that observed outcomes were due to the application of the theory. It can also cause assumptions that those without positive ecological systems lack in development; however, this can be misleading since some people lacking are well-developed (Guy-Evans, 2020).
The theory agrees with some of the nursing standards, interventions, and therapeutics. The theory holds that individuals encounter different environments, affecting how they behave and eventually leading to specific positive or negative outcomes. Some of the nursing interventions, such as health promotion, aim to create a positive environment by creating awareness to drive behavioral change. The nursing standards and intervention aim to influence one of the systems outlined in theory, and therefore they are congruent (Tan et al., 2020).
The theory holds some social and cross-cultural relevance and can explain some of the occurrences, for example, the negative behavior in some members of the society in poor environments or good conduct among individuals with good social backgrounds. However, in some cases, the theory lacks relevance and cannot explain the observations. For example, when people from good social backgrounds exhibit negative behaviors (Hertler et al., 2018).
The theory can be used in nursing to explain the factors that affect behavior among different age groups or cultures, including health behaviors. Using the theory framework develop interventions that address specific environmental factors to cause a behavior change. For example, the theory can be applied to design the most effective interventions in health promotion (Tan et al., 2020).
Hospital readmissions are a major concern in the healthcare industry due to the poor patient outcomes and the financial burden they impose on the industry. Bronfenbrenner’s social-ecological model theory can be used to assess the factors that contribute to hospital readmissions and therefore be used to guide case managers. The theory outlines ecological systems that influence the child’s development throughout life. By replacing the child with a patient, the theory can be used to assess how different factors interact and affect a patient’s health from sickness to full recovery. Therefore, the theory would be useful to case managers as they coordinate different players to ensure patients’ full recovery and prevent hospital readmissions.
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