Running head: INTRODUCTION AND OUTLINE
Introduction and Outline
Reducing Psychiatric Readmissions Using Self-Efficacy
Amy Taylor
Indiana University School of Nursing: IUPUI
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INTRODUCTION AND OUTLINE
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Reducing Psychiatric Readmissions Using Self-Efficacy
Introduction
Patients diagnosed with psychiatric illnesses often struggle to survive in our
communities. They find themselves often in jail or committed to psychiatric hospitals or in acute
care psychiatric wards. There are many factors that are in play as to why these patients are
finding themselves unable to achieve success once discharged from psychiatric hospitals. These
factors include a wide array of variables. According to Rylander (2016), they include the
disorder itself, comorbidity medical, psychiatric and substance abuse disorders, marital status,
gender, financial stability, support after discharge and community resource availability.
Almost thirteen percent of these patients are readmitted after discharge from acute care
(Akerele, 2017). While there is not a hard fast rule how long acute care can last it typically lasts
three to five days or up to a week. By contrast, an inpatient psychiatric admission is involuntary
and it is court ordered for 90 days. A patient does not have to complete the full 90 days and it is
common that commitments are continued. A quick look at these numbers and one could argue
that the patients need to be hospitalized longer. However, there has been a trend in healthcare to
decrease centralized services for psychiatric services as well as a trend to deinstitutionalize
patients in psychiatric settings (Rylander, 2016). Centralized services occur in a controlled
setting like an institution. The total care is taken upon the institution for the patient and little
contact with real world. While there were good intentions with these trends, it has led to a
decrease in beds available to this population as well as a trend to minimize stays.
In the advent of healthcare reform, there has already been a push to limit readmissions to
acute care medical hospitals. While psychiatric hospitals have not been looked at to deny funds
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for care, there is reason for concern for these facilities. According to Hamilton, et al (2015) these
rates “have been viewed as important indicators for health care planning due to their connection
to the quality and continuity of care for patients as well as the high costs associated with
additional inpatient care,” (572). The Joint Commission has been the accrediting agency used by
all hospitals. They set standards and quality indicators for acute care hospitals as well psychiatric
services. The Joint Commission set forth seven quality indicators for psychiatric services. Four
of these quality indicators involve discharge from the facility. Two of these indicators involve
post-discharge measures as well. They are “postdischarge continuity of plan created and
postdischarge continuity of care plan transmitted to next level provider,” as cited by Rylander, et
al. (2016).
While there have been studies to determine the factors that lead to readmission of these
patients, there has not been definitive evidence. The studies have differed by diagnosis, severity
of disease, post-care psychiatric care, and quality of inpatient care. One study showed that
although many factors are present in readmission, lack of engagement in treatment postdischarge was a firm predictor of readmission (Hamilton, 2015). A systemic literature review
performed by Vigod, et al (2013) revealed that the need for interventions to address postdischarge and bridging to community that are effective can reduce readmission rates. The focus
seems to need to be on the patient post-discharge and whether the patient can be successful living
in a community setting. One study found that costs could be reduced with transitional care by
reducing costs by almost $200 per subject (Moradi-Lakeh, 2017). While these costs may seem
trivial it can drastically improve the intangibles of life for the patient as well as the community.
Another study showed that with case management readmission rates could be dropped by about
20% (Kolbasovksy, 2009). Moreover, the need for transitional care can be found, according to
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Hanrahan, et al (2015) that 30% to 50% of clients relapse within 30 days of discharge and are
readmitted and 48% use emergency room services at a high rate.
Purpose
There are several factors which can lead to a patient’s readmission to psychiatric
hospital. These factors include medication noncompliance, treatment noncompliance, poor
support system, quality of inpatient care and financial difficulties. As one study purported that
fewer than half of psychiatric patients are engaged with post-discharge services prior to being
readmitted to psychiatric hospital. Furthermore, studies have found that patients not attending
appointments post-discharge have a greater chance of readmission. How can these factors be
improved?
One approach for improvement can be determined through theory and study. There are
several nursing theories but the theory of self-efficacy appears to be the most fitting for
improving transitional care for these patients. Self-efficacy theory was born from social
cognitive theory and is based on a triad of person, behavior and environment. The triad are
causative in nature in that they have an effect on the other. This theory is defined as a person’s
belief that they can complete a specific task. The purpose of this paper is to enlist transitional
care for psychiatric patients to adjust and maintain community living after discharge from
inpatient hospitalization.
Self-Efficacy Usage
Self-efficacy is a middle-range theory that discusses how a person uses their judgments
of themselves to gauge that they are capable of completing a specific task. (Bijl, 2002). There are
four components of self-efficacy. Performance accomplishments refers to what a person can
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accomplish and has accomplished. This refers to what a patient believes about themselves and
the likelihood that they will be successful in a task. Vicarious experience is described as how the
patient sees others accomplish a task. In short, it can be described as role-modeling. The patient
is looking at others to see how well they are accomplishing a specific task. Giving the patient
instructions and advice in order to help them accomplish task is verbal persuasion. Lastly, how
the body and mind react to a task is the physiological information.
Utilizing the four components of self-efficacy, can aid in reduction of readmission in
psychiatric patients. A patient must believe that they can be successful in discharge and living in
the community. The transitional team is to be a source of support and encouragement for the
patient. The patient should see that others are living successfully in community as well as healthy
role-modeling by those caring for them. Transitional care can be included to peer support as well
as coping skills used by transitional team. Giving the patient advice and instructions can be
easily obtained through transitional care for the patient. As life is unpredictable, being able to
assist patient in times of question and/or crisis as a resource to the community would be
valuable. Lastly, if the patient continues to have success their body and mind will continue a
healthy path which imparts physiological information. The biofeedback received will be positive
on the mind and body. The theory of self-efficacy is ready made for use with a transitional team
to reduce psychiatric readmissions. As Resnick (2017) described that self-efficacy has been used
for patient self-management. Self-management is the goal of the transitional team: the patient
takes care of themselves with medications, treatments, appointments, healthy lifestyle and caring
for self when triggers or stressors arise with healthy coping skills.
Literature Review
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A search was conducted with articles limited from 2009 to present. The need to go further
into research was the need to include articles with the most extensive research. The databases
that were searched included CINAHL, PubMed, Medline, and PsychINFO. There were several
keywords used in this search. They included psychiatric readmission, costs of psychiatric
readmission, transitional care, telemental care, continuity of care, assertive case management,
psychiatric transition, psychiatric discharge planning, reducing psychiatric readmission, and
psychiatric hospitalization.
As Hengartner (2015) pointed out the duration of psychiatric hospitalization has been
decreased so the need for a strong pre- and post-discharge plan with effective transition into
community is imperative. It is further addressed that transitional care does not occur in a vacuum
and that this population usually has limited social networks as well as being stereotyped.
(Hengartner, 2015). A pilot study conducted in Switzerland, used a program that used contact
with patients with a nurse that they had met and worked with prior to discharge. (Hegedus,
2018). Initial indications showed that there was improvement in patient’s lives who participated
in coping with obstacles. (Hegedus, 2018). Another study showed that patient who were
provided with care management were less likely to be readmitted within 30 days of discharge
(Taylor, 2016).
A study conducted with review of discharged patients with case management showed a
significant difference in care and keeping down healthcare costs. There were 347 individuals in
the baseline group. This baseline group received normal discharge procedure which included an
aftercare appointment scheduled within seven days of discharge as well as a staff member to
follow up that appointment was kept or to assist in rescheduling missed appointment. The case
management group consisted of 307 individuals. In addition to baseline group’s discharge
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interventions there was ongoing monitoring of symptoms and medication compliance, continuing
education with support system, barrier management identification and management and links to
community resources. According to Kolbasovksy (2009), the intervention cost was in staffing to
be about $41.39 per individual. A stark finding in this study showed that 101 members of
baseline group were readmitted within 30 days as opposed to 26 members of the case
management group, according to Kolbasovksy (2009). The dollars saved also translated into a
savings of $1528.91 per member in the case management group (Kolbasovksy, 2009).
The studies used to date have been limiting in their sampling size. However, one concept
rang loud throughout the review is that the quality of transitional care was paramount. Successful
discharge for mentally ill patients not only benefits the individual and the family but their
community. As a nurse, the goal for this patient population is make informed decisions and
support their efforts to maintain healthy and well lives. Nurses encourage self-efficacy for our
patients as well as being their support and advocate. The mentally ill deserve the case
management that many chronic medical patients receive at discharge from acute care medical
hospitals.
Self-Efficacy in Depth
Self-efficacy was founded by Albert Bandura as part of his Social Cognitive Theory.
Self-efficacy has a “triadic reciprocal causation model in which behavior of a person, the
characteristics of that person and the environment within which the behavior is performed, are
constantly interacting (Bijl, 3). It can be defined as a person’s belief that they can complete a
task. To expand further, “the expectation of a personal mastery (efficacy expectations or selfefficacy) and success (outcome expectations) determines whether an individual will engage in
particular behavior (Bijl, 3).
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There are four main components of self-efficacy theory. They are performance
accomplishments, vicarious experience, verbal persuasion, and physiological information.
Performance accomplishment is what a person can accomplish and has accomplished. This
component fits the saying “practice, practice, practice.” As described by Bijl (2001), people who
have high self-efficacy do not allow failure to consume them. They look at in terms of what went
wrong and that it is not a failure of them. Those with low self-efficacy will tend to believe that
failures are because of them and that they are not capable of succeeding. This component is the
most influential.
Vicarious experience is seeing how others have accomplished a task. This is a type of
role-modeling. Those who do not have much experience or concerns about their capabilities will
look to others that are similar to them to see who they handle a behavior or situation. This a
weaker source of self-efficacy but “can contribute to a person’s judgement of his own selfefficacy,” as described by Bijl (2001, 5).
The third component of verbal persuasion is the most used and easiest source of selfefficacy. This includes giving instructions and advice to a person to encourage their
accomplishment of a task. However, it is not without risk. According to Bijl, “credibility,
expertise, trustworthiness and prestige of the person doing the persuasion” is paramount (2001,
5). The drawback of this component is that a person still must go into the task as believing that
the can successfully accomplish the task. This component cannot be used by itself to instill selfefficacy.
Last is the physiological information component. This component is how the body and
mind react to the completion of the task. This is easily defined as a stress can have a negative
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impact upon their self-efficacy. In particular, Bijl (2001) explained, “what persons believe about
their illness and how they interpret symptoms influences the self-efficacy to deal with illness.”
This is the most subjective of the components.
Other researchers have expanded upon Bandura’s theory and added additional
components that can be sources for self-efficacy. These include environmental factors, selfesteem, individual’s ability, the task itself and external environment. To look deeper into these,
there is the depth of control that a person feels that they can exert over the task. The complexity
of the task plays a role as well. The mood that person has can affect their self-efficacy. Lastly,
the person looks how often the task will change due to environment and circumstances.
The clinical problem of this paper is to use transitional care team as a method to reduce
psychiatric readmissions within 30 days. The theory is being applied by looking at the
discharging patient’s self-efficacy as the catalyst to a successful discharge. Throughout the
hospitalization it is assumed that the treatment team and programming is driven to increase the
patient’s self-efficacy. The purpose of the transitional care team is to provide a bridge of support
as the patient transitions back into the community and a real-world environment.
The transitional team would consist of a nurse, therapist and social worker. The
discharging provider will be available for consultation from the transitional team. The whole
load will not be on one person but a rotating contact basis with patient. As needs or crisis arise,
the correct member can be notified and consulted. While verbal persuasion will be the most used
component in this model of care, it is also present to assist with the other three components to
enhance a person’s self-efficacy.
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A drawback of using this theory is that it has many assumptions. One assumption is that a
person can have the capability to be successful in managing the task. Mentally ill can have
diminished capacity for this whether from traumatic brain injury, substance abuse or lower
functioning intelligence. While this does not mean the theory cannot be used, it means that there
must be more care and attention brought to task that are assigned and expected for the patient.
Another assumption is that the choices that a person make will actually increase their selfefficacy and increase their health. Lastly, the patients need to feel and accept the responsibility
that they are in charge and have the skills necessary to complete the tasks that enable them to
successfully live in the community.
As Bijl (2001) described that self-efficacy and how it can affect on psycho-social
functioning: “choice behavior or selection process,” “effort expenditure…or motivational
processes, “thought processes or cognitive processes,” and “emotional affects or affective
processes.” (7-8). These act as a predictor as to how a patient will respond and react and
therefore affect their outcome expectations. Self-efficacy is the basis for “how people think, feel,
motivate themselves, and act”, as stated by Bijl (2001, 7).
The use of transitional care will be able to assess these aspects and adjust for the patient as
needed. With each successful completion of task or day in the community, the patient will build
upon their own performance accomplishments. Patients will be living in a community and
interacting with others with mental illness and see their successful accomplishments. The
transitional care will give verbal persuasion to enhance the self-efficacy. The patient will
incorporate the successful completion of tasks into their mind and build upon those successes. It
is taking one step at a time and handling life as it comes along with a support team. The patient
has to take the responsibility for successful tasks completions such as keeping appointments,
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staying sober, attending support groups, filling their day with a routine, and taking their
medication. The transitional care can support the patient as they gain self-efficacy.
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References
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