Introduction
The care of patients undergoing surgery or complex medical-surgical treatment is inherently clinical, yet it is deeply embedded within broader social contexts that shape the experience, trajectory, and outcome of recovery. Surgical interventions are often conceptualized as purely biomedical events; however, recovery does not occur in isolation from patients’ social environments, cultural beliefs, and resource availability. The success of surgical recovery thus depends not only on physiological stabilization but also on patients’ capacity to navigate social challenges that influence adherence, rehabilitation, and emotional well-being. This intersection underscores the need to move beyond the reductionist view of surgery as a purely technical endeavor and instead to view it as a biopsychosocial process in which clinical care and social determinants are intertwined.
Traditional perioperative and postoperative nursing emphasizes physiological stabilization, wound care management, infection prevention, mobilization, pain management, and monitoring of vital signs. These dimensions remain fundamental; however, emerging research consistently demonstrates that these clinical efforts may be undermined if patients face social vulnerabilities that restrict their ability to follow medical instructions or access postoperative care. Social determinants of health—including socioeconomic status, educational attainment, social support, health literacy, employment conditions, and accessibility of community resources—moderate the relationship between medical care and recovery outcomes. For instance, patients with low income or limited family support may experience delayed wound healing due to nutritional deficiencies, poor follow-up compliance, or increased psychological stress. Consequently, postoperative complications often reflect not merely physiological risks but also embedded social inequities.
Understanding how these social variables interact with clinical care therefore demands a bridging of social science theory and healthcare practice. Theoretical frameworks from sociology and behavioral sciences—such as structural functionalism, social capital theory, and the social ecological model—provide explanatory tools to analyze how individual recovery is shaped by relational and structural factors. Social capital theory, for example, highlights how interpersonal trust and support networks can enhance resilience and adherence during recovery, whereas the social ecological model emphasizes the multilevel nature of influences spanning individual, interpersonal, institutional, and community contexts. When nurses incorporate these theoretical perspectives, clinical decision-making can evolve toward a more holistic understanding of recovery that transcends the biomedical paradigm.
Global surgery initiatives further emphasize that millions of people worldwide lack access to safe, timely, and affordable surgical care, not solely because of clinical or infrastructural deficits but because of persistent social inequities, policy gaps, and structural barriers [1]. These barriers manifest through disparities in transportation, financial protection, health insurance, and cultural acceptability of surgical procedures. In this sense, the “social determinants of health” (SDOH) framework provides an essential conceptual foundation for understanding how non-medical factors profoundly influence surgical outcomes [2]. The SDOH perspective urges clinicians and policymakers to recognize that health inequities are socially produced and thus require interventions that address upstream causes rather than solely downstream symptoms.
In surgical populations specifically, empirical evidence indicates that socioeconomic deprivation, low educational attainment, and limited social support are associated with higher rates of postoperative complications, longer hospital stays, delayed wound healing, and increased readmission rates [3,4]. These associations persist even after controlling for comorbidities and surgical complexity, suggesting that social disadvantage exerts an independent effect on recovery trajectories. Moreover, psychosocial stress, limited health literacy, and social isolation can impair self-efficacy, adherence to rehabilitation protocols, and motivation for lifestyle changes, further compounding clinical vulnerability.
Despite growing awareness of these issues, most surgical care protocols worldwide continue to focus narrowly on physiological and procedural indicators, often neglecting social risk screening, socioeconomic assessment, or culturally informed interventions. This absence of sociocultural consideration represents a critical gap in comprehensive perioperative nursing. In many health systems, particularly in low- and middle-income settings, the integration of social risk assessment into nursing care remains minimal, often due to institutional constraints, time pressures, or lack of training. However, medical-surgical nurses occupy a unique position within the healthcare continuum—they are the primary coordinators of continuity of care, patient education, emotional support, and discharge planning. This proximity to patients situates nurses as the most strategically placed professionals to identify social vulnerabilities early and advocate for interdisciplinary collaboration with social workers, nutritionists, or community health agents.
From a social science perspective, integrating frameworks such as social capital theory, social network analysis, and patient empowerment models can substantially enhance the effectiveness of medical-surgical nursing. Social network analysis, for instance, enables understanding of how patients’ interpersonal connections influence adherence to postoperative regimens and how health professionals themselves form collaborative networks that shape the flow of care. Patient empowerment models, on the other hand, highlight the significance of self-efficacy and agency in recovery, proposing that surgical success depends as much on patients’ perceived control and understanding as on technical surgical quality. These frameworks offer conceptual and methodological tools for developing more responsive, equity-oriented, and socially attuned care strategies.
Building upon these theoretical underpinnings, this study aims to investigate the association between social determinants and surgical patient outcomes in a medical-surgical ward, while also exploring nurses’ and patients’ perspectives on the feasibility of integrating social science approaches into clinical care. The dual emphasis—quantitative analysis of social predictors and qualitative exploration of lived experiences—reflects a pragmatic recognition that recovery is both a measurable outcome and a human process influenced by social meaning and interaction. We hypothesize that (1) social disadvantage, as reflected by lower income, limited education, or weak social support, will predict worse recovery outcomes, and (2) nurses’ and patients’ insights will illuminate contextually appropriate strategies for embedding social risk–informed care into daily nursing practice. The findings are expected to contribute to the theoretical enrichment of medical-surgical nursing, the development of interdisciplinary frameworks linking clinical and social sciences, and the design of equitable care models that acknowledge the patient not merely as a biological organism but as a socially situated individual.
Methods
Design
This study employed a convergent mixed-methods design, integrating quantitative and qualitative approaches to provide a comprehensive understanding of how social determinants affect the outcomes of patients treated in medical-surgical wards. The use of a mixed-methods design was grounded in the principle of methodological complementarity, which allows for the triangulation of numerical and experiential data to enhance validity and deepen interpretation of the findings. The quantitative component used a retrospective cohort design to identify statistical relationships between social variables and clinical outcomes, while the qualitative component involved semi-structured interviews to capture the nuanced perspectives and lived experiences of both patients and nurses. Data collection and analysis were conducted concurrently, and results were integrated during the interpretation phase to ensure a holistic understanding of the phenomena under study.
Setting and Sample
The study was conducted in a tertiary-level referral hospital that serves as a major center for surgical and medical care. The hospital provides comprehensive surgical services and represents a diverse population with varied socioeconomic and cultural backgrounds.
For the quantitative arm, the sample included 120 adult patients (aged ≥18 years) who were admitted to medical-surgical wards and underwent major elective surgery during a 12-month observation period. This period was selected to capture seasonal variation in admission and recovery patterns. Inclusion criteria consisted of adult inpatients who had complete medical and sociodemographic data available in the electronic health records. Patients who underwent emergency surgery, were admitted directly from intensive care units, or had incomplete data were excluded to minimize bias and ensure comparability. Sample size taken from Undata Hospital since january until november 2024,
The qualitative component comprised 20 participants, including 10 registered nurses with at least two years of experience in medical-surgical wards and 10 postoperative patients who had recovered sufficiently to participate in interviews. A purposive sampling technique was used to achieve variation in participants’ social backgrounds, educational attainment, and occupational contexts. This heterogeneity was intended to enrich thematic diversity and provide insights that reflect multiple social strata and care-giving perspectives within the ward environment.
Variables and Measures
Quantitative Variables
The quantitative data set included both independent social variables and dependent clinical outcomes, with additional covariates used for statistical control.
Social variables: These included income level (self-reported and categorized into three strata), educational attainment (total years of formal education), household social support (assessed using a validated 10-point Likert scale measuring perceived instrumental and emotional support), and health literacy, evaluated with a validated instrument such as the Short Test of Functional Health Literacy in Adults (S-TOFHLA). These variables were chosen to reflect core domains of the social determinants of health framework that influence patient recovery.
Clinical outcomes: Outcome variables included length of hospital stay (measured in days from surgery to discharge), postoperative complications (binary variable, coded 1 = presence, 0 = absence, based on standardized clinical documentation), and 30-day readmission (binary indicator reflecting unplanned readmission for the same condition within 30 days of discharge).
Covariates: To control for potential confounders, demographic and clinical variables such as age, sex, comorbidity index (Charlson Comorbidity Index), and surgical category (general, orthopedic, cardiovascular, etc.) were included in the regression models.
Qualitative Data
The qualitative strand aimed to elucidate how social circumstances shape patients’ recovery experiences and how nurses integrate social awareness into care delivery. Semi-structured interviews were guided by an interview protocol consisting of open-ended questions exploring:
Perceived social and environmental barriers to recovery;
Strategies used by nurses to address patients’ social challenges;
Communication issues between staff, patients, and families;
The effectiveness of discharge planning; and
Recommendations for incorporating social risk assessment into routine nursing practice.
Interviews were conducted in a quiet, private room within the hospital to ensure confidentiality and minimize distractions. Each interview lasted approximately 40–60 minutes and was audio-recorded with participants’ permission. Field notes were taken to capture contextual observations and non-verbal cues. Data saturation was reached when no new codes emerged from subsequent interviews.
Analysis
Quantitative Analysis
Quantitative data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics (means, standard deviations, frequencies) were calculated for all variables. Group differences were examined using chi-square or ANovA tests as appropriate. To assess the independent effect of social determinants on outcomes, multivariate regression analyses were conducted: linear regression for continuous outcomes (length of stay) and binary logistic regression for categorical outcomes (complications and readmissions). All models were adjusted for covariates to mitigate confounding. Statistical significance was defined as p < 0.05. Multicollinearity was checked using the Variance Inflation Factor (VIF), and residual analyses were performed to confirm model adequacy.
Qualitative Analysis
Audio recordings were transcribed verbatim and analyzed using thematic content analysis supported by NVivo software (QSR International). Data coding followed an iterative process: initial open coding to identify emergent concepts, axial coding to group related categories, and selective coding to develop overarching themes. Coding reliability was ensured through independent verification by two researchers, with discrepancies resolved through discussion. Reflexive memos were used throughout the process to ensure transparency and reduce interpretive bias.
Data Integration
Following separate analyses, findings were integrated using a joint display approach. Quantitative results provided the empirical patterns of association, while qualitative findings offered contextual explanations. Integration occurred during interpretation to synthesize complementary evidence—highlighting how social disadvantage manifests in measurable health outcomes and in lived patient experiences.
Ethical Considerations
Ethical approval was obtained from the Institutional Review Board (IRB) of the participating hospital prior to data collection in Palu with number EC/7823/P/01/2024. All procedures complied with the principles of the Declaration of Helsinki and relevant national ethical regulations. Informed consent was obtained from all participants in both study arms. Quantitative data were anonymized at the source, and qualitative recordings were stored in password-protected digital files accessible only to the research team. Participants were informed of their right to withdraw at any time without consequences to their care.
Results
Quantitative Findings
The quantitative analysis provides a comprehensive overview of patient characteristics stratified by income level, as summarized in Table 1. Distinct patterns emerge across social strata that highlight the multifaceted relationship between socioeconomic conditions and clinical recovery outcomes in surgical care.
Table 1
Patient Characteristics by Income Stratum
Patients from lower income groups demonstrated significantly lower educational attainment, weaker social support, and poorer health literacy compared with middle- and high-income counterparts (p < 0.001 for all comparisons). These gradients suggest that socioeconomic position is not only a financial marker but also a proxy for accumulated social and cognitive resources that influence recovery behaviors, comprehension of care instructions, and adherence to treatment regimens.
The mean age and sex distribution did not differ significantly among groups (p > 0.80), indicating that the observed disparities in outcomes are not confounded by demographic imbalance. However, the steep gradient in education and health literacy scores underscores how social disadvantage translates into limited capacity to understand complex medical information, navigate hospital systems, and comply with postoperative self-care requirements.
The regression analysis (Table 2) further elucidates the independent effects of each social determinant on clinical outcomes. After adjusting for demographic and clinical covariates (age, sex, comorbidity, and type of surgery), income, education, social support, and health literacy remained statistically significant predictors of both length of hospital stay and postoperative complications.
Table 2
Multivariate Regression of Social Determinants on Outcomes
Patients with low income stayed an average of 2.4 days longer than those in the high-income group (β = +2.4, p = 0.004) and had more than twice the odds of developing complications (OR = 2.1, 95% CI = 1.2–3.7, p = 0.01). Each additional year of education reduced the risk of complications by approximately 8% (OR = 0.92, p = 0.04), suggesting that education may serve as a protective factor by enhancing comprehension of postoperative instructions and fostering proactive communication with health providers. Similarly, higher social support and health literacy scores were associated with shorter hospital stays and lower complication odds, emphasizing the cumulative buffering effects of psychosocial resources.
These findings underscore that clinical recovery is not solely determined by surgical precision or postoperative care protocols but also by broader social and cognitive dimensions that shape a patient’s ability to engage in recovery. The data reinforce the need to integrate socially responsive nursing interventions—such as targeted education, patient advocacy, and family-based support—within medical-surgical settings.
From a social science perspective, the statistical associations observed reflect structural inequality translated into clinical outcomes. Health literacy operates as a mediating pathway through which education and income influence recovery. Similarly, social support functions as a resource for both emotional regulation and practical assistance, buffering the physiological stress response and facilitating adherence to therapeutic regimens.
Overall, the quantitative analysis presents robust empirical evidence that social determinants exert a measurable impact on surgical recovery, warranting systemic incorporation of social assessments into nursing documentation and care planning.
Qualitative Themes
The qualitative strand enriches and contextualizes the quantitative findings by capturing lived experiences of patients and nurses in the medical-surgical ward. The five emergent themes collectively describe the social texture of recovery, revealing how interpersonal and structural dimensions intertwine with clinical processes.
“Invisible burdens.”
Many patients articulated underlying financial stress, transportation difficulties, and caregiving responsibilities that compounded postoperative fatigue and anxiety. These burdens often remained hidden from healthcare professionals, yet they directly influenced adherence to medication, attendance at follow-up visits, and early mobilization efforts.
Communication gaps.
Nurses consistently identified communication challenges when conveying postoperative instructions to patients with low education or limited literacy. The linguistic and conceptual gap between medical terminology and patient comprehension contributed to misinterpretation of wound care or medication schedules. This theme resonates with the quantitative finding linking low health literacy to prolonged hospital stay.
Social stigma and expectations.
Cultural norms shaped patients’ willingness to disclose difficulties or seek help. Some participants, particularly from low-income backgrounds, expressed feelings of shame in admitting dependence or inability to self-manage, leading to preventable complications after discharge.
Fragmented discharge planning.
Discharge coordination often lacked integration with social services. Nurses reported limited communication with community health workers or social agencies, which occasionally resulted in patients returning to inadequate home environments. This fragmentation mirrors broader systemic issues in transitional care.
Desire for social risk screening tools.
Both nurses and patients expressed support for structured yet simple tools to identify social vulnerabilities early in the care process. Nurses emphasized that incorporating a brief checklist addressing income stability, social support, and literacy could help tailor education and referrals without imposing additional workload.
Synthesizing both quantitative and qualitative strands reveals a coherent pattern: social disadvantage translates into clinical vulnerability through multiple interlocking pathways—educational, communicational, and structural. These results informed the development of a Socially Informed Nursing Care Model, which integrates routine social risk screening, context-sensitive patient education, and active interprofessional collaboration with social workers and community resources.
This integrative model underscores that medical-surgical nursing extends beyond physiological stabilization; it also encompasses social navigation and empowerment. Embedding social assessment into clinical workflow can transform bedside interactions into opportunities for equity-oriented care, thereby aligning nursing practice with global movements toward socially accountable healthcare.
Discussion
The integration of social science perspectives into medical–surgical nursing care provides a multidimensional understanding of health that transcends the biomedical model. This study demonstrates empirically that social determinants—specifically income, educational level, social support, and health literacy—exert significant influence on patient recovery outcomes, such as length of stay and postoperative complications. These findings substantiate the premise that health is socially produced and maintained through structural, interpersonal, and behavioral mechanisms [1–4]. In this regard, the medical–surgical ward represents a microcosm where the intersection between biological pathology and social reality is most visible.
The quantitative findings indicate a clear social gradient in recovery. Patients with lower income and education exhibited longer hospital stays and higher complication rates. This pattern aligns with the well-established social gradient in health theory, which posits that each step down the socioeconomic ladder corresponds to worse health outcomes [2,3]. Income and education shape not only access to material resources but also health literacy, self-efficacy, and the ability to navigate the healthcare system [5,6]. Therefore, postoperative recovery is not merely a function of surgical precision or nursing skill; it is embedded in the patient’s socioeconomic position and the degree of social capital available for coping and adherence.
The role of social support emerged as particularly significant in this study. Stronger social support networks were associated with shorter hospital stays and lower complication rates. From a sociological standpoint, social support represents both an instrumental and emotional resource that buffers stress and enhances compliance with medical recommendations. The results echo the classical understanding that recovery and rehabilitation are social processes shaped by interpersonal interaction and network cohesion [11]. In practical terms, this means that nurses in medical–surgical settings function not only as clinical caregivers but also as social mediators who connect patients to their support systems and community resources.
Health literacy also proved to be a powerful determinant. Patients with lower literacy scores faced greater risk of complications, reflecting the critical role of communication and comprehension in self-care and medication adherence [10,15]. From a social science lens, literacy is not only an individual cognitive skill but also a social capability tied to educational structures and power hierarchies. As such, interventions to improve health literacy should be framed as empowerment strategies rather than as remedial education.
The role of health literacy, and the transition from hospital to home, is not limited to the content of discharge instructions but also how and when information is delivered. The recent Creative Nursing article “Hospital Discharge Process: Context-Sensitive Care” demonstrates that discharge education tailored to patients’ levels of health literacy and social context reduces complications and readmissions among older cardiac surgical patients [26]. In line with this, a qualitative study in Australia found that inconsistent communication, unrealistic expectations, and insufficient involvement of caregivers intensify patient distress and compromise recovery when discharge plans are poorly coordinated [27].
Furthermore, cross-sector collaboration between hospital and community nursing emerges as a crucial determinant of postoperative recovery. In “Discharging older patients from hospital to home-care: conflicts in collaborative practices among nurses across sectors”, Hansen et al. show that unclear roles, lack of confidence in shared information, and communication breakdowns introduce friction that ultimately harms continuity of care, especially for socially vulnerable patients [28]. These dynamics reinforce that social determinants do not act in isolation—they are mediated by systems of care, professional interactions, and institutional capacities. Thus, improving surgical recovery outcomes requires not only addressing individual patient social risk but also strengthening discharge systems, interprofessional collaboration, and caregiving networks.
The qualitative findings complement the statistical results by revealing the lived experiences behind these associations. Patients described “invisible burdens” such as financial insecurity, transportation issues, and stigma, which intersect to delay recovery and follow-up. These narratives illustrate that surgical recovery unfolds within a social ecology of constraints and opportunities. Nurses’ accounts of fragmented discharge planning and limited social service linkage reinforce previous evidence that biomedical efficiency can inadvertently obscure social vulnerability [13,14]. In essence, the success of surgical care is not solely determined in the operating room but continues into the home and community environments where social realities dominate.
The role of health literacy, and the transition from hospital to home, is not limited to the content of discharge instructions but also how and when information is delivered. The recent Creative Nursing article “Hospital Discharge Process: Context-Sensitive Care” demonstrates that discharge education tailored to patients’ levels of health literacy and social context reduces complications and readmissions among older cardiac surgical patients [26]. In line with this, a qualitative study in Australia found that inconsistent communication, unrealistic expectations, and insufficient involvement of caregivers intensify patient distress and compromise recovery when discharge plans are poorly coordinated [27].
Furthermore, cross-sector collaboration between hospital and community nursing emerges as a crucial determinant of postoperative recovery. In “Discharging older patients from hospital to home-care: conflicts in collaborative practices among nurses across sectors”, Hansen et al. show that unclear roles, lack of confidence in shared information, and communication breakdowns introduce friction that ultimately harms continuity of care, especially for socially vulnerable patients [28]. These dynamics reinforce that social determinants do not act in isolation—they are mediated by systems of care, professional interactions, and institutional capacities. Thus, improving surgical recovery outcomes requires not only addressing individual patient social risk but also strengthening discharge systems, interprofessional collaboration, and caregiving networks.
From a theoretical standpoint, the study supports a Socially Informed Nursing Care Model, which integrates social determinants screening, tailored education, and interprofessional collaboration. This aligns with social capital theory, which posits that cohesive relationships and trust networks generate tangible health benefits [7]. By embedding social science reasoning into nursing routines, care becomes relational rather than transactional. The findings demonstrate that the bedside can be reimagined as a site of social interaction where nurses actively identify, interpret, and respond to social needs.
Moreover, the present study resonates with global discourses such as Global surgery 2030, which emphasizes equity, accessibility, and justice in surgical systems [20–22]. The findings illustrate how macro-level social inequities manifest in micro-level patient outcomes. By situating nursing practice within this broader socio-political context, the study extends the conversation from “what nurses do” to “why social realities shape what is possible to achieve.” The implication is that clinical excellence alone cannot close health gaps unless it is accompanied by structural sensitivity—an awareness of how poverty, stigma, and systemic inequality intersect with illness.
The results also invite reflection on the role of interdisciplinary collaboration. While surgeons and physicians often dominate decision-making, integrating social science perspectives encourages collective responsibility for addressing non-medical determinants of health. This reorientation is consistent with the World Bank’s Disease Control Priorities framework [21], which calls for social accountability and cross-sector partnerships in essential surgical care. Nurses are central actors in this transformation, as they possess the daily proximity to patients and the communication skills necessary for implementing socially responsive care models.
Another critical insight from this research concerns the translation of social awareness into clinical protocols. Despite recognition of social factors, healthcare systems often lack operational mechanisms to address them. Embedding a brief, evidence-based social screening tool within nursing admission assessments could provide actionable data on patients’ financial, educational, and social needs. Coupled with discharge planning that includes referrals to community-based organizations, this would operationalize the “social turn” in surgical care [16,17].
This study thus bridges the epistemological gap between the clinical sciences and the social sciences. It underscores that recovery trajectories are co-determined by biological repair and social reconstruction. The findings contribute to an emergent paradigm in nursing—socially embedded clinical practice— which recognizes that successful healing requires interventions at both biological and social levels.
Policy and Practice Implications
Implementing social science-informed nursing care requires institutional commitment. Training curricula should include modules on social determinants, communication strategies, and community partnership. Hospitals can pilot quality improvement initiatives that track social needs and outcomes to demonstrate cost-effectiveness—given that addressing social barriers can reduce readmission and length of stay. This aligns with current evidence linking socially responsive care to efficiency gains and better patient satisfaction [8,9,12].
Limitations and Future Directions
While the single-site design limits generalizability, the integration of quantitative and qualitative data strengthens interpretability. Future research should involve multi-site collaboration and longitudinal tracking to evaluate sustainability. Furthermore, exploring digital and technological tools for social determinants screening—such as mobile apps or electronic health record prompts—could enhance scalability.
Conclusion
In summary, this study provides empirical support for embedding social science principles within medical–surgical nursing. By demonstrating that social determinants significantly predict postoperative recovery, and by elucidating the experiential mechanisms through which social conditions affect healing, the study advocates for a paradigm shift from clinically focused to socially responsive nursing practice. Such integration promises not only to improve patient outcomes but also to advance the moral and professional mission of nursing as a discipline committed to social justice, human dignity, and equitable health for all.
